ChanBeDu/relevant_section_length · Datasets at Hugging Face

12,087

186,579

26287

Discharge summary

report

Admission Date: [**2136-1-3**] Discharge Date: [**2136-1-8**] Date of Birth: [**2093-11-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6021**] Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: 42 yo M with HIV on HARRT ([**10-21**] CD4 199 VL 79) with kaposi sarcoma on Doxil/Taxol. Now presents to the ED with gradually increasing swelling of the lower extremities. He also has been having fevers and diarrhea. The diarrhea has been present for 3 days with crampy abdominal pain. The diarrhea is watery without blood. He has also had RUQ pain x 12 hours. The patient also reports increased swelling in both legs bilaterally. . In the ED the patient found to have a fever to 102.7. Given levoflox and sent to the floor. On my evaluation the patient is lying in bed in moderate abdominal pain. Denies fevers, chills, chest pain, shortness of breath, HA, changes in vision/hearing, rashes, dysuria, hematuria. His legs feel full but not tender. Past Medical History: -HIV ([**10-21**] CD4 199 VL 79 at [**Hospital1 778**]) on HAART -Kaposi Sarcoma - diagnosed on R lower cervical node bx; course complicated by lower extremity swelling that has responded somewhat to chemotherapy, s/p 8 cycles of Doxil with no response and s/p 5 cylces of Taxol (last dose [**2135-12-21**]) -Rectal HSV Social History: From [**Country **] but much of family is from [**Country 7192**]. Tob - prior use <1 pack year Etoh - rare; Drugs - none . FROM PREVIOUS DISCHARGE SUMMARY: He was born in [**Country 6607**], although much of his family lives in [**Country 7192**], where he frequently visits (last in [**12/2134**]; no obvious strange exposures/foods/water). He has two brothers, one of whom lives in [**Name (NI) 2784**] and one in [**Country 7192**]. He lives alone and works as a financial analyst with no strange industrial exposures at work. He is a homosexual male with over 100 lifetime partners, has had unprotected sex on several occasions. He smoked about 1 pack per week for 10 years, quit 2 years ago. 1 alcoholic drink/day. He used crystal meth, ecstasy, and marijuana but no use since two years ago. No injection drugs. No pets. Family History: GM with DM. Parents/siblings healthy. Physical Exam: VS - 98.7 100/50 96 22 99% on RA gen - A+Ox3, NAD skin - maculopapular rash on chest, unchanged per patient over weeks. HEENT - OP clear, pink conjunctivae, EOMI, PERRL Neck - supple, no LAD Cor - RRR no murmur Chest - CTA B Abd - soft, non distended, RUQ severe tend, non-tender no guarding. Rectal - no lesions, brown stool, guiac neg Ext - warm, legs swollen, edema is somewhat pitting but more brawny in nature. Need to hold for a significant amount of time to caus a pit. Legs are also red (blanching) and warm. Swelling is equal bilaterally. Neuro - nl strength and [**Last Name (un) 36**] x 4 ext Pertinent Results: [**2136-1-3**] 06:40PM PLT SMR-NORMAL PLT COUNT-381 [**2136-1-3**] 06:40PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL [**2136-1-3**] 06:40PM NEUTS-66 BANDS-7* LYMPHS-15* MONOS-2 EOS-0 BASOS-0 ATYPS-10* METAS-0 MYELOS-0 [**2136-1-3**] 06:40PM WBC-2.8*# RBC-3.94* HGB-12.7* HCT-36.2* MCV-92 MCH-32.3* MCHC-35.1* RDW-14.8 [**2136-1-3**] 06:40PM ALBUMIN-3.9 [**2136-1-3**] 06:40PM LIPASE-24 [**2136-1-3**] 06:40PM ALT(SGPT)-86* AST(SGOT)-37 ALK PHOS-78 AMYLASE-37 TOT BILI-0.9 [**2136-1-3**] 06:40PM estGFR-Using this [**2136-1-3**] 06:40PM GLUCOSE-115* UREA N-12 CREAT-1.1 SODIUM-134 POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-24 ANION GAP-16 [**2136-1-3**] 06:58PM LACTATE-4.2* [**2136-1-3**] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2136-1-3**] 07:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2136-1-3**] 11:51PM LACTATE-3.0* . CT Pelvis with contrast [**1-3**]: DILATED GALLBLADDER WITH MILD INTRAHEPATIC DUCTAL DILATATION MEASURING 3 MM. NO CALCIFICATION OR PERICHOLECYSTIC FLUID SEEN ON THIS CT HOWEVER PRESENCE OF GALLSTONE CANNOT BE EXCLUDED. CLINICAL CORRELATION IS RECOMMENDED FOR THE POSSIBILITY OF CHOLECYSTITIS OR CHOLANGITIS. . CXR [**1-3**]: No acute pulmonary process. Pulmonary arterial hypertension, which may be seen in the setting of HIV. . RUQ Ultrasound [**1-3**]: IMPRESSION: Moderately dilated gallbladder with sludge, without stone, pericholecystic fluid or gallbladder edema. . Echo [**1-5**]: Conclusions: The left atrium is elongated. 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. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No evidence of endocarditis. Preserved global and regional biventricular systolic function. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [**2135-11-22**], the findings are similar. Brief Hospital Course: A/P 42 yo M with HIV on HARRT ([**10-21**] CD4 199 VL 79) with kaposi sarcoma on Doxil/Taxol. . # Strep Mitis Septicemia - Patient initially on Vanc/Zosyn. However [**Last Name (un) 36**] came back [**Last Name (un) 36**] to PCN. Evaluated by infectious disease and switched to ceftriaxone 2g/day to complete a 14 day course. Patient with negative trans thoracic echo. Afebrile at dischrge with PICC for home abx. . # Abd Pain - Patient with fever and diarrhea in setting of chemo and HIV. Patient also with RUQ pain. Alk phos and bili wnl. UA and CXR neg. ALT increased at 86. Abd pain may be from cramping, cancer progression, early hepatitis, or galbladder stone. Gallbladder found ot be enlarged. Patient with lactate of 4. Initialy thought to have cholangitis and sent to MICU for closer eval. Evaluated by surgery but no edema of GB wall and symptoms resolved with treatment of his septicemia. On discharge patient has no abdominal pain and is eating well. . # Diarrhea - Patient with diarrhea after coming out of MICU. initially thought to be BRBPR but guiac neg on mult occasions with stable Hct. Stool studies neg by cx as well as O+P. diarrhea resolved during hospitalization. Mult stool cx pending including strongyloides which will need to be followed up as an outpatient. . # HIV - continued on HAART and bactrim. CD4 while in house was 174. . # Leg Swelling - Severely increased over the past few days although equal bilaterally. Bilateral LENI neg [**1-4**]. went back to baseline with treatment of septicemia. Patient restarted on home lasix dose when was stable. . # hepatitis B - patient HBV sAg+; cAb+; sAb-. This is new for patient who reports having HBV vaccine. HCv ab -. Patient with hBV viral load 7900. Will follow up with outpatient PCP. [**Name10 (NameIs) **] told that he can also be seen in the [**Hospital **] [**Hospital 65085**] clinic if his PCP was willing to transfer his ID care. . # HSV - Patient developed rectal HSV exacerbation. Improved with po acyclovir. Will go home to complete a 5 day course. . Code - Full . Comm - Family in [**Country 6607**]; [**Telephone/Fax (1) 65086**] ([**Name (NI) **], aunt). Medications on Admission: 1) Kaletra Two tabs b.i.d 2) Epzicom one tablet daily 3) Bactrim 80-400 mg qd 4) Lasix 40 mg daily 5) Lunesta 2 mg prn Discharge Medications: 1. Ceftriaxone 2 g Recon Soln Sig: Two (2) grams Intravenous once a day for 10 days: last day should be [**2135-1-18**]. Disp:*10 dises* Refills:*0* 2. PICC Care Sig: One (1) care once a day: Please care for PICC per company routine. Disp:*10 days* Refills:*0* 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Epzicom 600-300 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lopinavir-Ritonavir 200-50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Acyclovir 200 mg Capsule Sig: One (1) Capsule PO 5X/D (5 times a day) for 4 days. Disp:*20 Capsule(s)* Refills:*0* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Strep Mitis septicemia Rectal HSV Secondary: HIV Hep B Kaposi Sarcoma Diarrhea Discharge Condition: stable, eating well, afebrile, hemodynamically stable Discharge Instructions: Please take all medications and make all follow up appointments as listed in the discharge paperwork. [**Name6 (MD) **] you MD or come to the hospital if you have fevers, chills, chest pain, nausea, vomitting, diarrhea, abdominal pain, pain with urine or stool, or other concerning symptoms. You were diagnosed during this admission with Hepatitis B. You will need to inform Dr. [**First Name (STitle) 6164**] about this. If he wants you can have your infectious disease care tranferred to our "co-infection" clinic. Also Dr. [**Last Name (STitle) **] should check your post-antibiotic labs. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2136-1-20**] 12:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3281**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2136-1-20**] 1:00 Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**] in [**2-18**] weeks. He should be informed of your Hepatitis B infection. You will need further testing and treatment for this. This can be done by Dr. [**First Name (STitle) 6164**] or at our infectious disease clinic. [**Telephone/Fax (1) 457**].

[ "070.30", "038.0", "682.6", "042", "054.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

8632, 8684

5587, 7753

320, 326

8807, 8862

2997, 5564

9507, 10161

2317, 2357

7923, 8609

8705, 8786

7779, 7900

8886, 9484

2372, 2978

275, 282

354, 1105

1127, 1448

1464, 2301

13,401

195,082

53006

Discharge summary

report

Admission Date: [**2189-1-21**] Discharge Date: [**2189-1-25**] Date of Birth: [**2125-1-31**] Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins / Aztreonam / Latex Attending:[**Doctor Last Name 10493**] Chief Complaint: hyperglycemia and altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 63 yo M with h/o DM type 1, PVD, and HTN who presents with hyperglycemia and altered mental status. The patient states that he was in his USOH until Monday, when he awoke with abdominal pain and nausea. He could not eat anything so he didn't take his insulin. He did not vomit or experience fevers/chills, nor any dysuria, new cough, or URI sxs. He did manage to go to his numerous medical appointments that day, when he was seen by PCP, [**Name10 (NameIs) **], and dentist. . Per wife, the dentist foud a large mouth abscess for which he was prescribed clindamycin 150mg qid x 7 days. Otherwise visits were without incident. Sugars have been running very erratically, with FSG on [**1-19**]- [**1-20**] ranging from 70's to 500+. Today, after returning from work, she found him slumped over at his computer and confused. Checked BS and was so high meter didn't read number. Called Dr. [**Last Name (STitle) 1007**], rechecked BS, was still higher than readable, so called EMS. Was disoriented, calling son by name and stating he needed 750 units of insulin. . In the ED, vitals were stable. Initial labs were notable for glucose 769, HCO3 9, AG 32, WBC 21.3, lactate 3.9, UA positive for ketones. CXR without acute process, EKG with new [**Street Address(2) 4793**] dep V5-6, 0.[**Street Address(2) 1755**] dep II, III, aVF. ABG 7.08/25/104/8. He was started on an insulin gtt at 8 units/hr, given 4 L IVFs, asa 325 po X 1, levaquin 500 mg IV X 1, and flagyl 500 mg IV X 1. . ROS positive for headache and blurry vision recently. Also endorses poor appetite and po intake due to nausea, abdominal pain, and vomiting today. Denies unusual polyuria or polydipsia. Denies CP or SOB. Past Medical History: DM type 1 dx'ed [**2151**], c/b ulnar and median neuropathies, PVD, retinopathy, and gastroparesis Diabetic foot ulcers with multiple prior infections including MRSA isolates, s/p L 4th toe osteomyelitis with gas gangrene in [**3-30**] requiring amputation OSA PVD s/p L femoral bypass GERD HTN Hypercholestolemia Depression Erectile dysfunction h/o broken neck at age 13 with C1-C2 repair. Social History: (+) tobacco use x40 years, currently smokes 3 cigs/day, patient denies past etoh abuse, although OMR notes indicate past chronic alcohol use. Denies illicit drug use. Married. Family History: Non-contributory Physical Exam: T BP 126/46 HR 95 RR 19 O2 sat 98% 5L NC Gen - elderly male, pleasant, NAD, tired, smells strongly of acetone HEENT - NC/AT, PERRLA, MM dry. Upper dentures. O/P clear, no ulcers or abscess noted. No tenderness to palpations CV - RRR, no m/r/g Lungs - CTAB Abd - S/NT/ND, + BS Ext - R foot with small <1cm ulcer on sole, bandaged. Does not appear infected. L foot with amputated 5th toe Neuro - A+O x 3 Skin - no rashes or ulcers noted aside from above Pertinent Results: [**2189-1-21**] ADMISSION . WBC-21.3*# RBC-3.60* Hgb-12.3* Hct-39.0* MCV-109* MCH-34.3* MCHC-31.6 RDW-12.0 Plt Ct-369 Neuts-95.2* Bands-0 Lymphs-2.4* Monos-2.1 Eos-0.1 Baso-0.2 . PT-12.7 PTT-22.7 INR(PT)-1.1 . Glucose-769* UreaN-43* Creat-1.6* Na-132* K-6.6* Cl-91* HCO3-9* AnGap-39* . Glucose-682* UreaN-43* Creat-1.6* Na-138 K-5.4* Cl-98 HCO3-8* AnGap-37* . [**2189-1-21**] 07:25PM BLOOD CK(CPK)-67 [**2189-1-21**] 07:25PM BLOOD CK-MB-NotDone [**2189-1-21**] 07:25PM BLOOD cTropnT-<0.01 . SERUM TOX: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . ABG Type-ART O2 Flow-4 pO2-104 pCO2-25* pH-7.08* calTCO2-8* Base XS--21 . URINE: Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . LABS DURING ICU STAY: SERIAL CHEMISTRIES: [**2189-1-22**] Glucose-131* UreaN-30* Creat-1.1 Na-140 K-4.3 Cl-110* HCO3-21* AnGap-13 [**2189-1-23**] Glucose-56* UreaN-11 Creat-0.6 Na-131* K-4.2 Cl-103 HCO3-22 AnGap-10 [**2189-1-24**] Glucose-237* UreaN-9 Creat-0.7 Na-131* K-3.9 Cl-95* HCO3-28 AnGap-12 . CARDIAC ENZYMES: [**2189-1-22**] 01:00AM CK(CPK)-82 CK-MB-7 cTropnT-0.02* [**2189-1-22**] 12:26PM CK(CPK)-597* CK-MB-15* MB Indx-2.5 cTropnT-0.08* [**2189-1-22**] 09:04PM CK(CPK)-603* CK-MB-14* MB Indx-2.3 cTropnT-0.05* [**2189-1-23**] 04:32AM CK(CPK)-670* CK-MB-14* MB Indx-2.1 cTropnT-0.03*\ . RADIOLOGY: [**1-21**] CXR IMPRESSION: No acute process. . CT HEAD W/O CONTRAST [**2189-1-22**] 2:17 PM Reason: eval for bleed There is no evidence of hemorrhage, edema, masses, mass effect, or infarction. The ventricles and sulci are normal in caliber and configuration. No fractures are identified. There is suggestion of a prior ethmoidectomy. There is a scalp hematoma in the midline at the vertex. IMPRESSION: Scalp hematoma. No acute bleed. . MICROBIOLOGY: [**1-21**] BCx: NGTD Brief Hospital Course: 63 yo M with h/o DM type 1 c/b gastroparesis and foot ulcers, PVD, and HTN who presents with DKA. . 1) DKA - On presentation, AG 30, HCO3 9, glucose 769. DDx includes poor insulin adherence, infection, or ischemia. UA was negative, CXR without acute process. Pt did c/o nausea and vomiting for 2 days but it is unclear whether this was acute precipitant of DKA or rather symptom. Appears that insulin regimen was very erraticly taken at home, which is probably the precipitant. Continued insulin gtt while checking q1h FS. Received aggressive IVF hydration with 1/2 NS @ 300cc/hr. Lytes were checked q4h with serial narrowing of AG noted. When AG closed, glucose was 120's. Switched to D5 1/2NS @ 300cc hr, d/c'ed NPO status, and initiated sQ long lasting insulin. D/C'ed insulin gtt 30 minutes later, but pt had dropped glucose to 50's, was given juice with good response. Also ate breakfast without problem. Threshold to add K to fluids was 4.0. [**Last Name (un) **] was consulted to clarify insulin regimen and do teaching with pt. Was continued on fixed 75/25 and HISS, with qid FSG, upon transfer from ICU. He was discharged the following day on insulin regimen of 75-25 44 units before breakfast and 20 units before dinner as well as a humalog sliding scale. Follow up was arranged with [**Last Name (un) **] prior to discharge. . 2) Demand Ischemia - Occuring in setting of profound DKA dehydration in a pt without known h/o CAD but with CAD equivalent in DM. Cardiac enzymes trended upwards at admission with TropT that peaked at 0.08. EKG has some T wave flattening, and at that point the pt was guaiac'ed (negative) and begun on a heparin gtt as well as given ASA and metoprolol. With a peak of the CE's and resolution of all sxs and EKG changes, heparin was dc'ed the next day. Pt only c/o nausea, no significant CP. Was monitored on tele with no events. An outpt stress is recommended for further w/u. Metoprolol held on discharge due to concern for labile diabetes and masking signs of hypoglycemia. He will follow up with his primary care doctor, Dr. [**Last Name (STitle) 1007**] to decide if adding metoprolol is appropriate. . 3) Leukocytosis - presented with WBC 21.3 with left shift. UA was negative, CXR was without acute processes. Per wife, seen at [**Hospital1 **] dental earlier this week for ? tooth abscess; however no abscess or pain noted on exam. Also pt afebrile. Leukocytosis is also a classic feature of DKA so this is the most likely etiology. WBC ct trended down during stay. Blood cultures were negative. Was continued on clindamycin 7 day regimen as precribed at outpt dental appointment ([**1-24**] = day [**5-30**]). . 4) Dental Abscess: continued outpt clindamycin 150mg qid as above . 5) Hyponatremia - presented with psuedohyponatremia [**1-24**] elevated glucose. Normalized with glucose correction. However, with subsequent aggressive hydration (almost 10 liters), pt developed basilar crackles and sodium again dropped. Likely hypervolemic hyponatremia, so was given a small amount of lasix and allowed to autodiures as renal function normalized. Sodium normalized prior to discharge at 137. . 6) Acute renal failure - In setting of DKA, was intravascularly dry, BUN/Cr ratio > 20. Aggressive IVF hydration led to quick reurn of renal function back to baseline. . 7) Nausea/vomiting - Also likely [**1-24**] DKA. Checked LFTs and amylase/lipase which were negaive. Pt also has a known history of gastroparesis so preprandial reglan was added with good effect. . 8) DM type 1 - DKA management as above. Continued lyrica for neuropathic pain. [**Last Name (un) **] was consulted as above. Reglan as above. . 9) Foot ulcers/PVD - Small noninfected ulcer on base of R foot. Followed by podiatry and [**Hospital **] clinic. Called podiatry for reassessment,no acute management required. Continued wound care. . 10) HTN - Continued diovan, amlodipine, lisinopril. . 11) Anemia ?????? HCT 28 on [**1-24**], down from 39 on presentation, most likely hemoconcentrated on admission [**1-24**] DKA. His historical baseline is 27-30. He was guaiac negative on [**1-21**], with no e/o head bleed on CT. HCT on discharge 31.8 . 12) Hypercholesterolemia - Continued statin. . 13) Depression - Continued wellbutrin, effexor. . 14) Code - full . 15) Communication - with pt and wife [**Name (NI) **] [**Name (NI) 5395**] [**Telephone/Fax (1) 109265**] Medications on Admission: (per OMR list [**1-19**], pt unable to confirm any) Diovan 80 mg daily Amlodipine 10 mg daily Simvastatin 80 mg daily Pantoprazole 40 mg daily Lyrica 75 mg [**Hospital1 **] Ibuprofen 400 mg q4-6h prn Tylenol prn Provigil 100 mg daily Qualaquin 324 mg [**Hospital1 **] prn Effexor XR 300 mg dialy Trazodone 100 mg qhs prn Varenicline 1 mg [**Hospital1 **] Wellbutrin 300 mg daily lisinopril 40 mg daily Lantus 46 units qhs --> pt states he takes 75/25 42 units [**Hospital1 **], which is not in keeping with most recent [**Last Name (un) **] note HISS --> pt states does not do this anymore Discharge Medications: 1. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO bid (). 2. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO QAM. 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) as needed. 9. QUALAQUIN 324 mg Capsule Sig: One (1) Capsule PO once a day as needed for cramps. 10. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every [**3-29**] hours as needed for pain. 11. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO three times a day. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 13. Clindamycin HCl 150 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 5 days: as directed by your dentist. 14. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Suspension Sig: as directed units Subcutaneous twice a day: Inject 44 units before breakfast and 20 units before dinner. Disp:*1 bottle* Refills:*2* 15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Insulin Lispro 100 unit/mL Solution Sig: as directed according to sliding scale Subcutaneous four times a day: inject according to sliding scale before breakfast, lunch and dinner and before bed. 17. Effexor XR 150 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO twice a day. 18. Indomethacin 50 mg Capsule Sig: One (1) Capsule PO twice a day. 19. Domperidone (Bulk) Miscellaneous Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetic Ketoacidosis . Secondary: DM type 1 dx'ed [**2151**], c/b ulnar and median neuropathies, PVD, retinopathy, and gastroparesis Diabetic foot ulcers with multiple prior infections including MRSA isolates, s/p L 4th toe osteomyelitis with gas gangrene in [**3-30**] requiring amputation OSA PVD s/p L femoral bypass GERD HTN Hypercholestolemia Depression Erectile dysfunction Discharge Condition: stable, improved, acidosis resolved Discharge Instructions: You were admitted to the hospital with uncontrolled diabetes leading to a condition called diabetic ketoacidosis, which can be life threatening. For this reason it is extremely important that you take your regularly scheduled insulin at home, regardless of whether or not you are eating. Your endocrinologists at the [**Last Name (un) **] will help you with a plan for adjusting your home insulin depending on what you eat. Your insulin regimen was adjusted by the [**Last Name (un) **] physicians. You are now taking 75/25 44units in the [**Last Name (un) 44550**] and 20 units before dinner. You should also check your blood sugars four times daily and follow the humalog sliding scale as directed. . Please take all of your medicines as prescribed. Please keep all of your outpatient appointments. If you develop high blood sugars, very frequent urination and thirst, confusion or sleepiness, or any other symptoms whic disturb you, please call your doctor right away, or go to the ER. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 17785**],MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2189-2-4**] 2:05 Please call and schedule an appointment to follow up with Dr. [**Last Name (STitle) 1007**] in [**12-24**] weeks. Please call the [**Last Name (un) **] and schedule an appointment to follow up within 2-4 weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]

[ "285.9", "250.63", "707.14", "583.81", "250.53", "536.3", "276.1", "410.71", "584.9", "443.9", "362.01", "401.9", "530.81", "250.43", "250.13", "357.2", "522.5", "327.23", "276.51", "272.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11867, 11873

5063, 9451

350, 356

12307, 12345

3199, 4255

13385, 13883

2692, 2710

10091, 11844

11894, 12286

9477, 10068

12369, 13362

2725, 3180

4272, 5040

271, 312

385, 2067

2089, 2482

2498, 2676

62,157

123,115

35934

Discharge summary

report

Admission Date: [**2132-1-25**] Discharge Date: [**2132-2-1**] Date of Birth: [**2057-5-12**] Sex: F Service: NEUROSURGERY Allergies: Codeine Attending:[**First Name3 (LF) 3227**] Chief Complaint: elective admission for craniotomy Major Surgical or Invasive Procedure: left craniotomy for tumor resection left EVD placement History of Present Illness: This is a 74-year-old woman with an intraventricular cancer who initially presented with ventriculitis secondary to a trapped left ventricle. The patient's neurologic status improved subsequent to an EVD placement and an extended course of antibiotic. The lesion was subsequently biopsied by Dr. [**Last Name (STitle) **] and the pathology was consistent with anaplastic astrocytoma. After discussion of treatment strategies, the patient elected to undergo resection of the exophytic portion of the mass. Past Medical History: Unknown Social History: non-contributory Family History: non-contributory Physical Exam: Patient is oriented x 1 only. She moves all extremities spontaneously. PERRL. Incision is clean, dry, intact. Pertinent Results: MRI Brain [**2132-1-26**]: FINDINGS: There has been interval resection of the left frontal [**Doctor Last Name 534**] mass. There is no evidence of residual tumor. There are postoperative changes, including intraparenchymal hemorrhage along the surgical pathway and surrounding edema are noted. The fluid signal intensity within the left lateral ventricle is higher on FLAIR than in the right lateral ventricle, this may represent a component of hemorrhage within the ventricle. Dependent material is noted within the left lateral ventricle, apparently representing a hematocrit level related to intraventricular hemorrhage. A ventriculostomy is present in the left frontal [**Doctor Last Name 534**]. CONCLUSION: Ventricular blood. A small amount of blood is present dependent within the left lateral ventricle. CT Head [**2132-1-29**]: FINDINGS: A left frontal craniotomy is again seen, with unchanged underlying extra-axial blood products. Previously noted pneumocephalus has decreased in extent. A left frontal ventriculostomy is again seen, terminating in or just inferomedial to the inferior aspect of the frontal [**Doctor Last Name 534**] of the left lateral ventricle. Small amount of blood is seen along the ventriculostomy path in the left frontal lobe, less dense than on the previous study. The amount of blood layering in the left lateral ventricle is unchanged. The frontal [**Doctor Last Name 534**] of the left lateral ventricle is slightly smaller, and other components of the ventricular system are stable in size. Previously noted shift of the anterior falx and the septum pellucidum to the right has slightly decreased. There is persistent opacification of the right posterior ethmoid air cell. There is new fluid in the right sphenoid sinus and new aerosolized secretions in the left sphenoid sinus, which may be related to the presence of a nasogastric tube. IMPRESSION: Expected evolution of postoperative changes, with slightly decreased shift of normally midline structures to the right and slightly decreased density of blood along the path of the left frontal ventriculostomy. Slightly decreased frontal [**Doctor Last Name 534**] of the left lateral ventricle. The remainder of the ventricular system is stable in size. Brief Hospital Course: The patient was admitted for elective craniotomy for tumor resection. The surgery went well and the patient went to the ICU afterwards. She had an EVD that was placed at the same time and was at 15 cm above the tragus and open. Her ICP remained within normal limits. The patient was not following commands after the surgery. She was noted to have a tremor in her lower extremities but this was not felt to be seizure activity. The patient was also found to have yeast in her urine. Her foley was removed. ID felt that no medication needed to be given. She was afebrile. The patient was transferred to the step down unit where her neuro status improved. She was able to follow some commands and she was more alert. The patient passed speech and swallow and was tolerating a regular diet. She was seen by OT/PT who recommended rehab. On [**1-30**] Dr. [**First Name (STitle) **] removed the EVD due to normal ICP. Her neuro exam had improved to near baseline with the exception of her RUE weakness ([**4-27**]). She was voiding on her own. She was discharged in the afternoon of [**2132-2-1**]. Medications on Admission: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): to continue until follow up appointment with Dr. [**Last Name (STitle) **]. 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: anaplastic astrocytoma Grade III Discharge Condition: neurologically stable Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You have dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions Your sutures will dissolve so you do not need to have them removed. Follow up with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2132-2-7**] 2:00 pm. Completed by:[**2132-2-1**]

[ "781.0", "191.5", "791.9", "V85.1", "443.9", "401.9", "729.89", "272.4" ]

icd9cm

[ [ [] ] ]

[ "01.59", "02.2", "96.6" ]

icd9pcs

[ [ [] ] ]

6107, 6187

3426, 4523

305, 362

6264, 6288

1146, 3403

7701, 7996

983, 1001

5399, 6084

6208, 6243

4549, 5376

6312, 7678

1016, 1127

232, 267

390, 900

922, 932

948, 967

29,621

114,755

4827

Discharge summary

report

Admission Date: [**2148-12-8**] Discharge Date: [**2148-12-31**] Date of Birth: [**2083-12-3**] Sex: M Service: MEDICINE Allergies: Nsaids Attending:[**Doctor First Name 2080**] Chief Complaint: s/p fall, left humeral fracture Major Surgical or Invasive Procedure: Central line placement (Left IJ) History of Present Illness: 65yo male with h/o ESRD on HD, CHF (EF 35%), diabetes, who presented to OSH s/p mechanical fall. States that he was in his usual state of health yesterday until he fell after dinner. He dropped his silverware and went to pick it up, and then fell over. Denies any CP, SOB, LH, or dizziness before or after event. Denies head trauma or LOC. Event was unwitnessed however wife was in other room and came immediately when she heard the patient fall. Patient was taken to OSH ED by EMS and was found to have comminuted left humeral fracture. Patient then transferred to [**Hospital1 18**] for further evaluation. . In ED initial VS were 97 70 100/50 18 93% on RA. Ortho consulted, however surgical intervention was not necessary. Patient was given IV pain medications and IV zofran. Noted to have BP in 80s. HCT noted to be 28 and trended down to 26, however there was no evidence of bleeding. Patient noted to have potassium of 5.7. Dialysis team aware, and patient taken for dialysis. Of note, patient had SBP in 60s at dialysis. . On encounter in dialysis, patient appeared comfortable at rest, however was in tremendous pain on movement. Patient denied any CP or SOB, dizziness, or lightheadedness. On admission to floor, patient triggered for hypotension. ROS: (+) Per HPI, endorses about 170lb weight loss over 1 year (-) Denies fever, chills and night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: Diastolic heart failure Hypertension ESRD on HD Morbid obesity Afib and h/o tachy-brady syndrome s/p pacemaker placement Diabetes Mellitus DVT CVA left frontal [**2136**] - L hemiparesis Sleep apnea Restrictive lung disease (thought [**2-20**] body habitus) Gout Chronic back pain Hx of Subarachnoid hemorrhage Social History: Married. Works as real estate developer. No tobacco or illicit drug use. Rare EtOH use, one drink every 2 weeks. Family History: Mother deceased secondary to MI age 77, Father deceased secondary to complications from renal disease. Physical Exam: Admission Exam VS 100.1 64/d 70 GEN: AAOx3, chronically ill appearing, no acute distress HEENT: EOMI, PERRL, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, right tunneled line without erythema or purulence or tenderness COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: crackles b/l without wheezes ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/ +1 edema b/l, dressing over left elbow with stained blood, pain in the left humerus. NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Patellar DTR +1. Plantar reflex downgoing. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: Admission Labs: [**2148-12-8**] 04:45AM BLOOD WBC-17.4*# RBC-2.82*# Hgb-9.7* Hct-28.5* MCV-101* MCH-34.5*# MCHC-34.1 RDW-14.7 Plt Ct-382 [**2148-12-8**] 04:45AM BLOOD Neuts-90.4* Lymphs-6.6* Monos-2.2 Eos-0.6 Baso-0.2 [**2148-12-8**] 04:45AM BLOOD PT-21.6* PTT-31.9 INR(PT)-2.0* [**2148-12-8**] 04:45AM BLOOD Glucose-195* UreaN-49* Creat-4.7* Na-137 K-5.7* Cl-97 HCO3-29 AnGap-17 [**2148-12-8**] 04:45AM BLOOD VitB12-1012* Folate-14.1 . Other Labs: [**2148-12-8**] 05:00PM BLOOD CK(CPK)-37* [**2148-12-8**] 10:05PM BLOOD ALT-17 AST-21 LD(LDH)-120 CK(CPK)-45* AlkPhos-75 TotBili-0.2 [**2148-12-9**] 05:06AM BLOOD CK(CPK)-65 [**2148-12-8**] 05:00PM BLOOD CK-MB-2 cTropnT-0.10* [**2148-12-8**] 10:05PM BLOOD CK-MB-2 cTropnT-0.11* [**2148-12-9**] 05:06AM BLOOD CK-MB-2 cTropnT-0.13* [**2148-12-9**] 05:06AM BLOOD Cortsol-25.9* [**2148-12-9**] 05:06AM BLOOD Digoxin-0.9 [**2148-12-9**] 12:21AM BLOOD Lactate-1.6 . Discharge Labs: . Microbiology: [**2148-12-8**] Blood cultures: pending, no growth to date [**2148-12-8**] Urine culture: negative [**2148-12-9**] Blood culture: pending, no growth to date . Imaging: [**2148-12-8**] EKG: One hundred percent A-V paced. Compared to the previous tracing of [**2148-1-29**] no diagnostic interval change. . [**2148-12-8**] Left Humerus X-ray: Three views of the left shoulder are slightly limited, though were the best obtainable given the patient's level of discomfort per the performing radiographic technologist. Note is made of a subtrochanteric left humeral fracture with some impaction of the humeral shaft into the humeral head. There is no evidence of dislocation of the humeral head. There is no other fracture or dislocation. A cardiac pacing device is partially imaged . [**2148-12-8**] CXR: Moderate right pleural effusion largely fissural has increased since [**9-17**]. Small left pleural effusion is unchanged. Right middle lobe is atelectatic, and moderate cardiac silhouette has increased in size, and there is greater pulmonary vascularity, but no edema. Transvenous right atrial and ventricular pacer leads are unchanged in their respective positions. As before, the dialysis catheter ends in the right atrium. No pneumothorax. There is no good evidence for pneumonia. . [**2148-12-8**] CXR: There is interval development of new bibasilar opacities consistent with newly developed aspiration given the short interval. Asymmetric pulmonary edema would be another possibility although less likely. The patient is rotated. Within the limitations of the differences in the position of the patient, no change in pleural effusion. The cardiomediastinal silhouette is unchanged. . [**12-30**] Shoulder X-ray: FINDINGS: Central venous access catheter incompletely evaluated. Dual-lead pacemaker present. The visualized left lung and ribs are unremarkable. Joint space narrowing of the AC joint. No dislocation. Again seen is the proximal left humerus fracture of the surgical neck, which extends into the humeral head, including the greater tuberosity. There is no significant change in healing or alignment. No new fractures. IMPRESSION: No interval change in left proximal humerus fracture, as above. . [**2148-12-10**] CT Chest w/Contrast: 1. No evidence of hemothorax. 2. Multifocal acute consolidation, most likely bacterial in nature. 3. Associated mild pulmonary edema. Brief Hospital Course: 65yo male with DM, ESRD on HD, CHF EF 35%, tachy/brady syndrome s/p PPM placement, afib on coumadin, CVA w/left sided weakness who presented s/p fall, was found to have comminuted humerus fracture, and with hospital course complicated with persistent hypotension. . #. Comminuted Left Humerus Fracture: Patient initially presented s/p mechanical fall, and was found to have left humerus fracture. Patient seen by ortho, who do not plan to surgically intervene at this time. They reccommended conservative (non-operative) management at this time such as sling and pain control. Patient also seen by acute pain service, for additional recommendations regarding pain control. Patient will need to wear arm in sling/collar, and follow-up with ortho for re-evaluation, he should schedule this appointment in early-mid [**Month (only) 404**]. Had follow up X-ray of his fracture shortly before discharge which showed no change. His pain was controlled with oxycontin 20mg [**Hospital1 **], tramadol PRN and dilaudid 2-4mg prn. He usually required only 2-4mg dilaudid a day. **Team asked patient and rehab to coordinate the follow up appt with Ortho within 1 month of discharge (mid [**Month (only) 404**]). . #. Hypotension: Patient's initial hypotension requiring MICU admission felt to be due to sepsis, likely secondary to multifocal pneumonia (HCAP) given CT chest findings. Was on vancomycin and cefepime for empiric coverage of HCAP, completed 8 day course on [**12-15**]. He then persisted to have hyptension averaging 70-90 every day and occasionally dropping to 55. He was afebrile, mentating well, with negative blood cultures. All anti-hypertensives were stopped. This hypotension was thought to be multifactorial: fluid shifts during HD, autonomic neuropathy, chronic CHF, and narcotics. He was sent back to the MICU for several days to receive CVVH to remove 11kg of fluid. Back on the floor, he continued to be hypotensive (more so in the evenings where he would be in the 60s) and he was given albumin 12.5g. If the albumin failed to increase his pressures, he was given midodrine 5mg. If neither albumin nor midodrine improved BP to the goal of 70s, he was given 250-500cc NS IVF bolus. His fluid intake was restricted to 1500cc/day. **Note: His BP ranges from 70-90s throughout hospitalization. At night, they frequently fell to 60s. When they are in the 60s-->try albumin 12.5 g once-->if BP still <70s then try midodrine 5mg once-->if BP still <70s try NS 250-500cc bolus. Goal BP should be 70s. Pt's organs appear well perfused and he mentates well at these pressures. **If pt is mentating well and afebrile, then the hypotension is unlikely concerning. However, if he does spike a fever of has altered mental status, then this would need further evaluation and workup. . #. Anemia, multifactorial: 10 point drop in HCT since [**42**]/[**2148**]. Was transfused 2 units PRBCs earlier in his hospitalization. Etiology of anemia unclear, and it is likely multifactorial: anemia in setting of ESRD, anemia of chronic inflammation, and marrow suppression in setting of acute illness as potential causes. HCT stabalized in the 26 range and pt was asymptomatic. . #. ESRD on HD: At home, patient has HD T/Th/Sun (noctural dialysis over 8 hr stretches which he tolerates well). During this hospitalization he was given CVVH in the unit to remove fluid and then daily HD/UF. He alternated: 3 days a week he would get HD and the alternating 3 days a week he would get Ultrafiltration with no clearance. He was also given albumin 25g during HD to improve pressures. Occasionally he was give midodrine 5-10mg on HD days to improve pressures, if needed. He was continued on neprhocaps and sevelamer. Pt would likely benefit from nocturnal HD since his pressures seem well controlled when he has a longer stretch of slow dialysis versus boluses 3 times a week. When he eventually goes home, he will resume nocturnal HD. **At rehab, he will likely need 3 days of HD (monday, wednesday, friday) for 4 hours each session. His last HD session was [**2148-12-30**] and last Ultrafiltration session was [**2148-12-31**]. The next session will be [**2149-1-1**]. **If pt building up fluid and not near his dry weight, would reccommend 3 days of UF on non-dialysis days alternating the 3 days of HD. (Ex: HD->UF->HD->UF...) **He might need albumin 12.5-25.0g (of 25% solution) on days of dialysis to improve pressures. **He might benefit from midodrine 5-10mg on days of dialysis to improve pressures. **He received HD on Monday [**12-30**], the day of discharge, and tolerated it well with 25g of albumin and midodrine 10mg. . #. Acute on chronic Systolic heart failure (LVEF 35%): Patient developed pulmonary edema earlier in the hospitalization, in setting of volume resusictation for hypotension. Pts heart failure likely contibuting to his hypotension. Lisinopril and metoprolol were discontinued in the setting of hypotension. . #. Afib and h/o tachy-brady syndrome s/p pacemaker: Pt found to mainly be in normal sinus rhythem. He was given coumadin 1-3mg daily for goal INR [**2-21**]. Metoprolol was stopped in setting of hypotension. He was continued on digoxin. INR at time of discharge was 2.4 and he was written for 2mg daily (up from 1mg daily the few days prior). . #. Hypertension at home: Stopped his home lisinopril and metoprolol in setting of hypotension. [**Month (only) 116**] resume outpatient, per cardiologist, if tolerated. . #Constipation: Was given aggressive bowel regimen for several days, including several enemas. He had several small bm and one medium bm day before discharge. He gets daily colace TID, daily senna. Prunes are effective. Lactulose PO is also effective. He was given fleet and soap suds enemas as well as manual dis-impaction. Pt very concerned about his bowel movements and wants to make sure if it still addressed at rehab. **Please continue daily aggressive bowel regimen with patient. This is very important to him. . #. Diabetes Mellitus: Monitored FSBS QID, continued FISS. Diabetic diet. . #. Gout: Continued allopurinol 100mg every other day (renally dosed). . #. h/o CVA with residual left weakness: Continued ASA, statin. Medications on Admission: Albuterol 2 puffs Q6H Allopurinol 150 mg daily Amiodarone 400 mg daily Astelin NS 137 mcg 2 sprays [**Hospital1 **] Bumetanide 4 mg [**Hospital1 **] Colace 100 mg TID Warfarin (1, 2.5, 2.5, or 5 mg as directed by coumadin clinic) Flexiril 10 mg at 3pm, 11pm Digoxin 125 mcg ([**1-20**] tab QMWFSat) ASA 325 mg daily Flovent 2 puffs Q12H Insulin NPH 34 units QAM and 45 units QPM Insulin HISS Lisinopril 2.5 mg QMWFSat Multivitamin Metoprolol succinate 50 mg daily Metrolotion topical Miralax 17gm daily Oxybutynin 10mg daily Percocet 7/500mg 1 tab Q3Pm/Q11pm Pantoprazole 40 mg daily Renagel 2400 mg TID Senna 2 tabs QHS Simvastatin 40 mg QHS Spironolactone 25 mg daily (temporarily off) Tylenol 1500 mg Q3PM/Q11pm Vitamin D 1000 units daily Zinc sulfate 220 mg daily Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO once a day. 2. MetroLotion Topical 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 4. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO QMOWEFR (Monday -Wednesday-Friday). 11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 13. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 15. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 17. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breakthrough pain: First try Tramadol. If no relief, then try Dilaudid. 18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): take standing. 19. oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 20. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply to left shoulder 12 hrs on and 12 hrs off every day. 21. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply to right shoulder. 12 hrs on and 12 hours off every day. 22. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 23. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 24. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 25. lactulose 10 gram/15 mL Solution Sig: 1000 (1000) MLs PO ONCE A DAY PRN () as needed for constipation. 26. midodrine 5 mg Tablet Sig: One (1) Tablet PO DAILY PRN DAY OF DIALYSIS OR SBP<70 () as needed for BP<70: If BP<70, first try albumin 12.5g (of 25% solution), then try midodrine 5mg. 27. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 28. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain: First try tramadol for breakthrough pain. If no relief, then try dilaudid. 29. pramoxine-mineral oil-zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day). 30. warfarin 1 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM: Goal INR [**2-21**]. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Primary Diagnoses: Left humerus fracture Sepsis Pneumonia Hypotension NOS Secondary Diagnoses: Systolic congestive heart failure Anemia 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: Mr. [**Last Name (Titles) 20197**], It was a pleasure taking care of you during your stay at [**Hospital1 18**]. You initially presented to the hospital after falling and fracturing your left shoulder. The orthopedic doctors saw [**Name5 (PTitle) **], but did not feel you needed surgery. You will need to follow-up with them in clinic. While you were here, you had a pneumonia and completed a course of antibiotics. You were also found to have low blood pressure. After carefully watching you for several weeks, it became clear that your new baseline blood pressure is in the 70-90s range. You tolerated these pressures very well and remeained asymptomatic. Your low blood pressure was attributed to several causes: your chronic heart failure, narcotics, fluid shifts during dialysis and autonomic neuropathy. Your blood pressure was often improved after giving you albumin, midodrine and/or fluids. You were also found to be anemic, and you received a blood transfusion. Your blood counts remained stable after the transfusion. We made the following changes to your medications: For gout, -DECREASED allopurinol dose to 100mg every other day For pain, -STOPPED your home percocet -STARTED Oxycontin 20mg twice a day (a long acting narcotic) - STARTED dilaudid (a shorter-acting pain medication) - STARTED Tramadol (another short acting medication) For your low blood pressure, -STOPPED metoprolol (because your blood pressure was very low) -STOPPED Lisinopril (because of your low blood pressures) - STOPPED Spironolactone (because of your low blood pressures) -STOPPED Bumetanide -Changed Digoxin 125 ([**1-20**] tab) M,W,F, Sat--> M,W,F (no longer taking on saturdays) . Please continue to take your other medications. Please follow up with your primary care doctor shortly after leaving rehab. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: -Schedule an appt with your primary care doctor within 1 week of discharge **Department: ORTHOPEDICS When: CALL TO SCHEDULE AN APPOINTMENT WITHIN 1 MONTH ([**Month (only) 404**], [**2149**]) [**Telephone/Fax (1) 1228**] With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: WEDNESDAY [**2149-2-19**] at 3:20 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9091**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "438.89", "038.9", "428.0", "274.9", "995.91", "427.31", "486", "403.91", "428.23", "780.79", "V45.11", "250.00", "278.01", "V45.01", "285.9", "585.6" ]

icd9cm

[ [ [] ] ]

[ "38.93", "39.95" ]

icd9pcs

[ [ [] ] ]

16694, 16741

6596, 12774

301, 336

16922, 16922

3242, 3242

19022, 19751

2430, 2534

13592, 16671

16762, 16837

12800, 13569

17099, 18158

4167, 6573

2549, 3223

16858, 16901

18187, 18999

230, 263

364, 1950

3258, 3679

16937, 17075

1972, 2284

2300, 2414

3691, 4151

12,141

101,625

11507+11508

Discharge summary

report+report

Admission Date: [**2158-7-14**] Discharge Date: [**2158-7-20**] Date of Birth: [**2120-3-22**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This 38-year-old white male has a history of chest discomfort. He had a history of mitral valve prolapse and mitral regurgitation. He is status post cardiac catheterization in [**2154**], which was negative and in [**2158-4-25**], he had an episode of severe substernal chest pain associated with diaphoresis, shortness of breath, nausea, and vomiting. He ruled out for a MI and had exercise tolerance test, which was negative for reversible defects, but had a possible small LAD infarct. An echocardiogram at that time revealed worsening MR and he again had chest pain in [**Month (only) **] and was admitted to [**Hospital1 69**] for rule out MI and had a positive tox screen for cocaine, but ruled out for MI. An echocardiogram on [**5-23**] revealed a left to right shunt across the intraatrial septum, a secundum ASD and EF of 75 percent, mitral valve leaflets were myxomatous and elongated. He had moderate-to-severe mitral valve prolapse with partial mitral leaflet flail and 4 plus MR. His stress test at that time revealed no significant ST changes and he underwent cardiac catheterization in [**2158-5-25**], which revealed an EF of 71 percent, 4 plus MR, and normal coronaries. He was admitted for elective mitral valve repair, and on [**7-14**], he underwent mitral valve repair with a quadrangular resection of the posterior leaflet and an anuloplasty with a 30 mm [**Doctor Last Name 405**] band. He had some bleeding in the OR. His chest was opened right after it was closed. They had not left the OR yet, and he had platelet transfusion and his bleeding subsided. He was transferred to the CSRU in stable condition. He remained intubated overnight. He was on Precedex overnight. He was extubated on postoperative day number one. Postoperative day two, his chest tubes were D/C'd, and he was transferred to the floor in stable condition. He continued to progress and had pacing wires D/C'd on postoperative day number three. DICTATION ENDED HERE. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) 18588**] MEDQUIST36 D: [**2158-7-20**] 16:05:35 T: [**2158-7-20**] 16:32:03 Job#: [**Job Number 36691**] Admission Date: [**2158-7-14**] Discharge Date: [**2158-7-20**] Date of Birth: [**2120-3-22**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 38-year-old white male who has had recurrent episodes of severe chest pain. He had a cardiac catheterization in [**2154**] which was negative for coronary artery disease. Then in [**2158-4-25**], he was admitted with severe chest pain, diaphoresis, shortness of breath, nausea, and vomiting and ruled out for a myocardial infarction. An exercise tolerance test at that time revealed a possible left anterior descending infarction, and an echocardiogram revealed worsening mitral regurgitation. On [**2158-5-22**] he was again admitted with chest pain, nausea, vomiting, and shortness of breath and was transferred to [**Hospital1 69**]. He ruled out for a myocardial infarction, but he had a positive toxicology screen for cocaine. An echocardiogram on [**5-23**] revealed a left-to-right shunt across the intraatrial septum, secundum as atrial septal defect, and an ejection fraction of 75 percent. His mitral valve leaflets were myxomatous and elongated, and he had moderate-to-severe mitral valve prolapse with partial mitral leaflet flare and 4 plus mitral regurgitation. He had a stress test on [**5-24**] which revealed no significant ST changes. He underwent cardiac catheterization on [**6-16**] which revealed an ejection fraction of 71 percent, normal coronaries, and 4 plus mitral regurgitation. He is now admitted for elective mitral valve repair. PAST MEDICAL HISTORY: Significant for a history of hypertension, hypercholesterolemia, a heart murmur for 12 years, mild L5-S1 disc protrusion, history of migraines, status post motor vehicle accident with chronic leg pain and low back pain requiring narcotics, a history of BPH, history of hemorrhoids, history of anxiety, history of depression, and a history of substance abuse. SOCIAL HISTORY: He is married. He works as an automobile mechanic but has not worked in several months. He smoked half a pack per day until recently and now smokes one to two cigarettes per day. He smokes marijuana and denies recent other kind of drug use. ALLERGIES: He is allergic to PENICILLIN (gets a rash). MEDICATIONS ON ADMISSION: Protonix 40 mg p.o. q.d., Elavil 50 mg p.o. q.h.s., lisinopril 10 mg p.o. q.d., Lipitor 10 mg p.o. q.d., Neurontin 300 mg p.o. b.i.d., Percocet one to two tablets by mouth q.4-6h. as needed, Klonopin 1 mg p.o. b.i.d., and he was on a prednisone taper for hives. PHYSICAL EXAMINATION ON ADMISSION: He was a well-developed and well-nourished white male in no apparent distress. Vital signs were stable. Afebrile. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. The extraocular movements were intact. The oropharynx had poor dentition. The neck was supple with full range of motion. No lymphadenopathy or thyromegaly. The carotids were 2 plus and equal bilaterally. No bruits. The lungs were clear to auscultation and percussion. Cardiovascular examination revealed a regular rate and rhythm with a holosystolic murmur. The abdomen was soft and nontender with positive bowel sounds. No masses or hepatosplenomegaly. The extremities were without clubbing, cyanosis, or edema. Neurologic examination was nonfocal. SUMMARY OF HOSPITAL COURSE: On [**7-14**], the patient underwent a mitral valve repair with a quadrangular resection of the posterior leaflet, and an anuloplasty with a 30-mm [**Doctor Last Name 405**] band, and a closure of a small atrial septal defect. He was ready to leave the Operating Room and had some increased chest tube drainage. He was reopened in the Operating Room, but by that time platelets and fresh frozen plasma had been transfused and his coagulopathy had resolved. The patient was transferred to the Cardiac Surgery Recovery Unit and was started on Precedex. He remained intubated overnight and was extubated on postoperative day one. He had his chest tubes discontinued on postoperative day two and was transferred to the floor. On postoperative day three and had his pacing wires discontinued. He had a lot of pain management issues and required respiratory therapy. He was ready for discharge on postoperative day five but spiked a temperature to 101.6. He was fully cultured, which was negative. His white count was 6700 and remained afebrile after that and was discharged to home on postoperative day six in stable condition. LABORATORY DATA ON DISCHARGE: Her laboratories on discharge were a hematocrit of 29, white count of 6500, and platelets of 319. Sodium was 141, potassium was 4, chloride was 105, bicarbonate was 31, blood urea nitrogen was 10, and creatinine was 0.8. MEDICATIONS ON DISCHARGE: 1. Potassium 20 mEq p.o. b.i.d. (for seven days). 2. Aspirin 325 mg p.o. q.d. 3. Colace 100 mg p.o. b.i.d. 4. Ibuprofen 600 mg p.o. q.6h. as needed. 5. Lasix 40 mg p.o. b.i.d. (for seven days). 6. Protonix 40 mg p.o. q.d. 7. Lipitor 10 mg p.o. q.d. 8. Klonopin 1 mg p.o. b.i.d. 9. Elavil 50 mg p.o. q.h.s. 10. Lopressor 45 mg p.o. b.i.d. 11. Neurontin 300 mg p.o. b.i.d. 12. Oxycodone 20 mg p.o. q.4-6h. as needed (for pain). 13. Nicoderm patch 14 mg topically q.24h. for 14 days then change to 7 mg topically once q.d. for 21 days. DISCHARGE FOLLOWUP: He will be followed up by Dr. [**Last Name (STitle) **] in one to two weeks, Dr. [**Last Name (STitle) **] in two to three weeks, and Dr. [**Last Name (STitle) **] in four weeks. DISCHARGE DIAGNOSES: 1. Mitral regurgitation. 2. Polysubstance use. 3. Hypertension. 4. Hypercholesterolemia. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) 18588**] MEDQUIST36 D: [**2158-7-20**] 17:45:06 T: [**2158-7-20**] 19:39:16 Job#: [**Job Number 36692**]

[ "424.0", "272.4", "401.9", "745.5", "998.11", "V11.3" ]

icd9cm

[ [ [] ] ]

[ "99.07", "39.61", "89.60", "35.71", "99.05", "34.03", "35.33", "99.04" ]

icd9pcs

[ [ [] ] ]

7945, 8280

7165, 7723

4660, 4944

5752, 6901

6916, 7139

7744, 7924

2550, 3931

4959, 5723

3954, 4314

4331, 4633

16,554

120,248

42940

Discharge summary

report

Admission Date: [**2159-4-11**] Discharge Date: [**2159-4-17**] Date of Birth: [**2108-12-4**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Motrin / Compazine / Vancomycin And Derivatives / Haldol / Nitrofurantoin Attending:[**First Name3 (LF) 1973**] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: 50 YO F with pmhx of HIV VL <50, CD4 927 ([**3-3**]) presents with increasing SOB, wheezes over the past 3 days. Of note, the patient recently seen in ER on [**4-8**] treated for sinus infxn, with congestion, nonproductive cough and asthma exacerbation with augmentin and prednisone, although did not start prednisone secondary to agitation, and called her PCP [**Last Name (NamePattern4) **] [**4-10**] because of increasing SOB, and also her zomig had run out. She states her last asthma attack was over ten years ago, has never been intubated, and her PF are typically 370. . In the ED she had a low grade temp 100.5 , HR 120 Bp 126/73 18 92% NRB, 74%RA, was placed on NRB and abg was 7.27/54/61 with a lactate of 2.1, she was given solumedrol, nebulizers, and ceftriaxone, with some symptomatic improvement, azithromycin was held for a history of Qt prolongation, . ROS: some CP, non radiating, after prednisone was started, subjective fevers, no dysuria, no diarrhea, abd pain. . Past Medical History: . HIV, sexually transmitted, diagnosed [**2150**] on HAART. Last CD4 927 [**3-3**] VL<50 copies 2. Hepatitis B and hepatitis C virus also sexually transmitted, diagnosed [**10/2151**], s/p IFN x6 months with failure to suppress VL. 3. Asthma. 4. Ovarian cancer diagnosed [**2142**], status post oophorectomy and chemotherapy. 5. Morbid obesity. 6. S/p MVA with L4-L5 laminectomy in [**2151**], operation c/b infection, including VRE requiring re-exploration and drainage. 7. Chronic back pain 8. Chronic L leg pain 9. Cholecystectomy [**2142**]. 10. Osteoarthritis involving bilateral knees 11. Recurrent UTIs last on [**4-4**] 12 Recurrent cystitis consistent with urethral syndrome or chronic cystitis 13. QT Prolongation -? assocation with abilify Social History: Lives alone. + tobacco - 3/4ppd x40 years, quit smoking 4 days ago, Quit drinking about 11 years ago. No IVDU. Prior h/o polysubstance abuse. Family History: NC Physical Exam: VS 98.1 100 121/79 22 98%NRB 15L GEN: morbidly obese, speaking in full sentences, comfortable with NRB HEENT: PERRL, EOMI, OP Clear, supple, CV: RRR no mrg CHEST: prolonged I/E ratio, exp wheezes throughout, minimal accessory muscle use ABD: normoactive BS, obese, soft, Ext; no/ c/c/e Neuro: AAOx3 Pertinent Results: [**2159-4-11**] 12:20AM BLOOD WBC-13.6* RBC-3.97* Hgb-14.4 Hct-43.3 MCV-109* MCH-36.2* MCHC-33.2 RDW-23.3* Plt Ct-273 [**2159-4-17**] 05:40AM BLOOD WBC-12.4* RBC-3.81* Hgb-14.0 Hct-42.2 MCV-111* MCH-36.9* MCHC-33.3 RDW-22.6* Plt Ct-288 [**2159-4-11**] 12:20AM BLOOD Neuts-79.9* Lymphs-16.9* Monos-2.8 Eos-0.2 Baso-0.2 [**2159-4-15**] 06:45AM BLOOD Neuts-78.3* Lymphs-13.6* Monos-2.6 Eos-4.8* Baso-0.7 [**2159-4-11**] 12:20AM BLOOD PT-13.0 PTT-26.2 INR(PT)-1.1 [**2159-4-17**] 05:40AM BLOOD PT-12.2 PTT-22.5 INR(PT)-1.1 [**2159-4-11**] 12:30PM BLOOD D-Dimer-1089* [**2159-4-11**] 01:55AM BLOOD Glucose-118* UreaN-10 Creat-0.7 Na-137 K-3.7 Cl-104 HCO3-25 AnGap-12 [**2159-4-17**] 05:40AM BLOOD Glucose-72 UreaN-11 Creat-0.6 Na-136 K-3.9 Cl-93* HCO3-33* AnGap-14 [**2159-4-11**] 01:55AM BLOOD CK(CPK)-310* [**2159-4-15**] 10:00AM BLOOD CK(CPK)-35 [**2159-4-11**] 01:55AM BLOOD CK-MB-10 cTropnT-0.07* proBNP-500* [**2159-4-14**] 01:30PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2159-4-15**] 10:00AM BLOOD CK-MB-1 cTropnT-<0.01 [**2159-4-11**] 01:55AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.8 [**2159-4-17**] 05:40AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.3 [**2159-4-13**] 03:00AM BLOOD VitB12-406 Folate-2.8 [**2159-4-11**] 01:33AM BLOOD Type-ART Temp-37.8 FiO2-92 O2 Flow-15 pO2-61* pCO2-54* pH-7.27* calTCO2-26 Base XS--2 AADO2-552 REQ O2-90 Intubat-NOT INTUBA Comment-O2 DELIVER [**2159-4-11**] 11:15PM BLOOD Type-ART Temp-37.7 pO2-70* pCO2-57* pH-7.29* calTCO2-29 Base XS-0 Intubat-NOT INTUBA [**2159-4-11**] 12:25AM BLOOD Lactate-2.1* [**2159-4-11**] 01:33AM BLOOD Glucose-111* Na-139 K-3.2* Cl-107 [**2159-4-11**] 05:23AM BLOOD O2 Sat-75 . CHEST (PORTABLE AP) [**2159-4-10**] 11:59 Bilateral symmetric air space opacities are most consistent with pulmonary edema. However, in the setting of patient's underlying HIV, infectious etiologies could also be considered. . ECG Study Date of [**2159-4-11**] 12:38:06 AM Sinus tachycardia Probable inferior myocardial infarction, age indeterminate - may be old Low precordial lead QRS voltages - is nonspecific Anterior myocardial infarct, age indeterminate Diffuse nonspecific ST-T wave abnormalities - cannot exclude in part ischemia Clinical correlation is suggested Since previous tracing of [**2158-12-27**], sinus tachycardia, precordial lead Q waves and further ST-T wave changes present. . CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2159-4-12**] 2:29 PM 1. No evidence of pulmonary embolism, as clinically questioned. 2. Extensive ground-glass opacities throughout the lungs. This appearance most likely represents pulmonary edema, although cannot exclude superimposed infection. Peripheral nodular densities may represent focal atalecasis. Recommend follow up imaging after appropriate treatment. 3. Chronic occlusion of left subclavian vein. . CHEST (PORTABLE AP) [**2159-4-12**] 3:45 AM Improving of pulmonary edema which still is of at least moderate degree. . ECHO [**2159-4-12**] The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is >20 mmHg. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 70%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . Compared with the findings of the prior report (images unavailable for review) of [**2153-8-6**], no gross or obvious change, but the technically suboptimal nature of both studies precludes definitive comparison. The pulmonary artery pressure could not be determined owing to the technically suboptimal nature of this study. . CHEST (PORTABLE AP) [**2159-4-13**] 10:14 AM Resolving alveolar edema. . CHEST (PA & LAT) [**2159-4-14**] 6:18 PM Central vascular congestion with mild edema. Overall continued slight improvement although not completely resolved. . CT CHEST W/O CONTRAST [**2159-4-16**] 4:10 PM Rapidly improving diffuse ground-glass attenuation and resolution of previously described focal nodular opacities. Considering interval diuresis, these findings are likely due to hydrostatic edema. . However, differential diagnosis for diffuse ground glass opacities is broad; in the appropriate clinical setting, pulmonary hemorrhage, hypersensitivity reaction (to drug or other antigens) and infection (viral or PCP) should also be considered. Brief Hospital Course: 50 F with pmhx of HIV, HepBC, asthma, morbid obesity presented initially with shortness of breath. . # Dyspnea, hypoxic respiratory failure Presented with fever, shortness of breath, and cough; had (and continues to have) marked hypoxemia. PE ruled out with CTA. She was empirically treated for pneumonia given her infiltrates (these actually seem more consistent with alveolar edema) and fever with ceftriaxone and azithromycin. No diagnostic sputum culture data, as her specimen was inadequate. PCP had been entertained, but sputum cx was a poor specimen, and this was unlikely in setting of robust CD4 count. The most likely explanation was pulmonary edema, supported by bilateral alveolar infiltrates on chest xray, ground glass opacities on CT, and her interval clinical and radiographic improvement with diuresis (diuresed total of > 1.5 L over past day). She was placed on slow steroid taper. Repeat CT scan after diuresis and antibiotics revealed reduction in hydrostatic edema and improvement of nodular opacities. Antibiotics were switched to cefpodoxime for completion of full course. Pt remained afebrile with resolution of leukocytosis. Discharged on standing daily lasix and home oxygen. Arranged for outpatient PFTs and cardiac [**Month/Day/Year **] testing. . # Pulmonary edema: In terms of cardiac etiology, she did have evidence of inferior Q waves, but these were old in comparison to prior EKG's. On [**4-11**] EKG, she had diffuse, non-specific ST/T changes as well. Her echocardiogram does not show any convincing evidence of systolic or diastolic failure or any regional wall motion abnormalities, but this was a technically poor study. The interpreting Cardiologist reported that a "focal wall motion abnormality can not be ruled out" due to the poor technical quality of the study. Pulmonary arterial pressures couldn't be assessed. Also, her estimated right atrial pressure was very high. She did have mild CK and troponin elevation on admission, though were flat on serial testing. Another possibility would be non-cardiogenic pulmonary edema or alternately an atypical infectious process. In summary, she had/has hypoxic respiratory failure with evaluation to date suggesting pulmonary edema with a technically inadequate assessment. Will need outpatient evaluation with PFTs and cardiac [**Month/Year (2) **] testing. . # HIV: Followed by Dr. [**Last Name (STitle) 1057**]. CD4 count >500. Continued on fosamprenavir 700mg [**Hospital1 **], ritonavir 100mg [**Hospital1 **], and emtricitabine/tenofovir 200-300mg daily. . # Chronic Back Pain: Likely due to morbid obesity and osteoporosis, cont methadone, gabapentin and topamax. . # UTI: Recurrent. On course of bactrim when admitted. Started on ceftriaxone, to which her pathogen was sensitive. Held bactrim and continued ceftriaxone which was switched to PO cefpodoxime for discharge. . # FEN: Sodium restrict diet . # PPX: PPI, heparin sc . # CODE: FULL . # Contacts: [**First Name8 (NamePattern2) 18404**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 92678**] . # DISP: Discharged to home with VNA services and supplemental oxygen. Medications on Admission: AMBIEN CR 12.5MG QHS ASTELIN 137 mcg--[**11-28**] sprays inh1 intranasal: [**11-28**] sprays [**Hospital1 **] BACTROBAN 2 % apply to both nostrils [**Hospital1 **] BENADRYL 25 mg [**Hospital1 **] COLACE 100 mg [**Hospital1 **] fosamprenavir 700mg [**Hospital1 **] with ritonavir 100mg [**Hospital1 **] emtricitabine/tenofovir 200-300mg daily LORATADINE 10 mg QD MAXAIR AUTOHALER 200 mcg/Actuation--2 puffs TID PRN MULTIVITAMIN QD Methadone 40 mg TID NEURONTIN 600MG TID NICOTINE 14 mg/24 hour--1 patch daily OMEPRAZOLE 20 mg QD PHENERGAN 25 mg PRN Pulmicort Turbuhaler 200 mcg (160 mcg delivered)--3 puffs [**Hospital1 **] RITONAVIR 100 mg--[**Hospital1 **] Senna-S 8.6-50 mg QD TOPAMAX 200MG--Take one half of a tablet in the morning, take 2 tablets before sleep TRIAMCINOLONE ACETONIDE 55 mcg--2 sprays QD TRIMETHOPRIM-SULFAMETHOXAZOLE 800 mg-160 mg--1 tablet(s) by mouth [**Hospital1 **] started [**4-4**] for 3 weeks VALIUM 5MG--[**11-28**] (2.5mg) twice a day as needed WELLBUTRIN SR 100MG--Take one tablet in the morning ZOMIG 2.5 mg--1 tablet(s) by mouth two hours as needed Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4-6H (every 4 to 6 hours) as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*2* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 4 days. Disp:*16 Tablet(s)* Refills:*0* 5. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). Tablet Sustained Release(s) 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fosamprenavir 700 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:*180 Capsule(s)* Refills:*2* 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Disp:*1 inhaler* Refills:*2* 12. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble PO TID (3 times a day). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 14. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 16. 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* 17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* 18. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 20. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-28**] Sprays Nasal QID (4 times a day) as needed. 21. Topiramate 100 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 22. Sumatriptan Succinate 6 mg/0.5 mL Solution Sig: One (1) Subcutaneous X1 (ONE TIME) as needed for headache. 23. Topiramate 100 mg Tablet Sig: Four (4) Tablet PO QHS (once a day (at bedtime)). 24. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Transdermal once a day. 25. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. 26. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for itching. Disp:*30 Tablet(s)* Refills:*0* 27. Home Oxygen Need supplemental oxygen 5L nasal cannula to maintain saturations 90-94%. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Asthma exacerbation Pneumonia NSTEMI . SECONDARY DIAGNOSES: Back pain Osteoporosis Discharge Condition: Stable. Discharge Instructions: You were admitted for shortness of breath and treated for pneumonia, asthma, and possible heart failure. Your new medications include: Lasix Metoprolol Aspirin Steroid taper . You will also need home oxygen and will receive home physical therapy and VNA services. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1085**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2159-4-25**] 12:00 Provider: [**Name Initial (NameIs) 10081**]/EXERCISE LAB Phone:[**Telephone/Fax (1) 1566**] Date/Time:[**2159-4-30**] 1:45 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1953**], [**Name12 (NameIs) 280**] Date/Time:[**2159-5-8**] 2:40 [**2159-5-10**] 12:30p [**Doctor Last Name **] AT [**Hospital1 18**] PULMONARY UNIT ([**Telephone/Fax (1) 513**] [**2159-5-10**] 10:30a PFT LAB AT [**Hospital1 18**] PULMONARY LAB ([**Telephone/Fax (1) 513**]

[ "724.5", "V10.43", "486", "799.02", "070.30", "599.0", "V08", "428.0", "493.22", "278.01", "070.70", "428.30", "733.00", "715.96" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14604, 14661

7409, 10535

353, 359

14788, 14798

2675, 7386

15110, 15746

2332, 2336

11668, 14581

14682, 14721

10561, 11645

14822, 15087

2351, 2656

14742, 14767

310, 315

387, 1377

1399, 2153

2169, 2316

2,657

175,039

47640+47641

Discharge summary

report+report

Admission Date: [**2169-5-13**] Discharge Date: Service: MEDICINE HISTORY OF THE PRESENT ILLNESS: This is a 79-year-old [**Year (4 digits) 595**] female who is non-English speaking who has a history of multiple medical problems including [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], CAD, breast cancer, who presents to the ED with abdominal pain, nausea, and vomiting. The patient has had this abdominal pain chronically for many months. It is a sharp pain. She has also had two episodes of vomiting. She denied blood in the vomit. She denied bloody stools or tarry black stools. The patient also describes chest pain, exertional, without any associated shortness of breath, nausea, vomiting, or diuresis. The pain the patient described in her stomach feels like her "ulcer pain" and like "constipation". Review of systems was positive for cough, weight loss of 25-35 pounds, night sweats, negative for fevers and chills and diarrhea. PAST MEDICAL HISTORY: 1. Status post CCY. 2. Status post appendectomy. 3. Sigmoid diverticulosis. 4. Hypertension. 5. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. 6. History of CVA. 7. History of breast cancer, status post lumpectomy, radiation, and Arimidex treatment with no negative dissection. 8. History of CAD. 9. History of choledocholithiasis. 10. Status post TAH/BSO. 11. Status post inguinal hernia repair. 12. Status post left arm fracture. 13. History of lung nodules. 14. Mild AS. EF 55%. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Clonidine patch 0.2 q. week. 2. Toprol XL 100 b.i.d. 3. Lotrel. 4. HCTZ 12.5 q.d. 5. Zoloft 100 q.d. 6. Arimidex 1 q.d. 7. Hydrea 500 four times a week. 8. Aciphex 20 b.i.d. 9. Compazine 10 q. six hours p.r.n. 10. Meclizine 12.5 q. eight p.r.n. 11. Ativan 1 q. six hours p.r.n. 12. Tylenol #3 p.o. q. six hours p.r.n. 13. Tylenol 500 mg p.o. q. six hours p.r.n. 14. Nitroglycerin 0.4 sublingual p.r.n. 15. Lactulose. 16. Metamucil. 17. Senna. 18. Sucralfate 1 gram q.i.d. 19. Plavix 75 q.d. 20. Fluoxetine. 21. Cipro. This medication list was compiled from the patient's doctor's office and may include some medications that the patient is not currently taking and by report of the patient's PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 100645**], the patient frequently does not take her medications. SOCIAL HISTORY: The patient lives with her husband. She is a nonsmoker, nondrinker. She has a son who lives in the area as well as a daughter in [**Name (NI) 531**]. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 95.6, heart rate 74, blood pressure 187/80, 94% on room air, respirations 19. General: She is a chronically ill cachectic, elderly female moaning. HEENT: The oropharynx was slightly erythematous. There were dry mucous membranes. Cardiovascular: Regular rate and rhythm. There was a II/VI systolic murmur in the left lower sternal border. Lungs: Decreased at the left bases, crackles bilaterally. Abdomen: Soft, nontender, hypoactive bowel sounds. No rebound tenderness. Guaiac negative brown stool. Extremities: No edema. Dorsalis pedis palpable. LABORATORY/RADIOLOGIC DATA: Significant for a white count of 14.8, hematocrit 53.5 which is elevated for her but the patient is chronically polycythemic from her [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], platelets 798,000, 89.5 neutrophils, 7 lymphs, 0 monos. Chem-7 was normal. The patient's initial CK was 21 and troponin less than 0.01. The patient's LFTs were normal and albumin was 4.8. The patient's U/A did not show evidence of a urinary tract infection. The patient's chest x-ray showed left midzone consolidation/collapse and a large left-sided pleural effusion which is new from previous x-rays but has been seen on x-rays here as recently as last year. An EKG was sinus with right bundle branch block. HOSPITAL COURSE: 1. ABNORMAL CHEST X-RAY: Given the patient's nonspecific complaints and lack of further information for the patient in the OMR secondary to a new MR number being assigned in the ER, the patient underwent a CT of the torso while in the ER. The CT demonstrated left upper lobe with a dense consolidation as well as a small opacity, 1.7 by 1.2 cm in the right upper lobe as well as a large left-sided pleural effusion and some small pretracheal nodes. Abdomen and pelvis were within normal limits. Given this new pleural effusion, the patient had a thoracentesis the night of admission which demonstrated an exudative effusion with 600 white cells, 54 lymphs, 5 polys, 9 mesothelials, 29 macrophages, and 15,000 reds. The Gram's stain was negative and the AFP was negative on direct smear. Given the concern for possible tuberculosis infection, the patient was placed on respiratory precautions the following day. However, the patient's story was much much more suspicious for a malignancy and indeed two days following admission the cytology for the pleural fluid was positive for adenocarcinoma, either metastatic from breast or new lung adenoma CA. The patient had two negative AFB sputums and a negative PPD and her respiratory precautions were discontinued. Oncology was consulted. At this time, they are awaiting further stains to determine whether it is metastatic or lung cancer as this will determine possibility of further (palliative) treatment. On chest x-ray following the thoracentesis, a small 10% apical pneumothorax was demonstrated. Interventional Pulmonary was consulted. They felt that the malignant effusion and pneumothorax warranted a pleurex catheter with pleuroscopy and possible pleurodesis. However, because the patient had been on Plavix, they would be unable to do it for five to seven days. They did a bronchoscopy with normal bronchi seen and no abnormalities on [**2169-5-18**]. The patient did have an oxygen requirement during her hospital stay. The patient was 88% on [**4-6**] liters after the revealing of the pneumothorax. The patient was placed on 100% nonrebreather. She was 100% on this. On room air, the patient was approximately 88% oxygen saturation without shortness of breath except on exertion. 2. CONGESTIVE HEART FAILURE: The patient, two days following admission, became acutely more short of breath. An ABG demonstrated respiratory acidosis and on examination, the patient sounded wet and she was then diuresed 2 liters with some improvement in her sats and symptoms. The patient was continued to be diuresed as her daily chest x-rays revealed worsening pulmonary edema, although no change in the apical pneumothorax. Her oxygen saturations remained 92-94% on [**4-6**] liters, 100% on 100% nonrebreather mask. The patient did undergo a bedside echocardiogram in the hospital which demonstrated diastolic dysfunction with a normal EF and moderate aortic stenosis. 3. ABDOMINAL PAIN: Outside records were obtained from [**Hospital 882**] Hospital which demonstrated that the patient had a recent EGD with duodenal ulcer. Her stools had been Guaiac negative. The patient was treated with Protonix and sucralfate and this appeared to improve her symptoms dramatically. 4. QUESTIONABLE PNEUMONIA: The patient did initially have a white count on admission but no fever. She was started on levo and Flagyl for a possible postobstructive pneumonia. Her white count decreased. She should be continued on the Levo and Flagyl for at least ten days and possibly until after the interventional pulmonary procedure is completed. 5. ACUTE RENAL FAILURE: The patient initially was in acute renal failure which was prerenal by electrolytes. She was given some IV fluids but secondary to CHF, the patient was encouraged to take p.o. Her creatinine did improve during her hospital course. 6. POLYCYTHEMIA [**Doctor First Name **]: The patient was continued on her Hydrea in-house. 7. CODE STATUS/END OF LIFE AND COMMUNICATION ISSUES: During initial family meeting with the patient and her husband, using a [**Name (NI) 595**] interpreter, the patient said that she did not want to be intubated or resuscitated. However, after calling the son to inform the whole family of the next cancer diagnosis, the son insisted that the patient not be told about her diagnosis. Ms. [**Known lastname 75607**] was directly questioned several times, and seemed equivocal about knowing the results of her tests. The patient also wanted to be at that time a full code. DISPOSITION: Due to the fact that the patient is on Plavix and it was discontinued on [**2169-5-18**], she will need five to seven day stay before Interventional Pulmonary can do the pleurodesis and pleuroscopy. Therefore, the patient will go to an acute rehabilitation facility and then return and at that time special stains that will diagnose the patient's cancer will be available and treatment options can be discussed as well as possible consultation with the Palliative Care Service. DISCHARGE DIAGNOSIS: Adenocarcinoma. CONDITION ON DISCHARGE: Serious. DISCHARGE MEDICATIONS: 1. Ceftriaxone 1 IV q. 24 hours. 2. Clonidine patch, one patch q. Saturday, 0.2. 3. Colace. 4. Subcutaneous heparin 5,000 q. eight. 5. Hydrea 500 q. Sunday, Tuesday, Thursday, and Saturday. 6. Flagyl 500 IV q. eight hours. 7. Lopressor 100 p.o. b.i.d. 8. Zyprexa 5 p.o. h.s. 9. Protonix 40 q.d. 10. Sucralfate 1 gram q.i.d. 11. Lasix 20 q.d. DISCHARGE FOLLOW-UP: The patient is to follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **] in the Interventional Pulmonary Clinic as well as Dr. [**Last Name (STitle) **] who follows her polycythemia [**Doctor First Name **] and Dr. [**Last Name (STitle) **] who has followed her for her breast cancer. Addendum: Ms. [**Name14 (STitle) **] was admitted under the MR# [**Medical Record Number 100646**]. However, upon further inspection, it appears that her true MR#[**Medical Record Number **]is [**Medical Record Number 100647**] ([**First Name8 (NamePattern2) **] [**Known lastname 75607**]). Medical records is currently investigating, and may need to merge the two records. The remainder of her hospital course will be dictated in an addendum. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Last Name (NamePattern1) 8141**] MEDQUIST36 D: [**2169-5-18**] 03:58 T: [**2169-5-18**] 16:02 JOB#: [**Job Number 100648**] Admission Date: [**2169-5-13**] Discharge Date: [**2169-6-2**] Service: ACOV ADDENDUM HOSPITAL COURSE: 1. Malignant pleural effusion and other pulmonary issues: Tentative treatment of the patient's malignant pleural effusion by pleurodesis was delayed secondary to the patient being on Plavix. She was finally taken to the operating room for a left sided VATS, chest tube placement, and tac pleurodesis on [**2169-5-25**]. She tolerated the actual procedure well but there was difficulty in extubating her. The patient remained in the post anesthesia care unit overnight with a prolonged intubated course complicated by bouts of hypotension and low urine output for which she received multiple intravenous fluid boluses. She was successfully extubated the following morning and returned to the floor. However, on the evening of the [**5-26**] she had an episode of desaturation to the 80s. She was placed on a nonrebreather and her O2 saturations responded to 95 percent. At the time she also elevated systolic blood pressure of 215 and an EKG with T wave inversions and ST depressions anteriorly in V1 through V3 which were new. The patient was given Lasix, Lopressor and Hydralazine all intravenous as well as Nitropaste and a central line was placed. She then became hypotensive likely in response to the aggressive blood pressure management, although her EKG changes did resolve with decreased blood pressure and was transferred to the [**Last Name (un) 100649**] Intensive Care Unit on a dopamine drip. She spent several days in the unit, was rapidly weaned off pressor support and weaned off O2 by face mask to nasal cannula. CT angiogram of the chest showed no evidence for pulmonary embolus. Chest x-ray and examination were consistent with some amount of pulmonary edema likely from the intravenous fluids she had received in the post anesthesia care unit for her hypotension. Additionally chest x-ray showed bilateral infiltrates consistent with mild ARDS secondary to the talc pleurodesis (the talc embolus syndrome which is a known side effect and complication of the procedure). The patient did well in the Intensive Care Unit and was called back out to the medicine floor on the [**5-28**]. Chest tube was discontinued on the 27th and the patient has continued to do well and her O2 requirement has decreased although her chest x-ray remains with bilateral infiltrates and pleural reaction to the talc pleurodesis. Final stains of the cytology cell blocks from patient's malignant pleural effusion were positive for cytokeratin 7, thyroid transcription factor 1 (TTS-1) and focally for cytokeratin 20. Additionally they were negative for GCBFP, ERN, PR and therefore more consistent with an adenocarcinoma of the lung primary despite the patient's history of breast cancer. She will follow up with Dr. [**First Name4 (NamePattern1) 16212**] [**Last Name (NamePattern1) **] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on the morning of discharge for further outpatient management. 2. Cardiovascular: When the patient acutely desaturated and became hypertensive on the evening of [**5-26**]. She had EKG changes anteriorly. She ruled out for a myocardial infarction and EKG changes resolved with control of her blood pressure and heart rate. It is felt that this is most likely secondary to demand ischemia. She is continued on her aspirin and beta blocker for her known coronary artery disease. 3. Blood pressure: The patient at baseline has hypertension. However, she had several episodes of hypotension during her stay in the post anesthesia care unit as well as briefly on the night of [**5-26**]. Therefore all of her hypertensive medicines were initially held while she was in the Intensive Care Unit on pressor support. However, her blood pressure has since returned to her elevated baseline and her metoprolol has been restarted and titrated upward so that she is now back on 100 p.o. b.i.d. Her Norvasc, hydrochlorothiazide and Clonidine patch are still being held. 4. Code status and social issues: The [**Hospital 228**] health care proxy is her son, [**Name (NI) 8096**] [**Name (NI) 75607**], home phone number [**Telephone/Fax (1) 100650**], cell phone number [**Telephone/Fax (1) 100651**]. During her hospitalization initially the team held a family meeting to speak with the patient, husband and son, [**Name (NI) 8096**] to inform the patient of her cancer diagnosis. However, before the patient could be so informed the son stopped the family meeting and he revealed that years ago when the patient was informed of her breast cancer diagnosis she became severely depressed for many months. Therefore, the family did not wish her to be informed of her cancer diagnosis. Multiple health care providers during the [**Hospital 228**] hospital stay spoke with the son about this point and he consistently insisted that the patient not be told about her diagnosis. With the presence of an interpreter, attending Dr. [**Last Name (STitle) **] and I spoke with the patient, asked her if she had any questions about any of the tests that were done while she was in the hospital. She indicated that she had no questions and when informed her that we had been speaking with her son and giving him all the information and allowing him to make all of the medical decisions she said, Yes indeed. That is how she wanted things to be. Therefore, the patient does not know that she has cancer. Additionally per the patient's wishes and her family's request, she is not to be informed that she has cancer. All medical decisions are being made by her son, [**Name (NI) 8096**] [**Name (NI) 75607**]. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and I spoke at length with her son about goals of care for the patient. He said that long term they hope to bring her home and hope to make her as comfortable as possible. Given this long term goal it was agreed that the patient would be DNR/DNI and that is now her code status. The son indicated that he would be open to further discussions about hospice services in the future. DISCHARGE CONDITION: Improved. Requires assistance with ambulance secondary to her prolonged hospital stay but her O2 sats are improving. DISCHARGE STATUS: To [**Hospital3 **] acute rehabilitation unit. DISCHARGE DIAGNOSES: 1. Adenocarcinoma, likely lung primary. 2. Malignant left pleural effusion, status post talc pleurodesis. 3. Hypertension. 4. Acute respiratory distress, resolved. 5. Hypotension, resolved. 6. Congestive heart failure, diastolic. 7. Talc embolus syndrome secondary to talc pleurodesis. 8. Duodenal ulcer. 9. Hypertensive emergency, resolved, with demand myocardial ischemia. 10. Polycythemia [**Doctor First Name **]. MAJOR SURGICAL OR INVASIVE PROCEDURES: 1. Bronchoscopy on [**2170-5-17**]. 2. Left lung VATS, chest tube placement (currently discontinued) and talc pleurodesis on [**2169-5-25**]. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. q day. 2. Hydroxyurea 500 mg p.o. Sunday, Tuesday, Thursday, Saturday. 3. Sucralfate 1 gram p.o. q.i.d. 4. Olanzapine 5 mg p.o. h.s. 5. Senna 1 tablet p.o. b.i.d. 6. Colace 100 mg p.o. b.i.d. 7. Plavix 75 mg p.o. q day. 8. Lovenox 40 mg subcutaneously q day. 9. Maalox p.r.n. 10. Percocet p.r.n. 11. Metoprolol 100 mg p.o. b.i.d. 12. Aspirin 325 mg p.o. q day. FOLLOW UP: 1. The patient is to follow up with her primary care physician one to two weeks after discharge from [**Hospital3 1761**]. 2. The patient is also to follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] as directed at her appointment on the morning of discharge. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Last Name (NamePattern1) 8978**] MEDQUIST36 D: [**2169-6-1**] 16:18 T: [**2169-6-1**] 16:39 JOB#: [**Job Number 100652**]

[ "518.5", "428.0", "512.8", "162.8", "428.30", "197.2", "238.4", "486", "584.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "34.92", "38.93", "34.21", "33.23", "34.91" ]

icd9pcs

[ [ [] ] ]

16631, 16817

16838, 17451

17474, 17871

9018, 9035

10572, 16609

1584, 2415

17882, 18441

2621, 3951

997, 1561

2432, 2606

9060, 9070

12,730

191,563

27186

Discharge summary

report

Admission Date: [**2114-11-14**] Discharge Date: [**2114-12-1**] Date of Birth: [**2060-2-22**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfur / Iodine Attending:[**First Name3 (LF) 5790**] Chief Complaint: Increased cough and wheezes Major Surgical or Invasive Procedure: [**2114-11-23**] Bronchoscopy, Right thoracotomy, Right lower lobe nodule Biopsy, Right Bronchoplasty [**2114-11-21**] Rigid Bronchoscopy with Stent Removal [**2114-11-19**] Flexible Bronchoscopy, Rigid bronchoscopy, Stent Placement History of Present Illness: Ms. [**Known lastname 56072**] is a 54-year-old woman who had previously undergone tracheoplasty and bilateral bronchoplasty with mesh on [**2113-6-23**] by Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**]. She represented recently with shortness of breath symptoms and was found to have severe recurrent bronchomalacia in the bronchus intermedius on the right. Placement of a bronchus intermedius silicone stent alleviated her symptoms markedly and because of this, she was considered for reoperation. Past Medical History: Tracheobronchomalacia s/p tracheobronoplasty with mesh [**6-/2113**] Recurrent Bronchomalacia Hypercholesterolemia Multiple sclerosis Urinary incontinence Tremors Postmenopausal Tonsillectomy Appendectomy Hysterectomy Social History: She works as a respiratory therapist in the past, currently on disability Lives with her husband Family History: non-contributory Physical Exam: General: 54 year-old well-appearing female in no acute distress HEENT: normocephalic, mucus membranes mosit Neck: supple no lymphadenopathy Card: regular, rate & rhythm, normal S1,S2 no murmur/gallop or rub Resp: decreased breath sounds --- GI: bowel sounds positive, abdomen soft non-tender/non-distended Extre: warm no edema Wound: clean, dry intact Neuro: non-focal Pertinent Results: [**2114-11-25**] WBC-16.3* RBC-3.68* Hgb-11.3* Hct-32.3* Plt Ct-233 [**2114-11-25**] Glucose-86 UreaN-13 Creat-0.8 Na-135 K-4.1 Cl-98 HCO3-26 Pathology Examination: SPECIMEN SUBMITTED: FS Right Lower Lobe Nodule. DIAGNOSIS: Lung, right lower lobe: Lung parenchyma with subpleural fibrosis, focal alveolar lining reactive changes, and scar. Clinical: Tracheal bronchomalacia. Brief Hospital Course: Mrs. [**Known lastname 56072**] was admitted on [**2114-11-14**] with increased shortness of breath and cough and underwent a flex bronchoscopy which revealed recurrent severe distal tracheobronchomalacia. Pulmonary was consulted and recommenced increasing her Nexium to 40 mg [**Hospital1 **] and Flovent and Serevent. GI was consulted and recommended aggressive reflux management. On HD #2 her cough and wheezes persisted and she was started on pulse steroids. ENT was consulted to assess her vocal cords which was normal. Her symptoms improved slightly and underwent a rigid bronchoscopy and silicone stent placement on HD #6. Her respiratory status continued to improved and the stent was removed on HD#8. On HD #9 ([**2114-11-23**]) she underwent successful Redo right thoracotomy, Removal of previous bronchoplasty Marlex mesh, Suture bronchoplasty of the right bronchus intermedius, coverage with a pleural flap buttress, flexible bronchoscopy and right lower lobe wedge resection. Post-operative pain was controlled with an epidural catheter which was later switched to a PCA. Two chest tubes were placed intraoperatively. Pt was extubated [**11-23**] and remained in the ICU post-operatively and was oxygenating well with a face mask. Pt was advanced to a regular diet on [**11-25**], was transferred out of the ICU to a regular floor bed, the chest tube was removed and the chest [**Doctor Last Name 406**] drain was placed to bulb suction. During the night of [**11-22**] pt had a decreased respiratory rate and oxygenation due to over narcotization and was given Narcan, supplemental O2, and a nebulizer with good effect. On [**11-26**] the pt underwent a flexible bronchoscopy which showed normal clearing airways. Pt was switched to oral pain medication on [**11-27**], supplemental oxygen was weaned, [**Doctor Last Name 406**] drain was removed, and central venous line was removed. peri-operative Levofloxacin and Vancomycin were completed on [**11-30**]. Pt was discharged on [**12-1**] tolerating a regular diet, pain well controlled with oral medication, and ambulating without assistance. Medications on Admission: -Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). -Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). -Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). -Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). -Cymbalta 1tab QHS -Betaseron 1cc QOD -Ambien CR PRN QHS -Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. -B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). -Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). -Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). -Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). -Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). -Ditropan XL 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. -Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID -30 MIN BEFORE B-FAST AND DINNER (). -Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for asthma. - Potassium 90mg. Two QAM - ASA 81 QDay Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). 2. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 10. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 11. Ditropan XL 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID -30 MIN BEFORE B-FAST AND DINNER (). 13. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for asthma. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day. 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 17. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for asthma: [**12-1**]: 2 tabs (10mg) [**12-2**]: 1 tab (5mg) [**12-3**]: 1 tab (5mg). Disp:*4 Tablet(s)* Refills:*0* 18. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 19. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:*60 Tablet(s)* Refills:*0* 20. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Tracheobronchomalacia s/p tracheobronoplasty with mesh Hypercholesterolemia Multiple sclerosis Urinary incontinence Tremors Postmenopausal Tonsillectomy Appendectomy Hysterectomy Discharge Condition: Good Discharge Instructions: Call Dr.[**Name (NI) 2347**] office if experience while here in [**Location (un) 86**] -Fever >101 or chills -Increased shortness of breath, cough or sputum production -Chest pain -Incision develops drainage Chest-tube site cover with a bandaid. Should site begin to drain cover with a clean dressing and change as needed to keep site clean and dry. No driving while taking narcotics No bathing or swimming for 6 weeks Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **]. Please call [**Telephone/Fax (1) 170**] to schedule a follow-up appointment Follow-up with your pulmonologist in [**State **]

[ "515", "340", "519.19", "493.90", "401.9", "530.81", "272.0", "333.1", "788.30" ]

icd9cm

[ [ [] ] ]

[ "98.15", "33.48", "34.03", "33.23", "96.05", "32.29", "33.22" ]

icd9pcs

[ [ [] ] ]

7607, 7613

2325, 4440

325, 560

7836, 7843

1922, 2302

8311, 8486

1493, 1511

5699, 7584

7634, 7815

4466, 5676

7867, 8288

1526, 1903

258, 287

588, 1120

1142, 1362

1378, 1477

22,460

172,937

53545

Discharge summary

report

Admission Date: [**2100-7-9**] Discharge Date: [**2100-7-18**] Date of Birth: [**2043-4-8**] Sex: F Service: Surgery, Gold Team HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 57-year-old white married female who was referred to Dr. [**Last Name (STitle) 1305**] by Dr. [**First Name4 (NamePattern1) 2127**] [**Last Name (NamePattern1) 10113**] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for colonic inertia. Ms. [**Known lastname **] has had collagenous colitis many years ago, but this has evolved into a colonic inertia. She has had constipation now for the past eight years, and it has been treated with a variety of agents without success. It has been increasing recently, and within the last she notes severe bloating and pain which is often followed by decompression with passage of a large amount of liquid stool. She has had workups with barium enemas and colonoscopy which have revealed multiple retained pills and fecal material, but no other visible abnormalities. She is managing this with magnesium citrate as well as Milk of Magnesia. Because of these symptoms she has undergone an extensive workup including rectal manometry which showed slightly elevated rectal pressures but with reasonable relaxations. She is to undergo a gastric emptying study, and then the plan is to be admitted for a colonic resection. Ms. [**Known lastname **] was admitted to the hospital on [**2100-5-23**] through [**2100-5-25**], for the chief complaint of constipation. She had a rectal tube placed at that time where a large amount of stool was released, and her symptoms continued to resolve over the next two days, and she was discharged to home to follow up with Dr. [**First Name (STitle) 10113**] to consider a subtotal colectomy with Dr. [**Last Name (STitle) 1305**]. PAST MEDICAL HISTORY: (Her past medical history is significant for) 1. Collagenous colitis. 2. Chronic constipation. 3. Uterine fibroids. 4. Osteoporosis. 5. History of alcohol abuse. 6. Anxiety and depression. 7. Status post tonsillectomy. 8. A history of multiple personality disorders. ALLERGIES: Allergies are ASPIRIN, NONSTEROIDAL ANTIINFLAMMATORY DRUGS, and ROWASA. MEDICATIONS ON ADMISSION: Her medications on admission were Colace 100 mg p.o. b.i.d., BuSpar 10 mg p.o. b.i.d., Prozac 100 mg p.o. q.d., Milk of Magnesia p.r.n., magnesium citrate p.r.n., Estrogen 1 mg p.o. q.d., and progesterone 2.5 mg p.o. q.d. PHYSICAL EXAMINATION ON ADMISSION: This is a thin woman with a blood pressure of 107/70, and a pulse of 70 which was regular. Examination of the head, ears, nose, eyes and throat, neck, chest, lungs, abdomen, and extremities was totally unremarkable. Rectal examination revealed no masses. There was a totally empty vault but some slightly decreased sphincter tone. PERTINENT LABORATORY DATA ON ADMISSION: A complete blood count preoperatively was white blood cell count 7.7, hematocrit of 47, platelets of 78. Sodium was 138, potassium was 4.1, chloride 108, bicarbonate 15, BUN was 4, and creatinine was 0.6. PT was 18.6, with an INR of 2.3, and PTT was 37.6. HOSPITAL COURSE: Ms. [**Known lastname **] was admitted on [**2100-7-9**], for a subtotal colectomy with an ileorectal anastomosis for her colonic inertia. Her surgery went uneventfully. However, in the recovery room approximately five hours later, it was found that she was tachycardic and looking pale with an increasing rigid abdomen and a quite tender abdomen. She was therefore taken back to the operating room at approximately 6:30 on [**7-9**] for a re-examination. Nearly 2 liters of blood were removed from the abdominal cavity; however, there were no active bleeding sites found. All of the remaining areas that had been dissected during the surgery were religated to prevent further bleeding. Approximately 3 units of packed red blood cells were transfused during the operation. Postoperatively, Ms. [**Known lastname **] went to the Intensive Care Unit for evaluation and close monitoring where she was stable on postoperative day zero and postoperative day one. Her hematocrit on admission to the Intensive Care Unit was initially 38.5, but serial hematocrits taken over on postoperative day one were 37, 38, 35, 33, 31.7, and 30.7 which was on hospital day two (on [**7-11**]). Her abdominal examination continued to be soft and nondistended but with discomfort. She was deemed to be hemodynamically stable by postoperative day three and was transferred to the floor with continued following of her serial hematocrits. By postoperative day three, her hematocrit had stabilized with serial hematocrits of 29, 28, and then 30.5, and 29.6. The Foley was discontinued on this day, and she continued to be n.p.o. She had an uneventful recovery on the floor through postoperative day four to eight except for a slightly slow recovery of bowel function. On postoperative day five, she continued to have pain control; however, a n.p.o. status due to no bowel function. On postoperative day seven, the pain was well controlled and Ms. [**Known lastname **] began to pass flatus and water guaiac-negative stools. She was therefore advanced to a clear liquid diet which she tolerated nicely. On [**2100-7-17**], her diet was advanced to fulls and then a regular diet which she tolerated well. She continued to have liquid bowel movements which were becoming more and more solid. Ms. [**Known lastname **] was quite satisfied with her progress, and she was cleared for discharge on [**2100-7-18**] without complaints. The pathology on the ileocolonic section that was sent showed a grossly normal section of large bowel. This was also histologically normal with many normal ganglion cells and neuronal plexus mucosa and submucosa intact. CONDITION AT DISCHARGE: Her condition on discharge was stable. DISCHARGE STATUS: Her discharge status was that she was to be discharged to home with her father. DISCHARGE DIAGNOSES: Status post ileocolonic subtotal resection for colonic inertia. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg p.o. b.i.d. 2. BuSpar 10 mg p.o. b.i.d. 3. Prozac 100 mg p.o. q.d. 4. Milk of Magnesia p.r.n. 5. Magnesium citrate p.r.n. 6. Estrogen 1 mg p.o. q.d. 7. Progesterone 2.5 mg p.o. q.d. 8. Percocet p.r.n. 9. Zantac 150 mg p.o. b.i.d. DISCHARGE FOLLOWUP: Her discharge followup should be to follow up with Dr. [**Last Name (STitle) 1305**] on an as needed basis with any questions or concerns. She should also follow up with Dr. [**First Name (STitle) 10113**] in two to three weeks to re-evaluate function status post ileocolectomy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1306**], M.D. [**MD Number(1) 1307**] Dictated By:[**Last Name (NamePattern1) 110055**] MEDQUIST36 D: [**2100-7-18**] 11:07 T: [**2100-7-24**] 09:09 JOB#: [**Job Number 22536**]

[ "311", "276.5", "560.1", "300.00", "300.14", "997.4", "998.11", "285.1", "564.89" ]

icd9cm

[ [ [] ] ]

[ "45.93", "45.79", "54.19" ]

icd9pcs

[ [ [] ] ]

5997, 6062

6088, 6345

2254, 2498

3165, 5818

5833, 5974

6366, 6937

174, 1841

2888, 3147

1864, 2227

81,157

150,405

41312

Discharge summary

report

Admission Date: [**2109-5-28**] Discharge Date: [**2109-6-11**] Date of Birth: [**2041-12-10**] Sex: F Service: CARDIOTHORACIC Allergies: Latex / Artificial Sweeteners Attending:[**First Name3 (LF) 5790**] Chief Complaint: Dypsnea Major Surgical or Invasive Procedure: bronchoscopy with stent removal and dilation to 12mm bronchoscopy with long metallic stent placement History of Present Illness: History of Present Illness: 67F w/ myasthenia [**Last Name (un) 2902**] and post-intubation tracheal stenosis s/p stenting [**4-23**], presenting from interventional pulmonary clinic with worsening dyspnea and stridor. . In [**Month (only) 958**]-[**2109-3-8**] she was at [**Hospital 1562**] Hospital with MG crisis requiring prolonged intubation and plasma exchange. She was transferred to the [**Hospital1 18**] [**Date range (1) 89937**] when she was diagnosed with post-intubation tracheal stenosis. This was a contact stenosis, and ideally she would have gotten tracheal reconstruction from thoracic surgery. However she was not a good candidate (on steroids), so she got a balloon dilation with improvement in symptoms. On [**4-23**], she got a stent for stridor. In pulmonary clinic today, for scheduled follow-up, had audible stridor and noted to be dyspneic with mild activity. . On the floor, she states that her dyspnea has been progressive since leaving the hospital, particularly over the past week with coughing fits. Denies sputum, fevers or sick contacts to me. She states her dyspnea is at its worst when supine and with minimtal exertion of 20ft. States that her audible stridor has also been worse over the past week. . Review of systems: (+) Per HPI, urinary incontince X 2 months since hospitalization, no dysuria, malodor (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - tracheal stenosis - Myasthenia [**Last Name (un) **] - diagnosed about 3 years ago with body weakness, diplopia, dysarthria, has only been on Mestinon 60 mg QID - DM - HTN - HLD - Glaucoma - Cataracts Social History: Lives at home with a husband but she indicated that their relationship was strained. She is a long term smoker, smoked 1PPD for 50 years, has cut down to 1/4 pack over last few years. No etoh, no drugs Family History: No family history of MG or other neurological diseases. Some DM in the family. Physical Exam: Discharge exam Vitals: 97.8, 76 SR, 110/61, 17, 93 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally 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 Incision: cervical incision clean, margins well approximated, no erythema Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: awake, alert, oriented, walks independently Pertinent Results: Admission Labs: ================= [**2109-5-28**] GLUCOSE-130* UREA N-19 CREAT-0.7 SODIUM-142 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-30 ANION GAP-10 [**2109-5-28**] ALT(SGPT)-20 AST(SGOT)-13 [**2109-5-28**] CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-2.1 [**2109-5-28**] WBC-10.0 RBC-4.01* HGB-12.2 HCT-37.4 MCV-93 MCH-30.3 MCHC-32.6 RDW-14.6 PLT COUNT-262 [**2109-5-28**] PT-11.4 PTT-24.1 INR(PT)-0.9 Discharge Labs: [**2109-6-6**] WBC-9.2 RBC-3.40* Hgb-10.8* Hct-32.0* MCV-94 MCH-31.7 MCHC-33.7 RDW-14.3 Plt Ct-307 [**2109-6-6**] Glucose-178* UreaN-15 Creat-0.5 Na-140 K-3.6 Cl-104 HCO3-28 [**2109-6-6**] Calcium-8.5 Phos-3.3 Mg-1.9 Micro: MRSA screen negative Interventions/Radiographs: ========================== CXR [**2109-6-9**] Appearance of the trachea is unchanged since the prior chest x-ray of [**Month (only) **] the 30th. The lungs appear clear. Cardiac size is normal. There is no failure. [**5-28**] PORTABLE FRONTAL CHEST RADIOGRAPH: Small apical nodules and pleural thickening is identified, findings consistent with prior granulomatous disease. There is no focal consolidation or pneumothorax. There is no vascular congestion or pleural effusions. Cardiomediastinal and hilar contours are within normal limits. Evaluation of the trachea is limited on this single frontal chest radiograph. IMPRESSION: No acute cardiopulmonary process or evidence of pneumonia. CXR [**5-29**] FINDINGS: In comparison with study of [**5-28**], there is no interval change. Again there is mild hyperexpansion of the lungs but no acute focal pneumonia or pneumothorax. Brief Hospital Course: 67F w/ myasthenia [**Last Name (un) 2902**] and post-intubation tracheal stenosis s/p stenting [**4-23**], presenting from interventional pulmonary clinic with worsening dyspnea and stridor, admitted to the MICU for respiratory failure. Patient's breathing improved. On [**2109-5-29**], patient taken to OR for bronchoscopy, stent removal, and balloon dilation. Patient returned to MICU with stable vital signs. Stridor and respiratory distress recurred, stabilized with heliox. Patient was taken back to OR the same day, underwent second bronchoscopy and was re stented with long metallic stent and re-dilated to 12 mm. Observed in MICU for a day and transferred to Medicine [**Hospital1 **] for further monitoring in anticipation of tracheal reconstruction with Thoracic Surgery. . # Tracheal stenosis with stridor: Stenosis was result of prolonged intubation in during previous hospitalization in [**Month (only) 958**]-[**2109-3-8**] for myasthenia [**Last Name (un) 2902**]. The decompensation had to do with migration of the stent-tube. She underwent bronchoscopy with removal of the stent. She decompensated and was placed on heliox. She underwent a second bronchoscopy with placement of a longer stent as a bridge to definitive tracheal reconstruction by thoracic surgery. In order to undergo surgery, her prednisone was tapered down to 10mg daily. Observed in MICU for a day and transferred to Medicine [**Hospital1 **] for further monitoring in anticipation of tracheal reconstruction with Thoracic Surgery. On the floor, after a maneuvering herself for a shower, patient suddenly felt short of breath. O2 sat remained in the mid-high 90s, however patient felt anxious, diaphoretic, and SOB and so was transferred to the MICU for observation until going to the OR for her tracheal reconstruction 36 hours later. Procedure was uneventful, area of stenosis was resected, trachea was anastomosed, and patient was transferred to the SICU post-op. She passed a bedside swallow evaluation on post operative day two and had her diet advanced slowly. By post operative day 2 she was returned to the regular floor and had her JP drain at the surgical site removed. On the floor her head was kept in bolsters except when she was up and out of bed walking. On [**2109-6-11**] she had a bronchoscopy to evaluate the anastomosis that showed wide patency of the anastomosis, and the anastomosis looked completely intact. She respiratory status improved she continued to make steady progress. . # myasthenia [**Last Name (un) 2902**]: Currently on prednisone taper which has precluded surgery in the recent past; prednisone was decreased as above to make surgery possible. Also continued CellCept and pyridostigmine bromide. Bactrim for PCP [**Name Initial (PRE) **]. She was given stress dose of hydrocortisone during her operation and returned to her pre-op dose of prednisone on post operative day 2. This is off her current steroid taper but endocrine service stated that she is OK to continue on prednisone 10mg daily after surgery if she is asymptomatic, which she has been. . # DM: Insulin sliding scale while in house. Of note, she has anaphylaxis in response to artificial sweeteners. Her insulin sliding scale had to be adjusted because of her Hydrocort stress dose and return to prednisone. Once taking PO her home dose Metformin was restarted and insulin sliding scale to maintain blood sugars < 150. . # HTN: Continued home losartan. # HLD: continued home statin . # GERD - PPI started for prophylaxis while on steroids # glaucoma - home latanoprost Disposition: she was discharged to home on [**2109-6-11**] with her husband. She will follow-up with Dr. [**Last Name (STitle) **] and her neurologist as an outpatient. Medications on Admission: Medications (confirmed with patient) patient unsure if takes pantoprazole or omeprazole 1. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): 40 mg until [**5-1**]; 30 mg until [**5-15**]; 25 mg until [**5-22**]; 20 mg until [**5-29**]; 17.5 mg until [**6-5**]; 15 mg until until [**6-12**]; 12.5 mg until [**6-19**]; 10 mg until [**6-26**] . 3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. pyridostigmine bromide 60 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 5. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 11. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 12. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 13. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 14. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 16. latanoprost 0.005 % Drops Sig: One (1) drop Ophthalmic at bedtime. 17. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day. 18. Mucinex Discharge Medications: 1. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. pyridostigmine bromide 60 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 3. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*70 Tablet(s)* Refills:*0* 8. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. pantoprazole 20 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* 11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 12. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Mucinex 1,200 mg Tablet, ER Multiphase 12 hr Sig: One (1) Tablet, ER Multiphase 12 hr PO every twelve (12) hours. 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Post intubation cervical tracheal stenosis. Myasthenia [**Last Name (un) 2902**] Hypertension Hyperlipidemia Emphysema Insulin dependent diabetes mellitus Glaucoma, Cataract Migraine Stress incontinence Jaw surgery [**2077**] 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, chest pain or stridor -Neck incision develops drainage Pain -Acetaminophen 650 every 6-8 hours as needed for pain -Oxycodone [**4-16**] every 4-6 hours as needed for pain Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tubs until incision healed -Walk frequently as tolerated Medications-Continue home medications. -Check blood sugars and increase Metformin 500 to 3 times a day if they are continuously elevated -Prednisone 10 mg daily. Please follow-up with Dr. [**Last Name (STitle) 37393**] for further steroid instructions. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 89938**] on [**2109-6-25**] at 10:30 in the [**Hospital Ward Name 517**] [**Hospital **] Clinic: [**Hospital **] CLINIC [**Hospital1 **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **] Chest X-Ray [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology 30 minutes before your appointment Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2109-8-23**] 10:30 [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center Completed by:[**2109-6-11**]

[ "E878.1", "519.19", "358.00", "996.59", "272.4", "V58.65", "401.9", "250.00", "305.1", "491.21" ]

icd9cm

[ [ [] ] ]

[ "33.23", "31.79", "31.99", "96.05" ]

icd9pcs

[ [ [] ] ]

11342, 11348

4899, 8635

305, 407

11618, 11618

3311, 3311

12535, 13179

2594, 2676

10067, 11319

11369, 11597

8661, 10044

11769, 12512

3720, 4876

2691, 3292

1695, 2130

258, 267

463, 1676

3327, 3704

11633, 11745

2152, 2357

2373, 2578

48,327

189,985

5921

Discharge summary

report

Admission Date: [**2184-11-14**] Discharge Date: [**2184-11-24**] Date of Birth: [**2126-5-8**] Sex: F Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 832**] Chief Complaint: Fall Major Surgical or Invasive Procedure: none History of Present Illness: This is a 58 year old female s/p witnessed fall down 8 wooden stairs today at approximately 1230. Had a 4min LOC. When EMS arrived she was A&0x3 and was brought into [**Hospital1 18**] for further evaluation. While in the CT Scanner here she vomited x1 while supine, and soon after developed altered mental status. She was subsequently intubated. CT demonstrated diffuse SAH. The patient is currently intubated and sedated. Past Medical History: ++ Diabetes mellitus, type 1 - history of insulin pump, but d/c since transplant [**10/2182**] ++ Renal transplant, living related donor (brother) - [**2163**], secondary to diabetic renal dz ++ Pancreatic trasnplant - [**2182-10-22**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] - Fluconazole, Unasyn peri- and pre-operatively - tapered steroids to prednisone; Cellcept+Prograf ++ Hypertension ++ Hypercholesterolemia ++ Hypothyroidism ++ Squamous cell Ca - RLE, excised ~ 2 years PTA ++ Chronic foot ulcers - h/o multiple surgeries and antibiotic courses for Charcot foot - last hospitalization [**7-/2180**] ++ bilateral fibroadenomas of breast, excised ++ Endometrial biopsy ++ h/o vitrectomies, laser surgery, cataract surgery bilat eyes Social History: Lives in [**Location 2312**] with daughter, and sister and sister's children in same house. Functional with basic and most advanced ADLs. Works as a special needs teacher. Denies any history of tobacco, alcohol, tobacco use. Family History: 2 brothers with diabetes. Mother - died at 86yrs of old age Father - died at 76yrs, had Parkinson's dz Physical Exam: PHYSICAL EXAM: O: T:96.4 BP: 186/82 HR:86 R: 18 O2Sats 97t Gen: intubated/sedated HEENT: NC, laceration to R parietal area Pupils: Surgical, non reactive EOMs n/a Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Intubated. Off sedation, grimaces and opens eyes to nox. Cranial Nerves: I: Not tested II: Pupils surgical III, IV, VI: n/a V, VII: n/a VIII: n/a IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: n/a XII: n/a Discharge Exam (Pertinent Positives) Neuro: Alert and Oriented x 3. Patient is interactive, with appropriate attention. Strength: UE: [**4-21**] symmetric, LE R: [**4-21**], L Hip flexor/Extensor [**4-21**]. L thigh Flexor/Extensor 0/5, L plantar dorisflexion/plantar flexion 0/5. Sensation intact bilaterallly. Pertinent Results: Admission: [**2184-11-14**] 01:00PM BLOOD WBC-15.4*# RBC-4.22 Hgb-12.5 Hct-37.4 MCV-89 MCH-29.6 MCHC-33.4 RDW-14.5 Plt Ct-385 [**2184-11-14**] 01:00PM BLOOD Neuts-39.6* Lymphs-51.6* Monos-2.9 Eos-4.6* Baso-1.4 [**2184-11-14**] 01:00PM BLOOD PT-11.7 PTT-22.7 INR(PT)-1.0 [**2184-11-14**] 01:00PM BLOOD Glucose-114* UreaN-36* Creat-1.3* Na-136 K-4.5 Cl-102 HCO3-28 AnGap-11 [**2184-11-14**] 01:00PM BLOOD ALT-24 AST-35 LD(LDH)-189 AlkPhos-173* TotBili-0.2 [**2184-11-14**] 01:00PM BLOOD cTropnT-<0.01 [**2184-11-15**] 02:26AM BLOOD Calcium-8.2* Phos-3.6 Mg-1.8 [**2184-11-15**] 04:51AM BLOOD tacroFK-3.6* [**2184-11-14**] 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2184-11-14**] 04:36PM BLOOD Type-ART pO2-428* pCO2-38 pH-7.44 calTCO2-27 Base XS-2 [**2184-11-14**] 01:13PM BLOOD Glucose-116* Lactate-1.7 K-4.6 Discharge: [**2184-11-24**] 06:25AM BLOOD WBC-11.9* RBC-3.41* Hgb-10.0* Hct-30.4* MCV-89 MCH-29.5 MCHC-33.1 RDW-14.6 Plt Ct-416 [**2184-11-18**] 03:47AM BLOOD Neuts-61.2 Lymphs-33.2 Monos-4.6 Eos-0.3 Baso-0.6 [**2184-11-24**] 06:25AM BLOOD Plt Ct-416 [**2184-11-17**] 12:44PM BLOOD CK(CPK)-63 [**2184-11-17**] 12:44PM BLOOD CK-MB-4 cTropnT-0.12* [**2184-11-24**] 06:25AM BLOOD Calcium-9.5 Phos-2.1* Mg-2.1 [**2184-11-17**] 02:36AM BLOOD Lactate-1.3 . [**11-14**] CT head: IMPRESSION: Small intraparenchymal hemorrhage within the right frontal lobe with subarachnoid hemorrhage in the frontal lobes bilaterally and right temporal lobe. Vascular calcifications- correlate for risk factors. Dense focus in the left ocular lens- correlate with history and examn. . [**11-14**] CT Cspine: IMPRESSION: No fracture. Alignment maintained. Small lucencies in the cervicalv ertebrae- may relate to cysts/ fat depostis. Correlate with any h/o primary malignancy. If there si continued concern for cord, ligamentous/neural injury, MR can be considered if not CI> Minimal mucosal thickening/fluid in the mastoid air cells on both sides. Small calcified focus in the right pretracheal region-? node/ exophytic thyroid nodule. . [**11-14**] CT Torso: IMPRESSION: 1. Bilateral atelectasis but no evidence of significant aspiration or pneumonia. No pneumothorax. 2. Within the limitations of a non-contrast study, no evidence of acute abdominal or pelvic traumatic process. 3 Right adnexal cyst which is stable in size since at least [**2181**]. . [**11-14**] CT Head: 1. Stable right frontal parenchymal hemorrhage with subarachnoid hemorrhage in bilateral frontal lobes. Subarachnoid hemorrhage in the right temporal lobe area is not clearly visualized on this study. 2. Hyperdensity within the sulcus at the left frontal vertex may represent artifact; however, could represent a small focus of hemorrhage. . [**11-15**] CT head: 1. Significant clearance of the predominantly subarachnoid hemorrhage with persistent hyperdensity in the frontal lobes bilaterally and along the falx, which may represent a combination of subdural and subarachnoid blood. 2. No evidence for new hemorrhage. 3. Prominence of the subdural space along the right frontal lobe, increased compared to prior; therefore, this may represent a developing right frontal subdural hygroma. 4. Central and cortical atrophy, predominantly frontal. . IMPRESSION: AP chest compared to [**11-15**]: Mild-to-moderate pulmonary edema is new. Mild cardiomegaly is stable. Mediastinal vascular distention has increased indicating biventricular cardiac decompensation and/or volume overload. Small left pleural effusion is presumed. Dr. [**Last Name (STitle) 23354**] [**Name (STitle) 23355**] was paged. . ECHO The left atrium and right atrium are normal in cavity size. A small secundum atrial septal defect is present. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Doppler parameters are indeterminate for left ventricular diastolic function. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. 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. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric LVH with hyperdynamic LV systolic dysfunction. Positive bubble study consistent with small ASD/stretched PFO. Indeterminate indices for diastolic function assessment. Compared with the prior study (images reviewed) of [**2184-5-7**], bubble study reveals a likely ASD/stretched PFO. . Portable CXR: HISTORY: Possible volume overload. FINDINGS: In comparison with the study of [**11-16**], there are lower lung volumes. There is some continued engorgement of pulmonary vessels, consistent with volume overload. Bilateral pleural effusions with bibasilar compressive atelectasis is seen. Widening of the vascular pedicle is again noted. . RIGHT FOOT, THREE VIEWS, [**2184-11-17**] AT 15:08 HOURS. HISTORY: Recent pinning operation. COMPARISON: Multiple priors, the most recent dated [**2184-11-14**]. FINDINGS: There is a dressing over the entirety of the foot. There has been prior transmetatarsal amputation of the fourth and fifth digits. There has also been segmental osteotomies involving the second and third metatarsals. These changes are markedly chronic and stable. There are longitudinal K-pins through the first ray, extending through a truncated distal phalanx and traversing the interphalangeal joint as well as the first metacarpophalangeal joint. Extensive bony hypertrophy of the first metatarsal is again present and markedly stable. Overall, the alignment has not changed across multiple prior examinations. There is no radiographic evidence of loosening or other hardware compromise. A thin linear metal foreign body again projects within the plantar soft tissues of the foot. . IMPRESSION: Markedly stable appearance of the foot. The longitudinal K-pins in the first ray are stable in position and course. . [**2184-11-18**]: LE US: IMPRESSION: No evidence of deep vein thrombosis in either leg. . MRI/MRA Neck/Brain IMPRESSION: 1. A somewhat linear-appearing focus of abnormally slow diffusion in the white matter of the right frontal lobe, subjacent to the known intraparenchymal hematoma. This could represent an acute lacunar infarct, or extension of the blood products. 2. Some residual subarachnoid blood noted within the sulci of the left frontal lobe. Stable bilateral subdural effusions along the convexities. 3. MRA demonstrating moderate narrowing of the cavernous internal carotid arteries, right greater than left, as well as mild irregularity of the proximal MCA branches bilaterally, all suggestive of atherosclerosis. 4. Normal MRA of the neck. The study and the report were reviewed by the staff radiologist . Portable CXR [**2184-11-22**]: HISTORY: Aspiration and fever, to assess for worsening pneumonia. . FINDINGS: In comparison with study of [**11-19**], the PICC line appears to have been pulled back to the axillary region, outside of the hemithorax. There is some increased sharpness of the hemidiaphragm, suggesting decreasing pleural effusion and atelectasis at the left base. . Micro: UC: NG -> Final BC: NGTD (two pending), Remainder NG -> final Brief Hospital Course: 58 yo woman with h/o Type I DM s/p pancreas transplant who had a recent surgery of right toe, which needed pinning. After surgery, fell and hit her head after falling down 8 stairs. Found to have bilateral SAH in the frontal lobes on CT. During the CT she aspirated and has had altered MS since then. She required intubation and sedation in the ED, given her AMS. Neurosurg evaluated her and did not feel her SAH required drainage. . On [**11-14**], after intubation and sedation she was admitted to the SICU for monitoring. She was started on dilantin for seizure prophylaxis. Repeat head CT on [**11-15**] showed significant clearance of the subarachnoid hemorrhage with persistent hyperdensity in the frontal lobes bilaterally and along the falx. No further hemorrhage was seen. No evacuation was performed. She was extubated on [**11-15**]. At that time she was having trouble moving her L arm and L Leg, but was able to wiggle her fingers and toes on that side. Neurosurgery felt that this weakness was not related to her SAH as the sx would not be explained by the location of the bleed. . Nephrology was consulted given transplant history and tacrolimus, and they recommended daily tacrolimus levels, especially in the setting of concomitant dilantin therapy, which increases metabolism of tacrolimus. An increased dose of tacro was recommended (4 mg suspension [**Hospital1 **]) with target tacro levels of [**5-25**]. . Between [**11-15**] and [**11-16**] she has had a worsening leukocytosis with white count rising to 22. On the night of [**11-15**] she had a desaturation event to high 80s on 5 L O2; she briefly required a face mask, after which her saturations improved to mid-high 90s. Low grade temperatures overnight to 100.3. Chest x-ray done this morning showed an infiltrate in left lower lobe, assumed to be aspiration PNA. She was transferred to the medical service for management of her presumed aspiration pneumonia. . On the medical floor the patient was treated with Vanc, Unasyn, and Levofloxacin for aspiration pneumonia. On the evening of [**11-16**] the patient became increasingly tachypneic and oxygen requirement increased to 5 liters with oxygen saturation in the mid 90s. CXR bilateral infiltrate concerning for volume overload versus ARDS. Pt given nebs, broadened to Vanc, Zosyn, and given 20mg IV lasix x2. Patient was transferred to the MICU. . In the MICU she was diuresed and converted to Unasyn for her aspiration PNA. Neurology was consulted for decreased movement on her L side. She also had an ECHO which demonstrated a PFO. Of note, her hypoxic respiratory failure improved and she was transferred to the floor. She underwent an MRI/MRA of the neck to evaluate for extension of SAH vs ischemic stroke. The MRI/MRA demonstrated extension vs new slow bleed. Clinically, however, she continued to improve and started to move her L arm and Leg. She was maintained on Unasyn and transferred to the floor for further evaluation. . Upon arrival to the floor she was hemodynamically stable, and afebrile. She had no respiratory distress and was noted to be moving her left arm, and her left hip, but not her left leg. She was evaluated by podiatry who removed her bandage and noted that the pins were in place. On the morning of [**2184-11-22**] she spiked a fever to 101. She had a portable CXR which showed a midline intravenous catheter, but no acute intra-pulmonary process. Her effusions were decreased in size at the time of the study. All culture data has been negative to date. Her antibiotic coverage was broadened to Cefepime, Vancomycin, and Metronidazole for presumed inappropriate treatment of an aspiration PNA. Since she has been broadened, she has been afebrile. She was followed by [**Last Name (un) **] to help adjust her insulin sliding scale. . Follow up: - She will need to be seen by Neurology on the date listed on page one. - Please follow up on a VANC level prior to her next dose at rehab. - Her antibiotics course will be completed on [**2184-11-30**]. Please d/c midline central venous catheter after antibiotics are completed. Medications on Admission: 1. ASA 81mg Daily 2. Calcium Carbonate 3. Lasix 20mg Daily 4. Levothyroxine 150mcg Daily 5. Lisinopril 10mg Daily 6. MVI Daily 7. Novolog pump 8. Pravastatin 40mg Daily 9. Prednisone 2.5mg Daily 10. Sulfamethoxazole - T 400mg/80 Daily Discharge Medications: 1. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H:PRN as needed for fever. 8. labetalol 100 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO BID (2 times a day). 10. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. insulin aspart 100 unit/mL Cartridge Sig: One (1) Please see sliding scale Subcutaneous four times a day: Please see attached sliding scale. 12. insulin glargine 100 unit/mL Cartridge Sig: One (1) Please see insulin sliding scale for fixed doses Subcutaneous ONCE as scheduled dose. 13. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Three (3) ML Intravenous Q8H (every 8 hours) as needed for line flush. 14. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 15. mycophenolate mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2 times a day) as needed for constipation. 18. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 19. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 20. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous once a day. 21. cefepime 2 gram Recon Soln Sig: One (1) Intravenous Q12H. 22. calcium carbonate-vitamin D3 600-400 mg-unit Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary Diagnosis: SAH Secondary Diagnosis: Aspiration PNA Hypoxic Respiratory Failure due to Pulmonary Edema 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 23356**]- You were admitted to the hospital after you fell, and then developed a bleed in your brain. Your hospital course was complicated by a PNA, pulmonary edema (fluid in your lungs), and decreased movement of your left arm and leg which may have been due to an additional bleeding in your brain. You were given antibiotics for your pneumonia, and had several imaging studies to follow the bleed in your brain. You were sent to a rehabilitation facility to help you regain your strength, and help you understand what activities you will be to do at home. You will need to take the following medications at home: ADDED: Vanc, Cefepime, Metornidazole, Labetolol, lactulose, senna, colace, bisadocdyl, tylenol CHANGED: lisinopril STOPPED: None Nursing Orders for Tonight/Tomorrow: -Please draw a Vanc trough prior to the next Vanc dosing. Goal -If blood pressure is normal on [**2184-11-25**]. Please [**Name8 (MD) 138**] MD to increase lisinopril dose, and decrease labetolol dose. -Please make a note that antibiotics (Vanc, Cefe, Metronidazole) should be stopped on [**2184-11-30**]. -If her blood pressure is stable on [**2184-11-25**], please [**Name8 (MD) 138**] MD regarding adding home lasix dose (20 mg PO daily) Followup Instructions: Department: PODIATRY When: THURSDAY [**2184-11-25**] at 9:40 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage . [**2185-1-10**] 01:00p [**Last Name (LF) 162**],[**First Name3 (LF) **] [**Hospital6 29**], [**Location (un) **] NEUROLOGY UNIT CC8 (SB . [**2185-1-4**]: 9:30 Dr. [**Last Name (STitle) **]: Neurosurgery. Location: [**Location (un) 470**] of [**Last Name (un) 2577**] Building. Please get a head CT on CC3 at 8:45 am prior to your appointment Completed by:[**2184-11-24**]

[ "272.0", "434.91", "250.03", "V10.83", "E880.9", "745.5", "V42.83", "V42.0", "507.0", "401.9", "342.90", "244.9", "799.02", "787.20", "437.0", "852.02", "518.0", "518.81", "511.9", "514" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

16713, 16783

10264, 14080

274, 280

16938, 16938

2744, 4057

18396, 19118

1801, 1906

14659, 16690

16804, 16804

14399, 14636

17114, 17741

17762, 18373

1936, 2163

14091, 14373

230, 236

308, 738

2253, 2725

5510, 10241

16849, 16917

16823, 16828

16953, 17090

760, 1543

1559, 1785

48,297

149,732

52365

Discharge summary

report

Admission Date: [**2164-6-8**] Discharge Date: [**2164-6-25**] Date of Birth: [**2098-8-14**] Sex: F Service: EMERGENCY Allergies: Lipitor Attending:[**First Name3 (LF) 2565**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: intubation, PEG tube, trach History of Present Illness: 65 year old woman with history of PE on lifetime coumadin, asthma, recent CABG [**4-20**] with long stay complicated by PTX, a fib, and pleural effusions presents with nonproductive cough, dyspnea and low grade fevers x 5 days. She saw her cardiologist on [**2164-5-21**] and CXR confirmed left sided pleural effusion. She was then seen by pulmonary who felt that ethis should either be tapped, or should be considered for pleurodesis. She was then scheduled to see CT surgery, who scheduled her to have this tapped on Tuesday [**6-12**] but became too symptomatic to wait. Of note, she was told to hold her coumadin on [**2164-6-6**] and take lovenox. Initially on [**2164-6-3**] she complained of a stomach virus with profuse vomitting then later dry heaving for a few days. Subsequently, she developed a nonproductive cough, fever to 100.6, fatigue, malaise, and worsening dyspnea. Due to her worsening symptoms she decided to come to the ED. . In the ED, the patient had the following vital signs: 97.3 103/36 111 24 97%RA. The patient was found to have a stable left sided pleural effusion but they could not tap because of an INR of 9. She also had a WBC count of 21. She was evaluated by CT surgery who recommended IR guided tap once INR <2. She was seen by cardiology who did a bedside echo that was unremarkable. During her ED stay, she developed a fib with RVR in 170s, she was being given lopressor 5 when she dropped her SBPs to the 70s, then fortunately spontaneously converted to sinus tach in 110s. She then later got up to go to the restroom and developed again a fib with RVR to 180s and againwas given lopressor 5mg IV x 2. She converted to NSR at a rate of 88 with BP of 113/77. She remained afebrile in the ED. She was also given ceftriaxone 1gm IV ONCE, azithromycin 500mg PO ONCE and vitamin K 5mg IV ONCE. She was also given levoquin 750mg IV ONCE just prior to transfer and sent to the MICU given her unstable hemodynamics. . ROS: She reported palpitations only during very fast a fib. She also reports weight loss x 1 month. She denied any chest pain, weight gain, abdominal pain, recent nausea, vomitting, diarrhea, calf pain, recent travel, hemoptysis, hematemesis, black or bloody stools, dysuria, urinary frequency, headache, neck stiffness. Past Medical History: Diffuse carotid disease Hodgkin's disease stage 2 in '[**22**] treated with total body radiation Reactive airways disease/Pulmonary Fibrosis Multiple PNAs, most recently in [**2163-6-11**] requiring ICU care for sepsis/hypotension Functional Asplenism s/p radiation treatment Radiation induced ovarian failure s/p total hysterectomy and Estradiol therapy Hypothyroidism Supraventricular tachycardia (Presumably Afib) Gastroesophageal Pulmonary emoblism (VTE) in '[**54**] on longterm low-dose coumadin Right chest lentigo [**Female First Name (un) 564**]/HSV esophagitis in setting of being on steroids s/p Staging laparotomy [**2122**] Social History: Patient is married and lives in [**Location 1514**], MA with her husband. She is a retired school administrator. She is independent and performs ADLs without limitation. Physically, she has difficulty climbing stairs and hills. No tob or drugs. Occasional EtoH, but rarely. Family History: No family history of lung or cardiac diseases. NC for CAD, SCD or arrhythmia. Mother: [**Name (NI) 2481**] Maternal GM: Uterine cancer Physical Exam: On admission: GEN: Chronically ill appearing pale woman in mild respiratory distress HEENT: PERRL, anicteric, MMM, op with ?thrush, RESP: Reduced breath sounds at left field [**2-12**] way down, reduced sounds at right base, no egophony or rales CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII grossly intact except anisocoria Pertinent Results: Labs on admission: [**2164-6-8**] 02:55PM BLOOD WBC-21.3*# RBC-3.73* Hgb-10.6* Hct-32.4* MCV-87 MCH-28.4 MCHC-32.8 RDW-16.1* Plt Ct-545* [**2164-6-8**] 02:55PM BLOOD Neuts-84* Bands-12* Lymphs-0 Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2164-6-8**] 02:55PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL Poiklo-1+ Macrocy-NORMAL Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL Burr-1+ [**2164-6-8**] 02:55PM BLOOD PT-78.5* PTT-71.7* INR(PT)-9.0* [**2164-6-8**] 10:32PM BLOOD Fibrino-860*# [**2164-6-8**] 02:55PM BLOOD Glucose-86 UreaN-26* Creat-0.9 Na-125* K-5.0 Cl-87* HCO3-25 AnGap-18 [**2164-6-8**] 02:55PM BLOOD CK(CPK)-41 [**2164-6-8**] 02:55PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-4832* [**2164-6-8**] 02:55PM BLOOD Calcium-8.3* Phos-2.9 Mg-1.9 [**2164-6-8**] 10:32PM BLOOD D-Dimer-3019* [**2164-6-8**] 02:55PM BLOOD TSH-3.2 [**2164-6-11**] 04:31AM BLOOD Cortsol-32.3* [**2164-6-11**] 04:31AM BLOOD Vanco-28.9* [**2164-6-11**] 07:57AM BLOOD Type-[**Last Name (un) **] pO2-42* pCO2-53* pH-7.27* calTCO2-25 Base XS--2 [**2164-6-11**] 07:57AM BLOOD Lactate-1.5 . Labs on discharge: [**2164-6-25**] 05:51AM BLOOD WBC-9.4 RBC-3.06* Hgb-8.7* Hct-27.0* MCV-88 MCH-28.5 MCHC-32.3 RDW-16.8* Plt Ct-321 [**2164-6-25**] 05:51AM BLOOD PT-14.1* PTT-38.4* INR(PT)-1.2* [**2164-6-25**] 05:51AM BLOOD Glucose-106* UreaN-25* Creat-0.6 Na-143 K-3.7 Cl-102 HCO3-38* AnGap-7* [**2164-6-25**] 05:51AM BLOOD Calcium-7.8* Phos-2.3* Mg-1.7 . Micro: Catheter tip [**2164-6-14**]: [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. >15 colonies, . Echocardiogram (TTE) [**2163-6-12**]: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is moderate global left ventricular hypokinesis (LVEF = 35 %). Right ventricular chamber size is normal with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**2-12**]+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with global hypokinesis. Mild aortic regurgitation. Mild-moderate mitral regurgitation. Compared with the prior study (images reviewed) of [**2164-6-8**], left ventricular systolic function is minimally improved and the large/complex left pleural effusion is no longer visualized. . Left upper extremity ultrasound [**2164-6-13**]: No evidence of deep vein thrombosis in the left arm. . CT abdomen/pelvis without contrast [**2164-6-14**]: 1. New hydropneumothorax in the left side with decreasing right basilar opacity and new ground glass opacities in the left lung. 2. Decrease in size of left pleural effusion; however, increasing size of right loculated pleural effusion. 3. No intrabdominal abscess or colitis. . Abdomen (supine only) [**2164-6-24**]: 1) Gastrostomy PEG-type tube. There is a small amount of free intraperitoneal air, corresponding to the fniding on recent CXR, which may have been introduced at the time of the recent procedure. 2) Relative paucity of bowel gas throughout the abdomen, for which clinical correlation is requested. . CXR (portable AP) [**2164-6-25**]: In comparison with study of [**6-24**], the tracheostomy tube is unchanged, as is the central catheter and pacemaker leads. Substantial decrease in the amount of free intraperitoneal gas. Little overall change in the appearance of the heart and lungs. Left hemidiaphragm is again not well seen, suggesting substantial volume loss in the left lower lobe. Brief Hospital Course: 65 year old woman with history of PE on lifetime coumadin, asthma, recent CABG [**4-20**] complicated by PTX, a fib, and pleural effusions presents with nonproductive cough, dyspnea and low grade fevers. She saw her cardiologist on [**2164-5-21**] and CXR confirmed left sided pleural effusion. Her hospital course has been most notable for intubation, VATS procedure, treatment for pneumonia, failed extubation, and subsequent tracheostomy and PEG tube placement. . # Hypoxic respiratory failure/dyspnea: most consistent with an acute pneumonia. She most likely aspirated after her stomach virus and developed a bacterial pneumonia. Although community acquired pathogens are most likely, she is also at risk for health-care associated organisms. There may also be a component of reactive airway disease. Acute CHF is also a possible contributor given elevated JVP, wheeze, and the pleural effusions. During her ICU stay, she was started on vancomycin, cefepime, and azithromycin. She was subsequently broadened to vancomycin, cefepime, and levofloxacin and completed 10 days of vanc/cef and 8 days of levofloxacin. She underwent thoracentesis with placement of pigtail catheter initially, given loculated pleural effusion. This was subsequently converted to two chest tubes, and she later underwent successful VATS with drainage of left sided effusion, drained 750cc of inflammatory appearing fluid that did not grossly appear infected (cx negative). She did develop a small PTX during the above procedure, which was monitored with serial CXR, and subsequently self improved. However, she was intubated on hospital day 3, in the setting of tachyarrhythmia (SVT) to HR 180s, dropped her pressures to SBP 70s. She was slowly weaned from the ventilator, however, failed her first extubation from multiple causes including poor nutrition, deconditioning/weakness, hypertension, tachyarrhythmia, mild volume overload and anxiety. This was despite attempting nitro gtt during her SBT. Per discussion with the husband and family, tracheostomy and PEG tube placement were pursued on hospital day 13. -in order to optimize status would recommend diuresis (currently getting 40 PO daily) with goal of -500 to 1L daily while following creatinine. -Advair was held during admission after intubation. It was changed from Diskus to HFA at the time of discharge. . # Atrial fibrillation with rapid ventricular rate: intermittently had episodes of SVT into HR 140s. Felt to be exacerbated by her pulmonary infection. Patient is very tenuous as she develops a fib with RVR with hypotension with minimal exertion. TSH was wnl. She was loaded with amiodarone gtt and kept on maintenance 400 mg [**Hospital1 **], per discussion with her cardiologist Dr.[**Name (NI) 3733**]. Her pacer setting was increased to 80 and remainded on this on discharge. She was bridged with heparin gtt and was started on coumadin prior to discharge. Heparin gtt was changed to Lovenox prior to discharge. -her INR was 1.2 on the day of discharge and she will need Lovenox 60 mg SC Q12H until INR is therapeutic (goal [**3-15**]). Coumadin dose increased from 1 mg to 2 mg daily on the day of discharge. The Coumadin dose will likely need to be adjusted once the patient is therapeutic. She will need daily INR checks until on a stable regimen of Coumadin. -monitor QTc while on amiodarone. QTc was 435 on [**2164-6-19**]. . # Leukocytosis: felt to be related to pnuemonia and stress response. She completed course of vancomycin, cefepime, and levofloxacin for HCAP. Remainder of culture data was negative, with exception of catheter tip growing [**Female First Name (un) 564**] (see below). She was continued on IV flagyl and PO vancomycin during her Abx, given her history of Cdiff. . # Hypotension: Patient with hypotension primarily in setting of rapid a fib, suggesting that she is dependent on her atrial kick. She was also treated for early sepsis for pnuemonia. Her AM cortisol was normal. It was noted that her upper extremity BP were 40 points lower than her arterial line pressures. As such, blood pressures should be measured in her thighs for accuracy. . # [**Female First Name (un) 564**] from catheter tip: she was continued on fluconazole to complete a 2 week course. -last day [**2164-7-1**] . # Free air in abdomen: Small amount of free air seen in abdomen after PEG tube placement. G-tube study was done that showed all contrast in the stomach so this was felt likely to be expected amount of air with PEG placement and not pathologic. Repeat CXR on the day of discharge showed improvement in free air. . # Anemia: Patient required red blood cell transfusion on 3 occasions in the ICU, though the patient never had any signficant bleeding, she remained guaiac negative and and so her anemia was felt most likely due to frequent blood draws, poor nutritional status and laboratory fluctiations. Her last HCT <25 occurred on [**2164-6-23**] and she received 1 unit PRBCs. Her HCT on the day of discharge is 26.5 and should be rechecked every 3-7 days and transfused for HCT <24 given her cardiac history. . # Left upper extremity swelling: LENIs negative for DVT. Pulses remained adequate and within normal limits. . # Nutrition: PEG tube was placed on hospitald day 13. Patient has small amount of free air seen on her ABD XRAY which is presumably due to PEG placement as patient has no abdominal pain, has good stool output. -repeat Abd Xray to ensure improvement in free air -consider increasing fiber content of tube feeds if needed for constipation . # Psych: SW has been involved, but pt clearly feels profoundly frustrated, angry, and despondant about her condition and her difficult medical course. -will need social work and possibly psychiatric support ongoing. . # Dispo: rehab Medications on Admission: AMOXICILLIN-POT CLAVULANATE - 875 mg-125 mg Tablet - TAKE ONE TABLET ONLY IF YOU HAVE A TEMP 100.4 OR ABOVE. CALL YOUR DOCTOR RIGHT AWAY. ENOXAPARIN - 60 mg/0.6 mL Syringe - Inject one syringe every 12 hours as directed - given for fever given splenectomy FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 inhalation twice a day - RINSE MOUTH AFTER EACH USE LEVOTHYROXINE [LEVOTHROID] - 100 mcg Tablet - 1 (One) Tablet(s) by mouth Monday through Friday LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth once a day as needed as needed for at night for sleep METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet(s) by mouth three times a day ONDANSETRON - 8 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth once or twice daily as needed for nausea WARFARIN - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) MD to dose daily for goal INR [**3-15**], dx: a-fib, PE Medications - OTC ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth DAILY (Daily) CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (OTC) - 500 mg (1,250 mg)-400 unit Tablet - 1 Tablet(s) by mouth twice a day DOCUSATE SODIUM - (Prescribed by Other Provider) - 50 mg/5 mL Liquid - 1 Liquid(s) by mouth twice a day Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Loculated Pleural Effusion, inflammatory, s/p VATS RUL Pneumonia [**First Name4 (NamePattern1) 564**] [**Last Name (NamePattern1) **] infection Atrial Fibrillation with RVR Respiratory Failure requiring intubation and tracheostomy Deconditioning Malnutrition Discharge Condition: Activity Status: Bedbound with tracheostomy Level of Consciousness: Alert while off of sedation Discharge Instructions: You came to the hospital with shortness of breath and we found that you had pneumonia. We treated your pneumonia with antibiotics and took fluid from your lung. Then Thoracic surgery did a VATS procedure which you tolerated well. You were intubated and did not easily wean from the ventilator so you required trach and PEG. You also had rapid atrial fibrillation and you were started on amiodarone which helps to control your rate. . Please follow up with your doctors as below. Followup Instructions: Department: [**Hospital3 249**] When: WEDNESDAY [**2164-6-27**] at 11:40 AM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2164-8-15**] at 9:00 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Need to arrive at 3pm on [**Hospital Ward Name 23**] 4 radiolgy for chest xray and then to appointment: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2164-7-10**] at 3:30 PM With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: TUESDAY [**2164-7-31**] at 9:00 AM With: DR. [**First Name (STitle) **] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2164-6-25**]

[ "427.31", "511.89", "584.9", "V12.51", "493.90", "428.0", "482.9", "428.23", "518.83", "038.9", "263.9", "008.8", "112.89", "285.29", "999.31", "V53.31", "V45.81", "300.00", "244.9", "V10.72", "507.0", "427.89", "785.52", "995.92", "429.4", "E878.8", "515" ]

icd9cm

[ [ [] ] ]

[ "34.04", "34.91", "96.72", "34.52", "96.6", "43.11", "31.1" ]

icd9pcs

[ [ [] ] ]

14987, 15053

7909, 13680

276, 305

15356, 15454

4196, 4201

15985, 17292

3576, 3713

15074, 15335

13706, 14964

15478, 15962

3728, 3728

229, 238

5292, 7886

333, 2608

4215, 5273

2630, 3268

3284, 3560

9,778

178,189

26221

Discharge summary

report

Admission Date: [**2153-1-26**] Discharge Date: [**2153-2-19**] Date of Birth: [**2124-2-13**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1850**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Tracheal piece replacement GJ Tube placement Bronchoscopy History of Present Illness: 28 year-old quadrapedic female with severe mental retardation and cerebral palsy chronically trached who presented from OSH with respiratory distress. Pt was previously seen at [**Hospital1 64975**] for respiratory distress one day PTA and sent home on Keflex. She represented to the OSH with worsening secretions and continued labored breathing. ABG: 7.45/47/120 (35%). Pt usually recieves care at [**Hospital1 **] (Chronic Care Service/Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4027**] - [**Telephone/Fax (1) 64976**]) or [**Hospital1 112**], however, there was no available beds so the pt was transferred to [**Hospital1 18**] with concerns of worsening respiratory distress in setting of suspected PNA. She was recently admitted to [**Hospital3 1810**] from [**1-2**] - [**1-13**] for LLL PNA treated with Aztreonam and Clinda (pansensitive pseudomonas and [**Doctor First Name **] as per ID fellow, Dr. [**Last Name (STitle) 64977**] at [**Hospital1 **]). . In the ED the pt received ABX (Levofloxacin, Vanco and Flagyl), albuterol neb, and KCL 20 mEq. A central line was placed. Bld and urine cultures sent. WBC count noted to be 36 with 6 % bandemia. CXR revealed a possible subtle retrocardiac density. . The pt previously had a customized trach without a cuff which was found to have a leak in the ED. IP was consulted in the ED and the trach was changed to one with a cuff so the pt could be vented. During the procedure, significant amounts of granulation tissue was found distal to the trach impeding air flow (approximately 80% luminal obstruction). The new trach was pushed through the granulation tissue to 3cm above the carina. A bronchoscopy was performed in the ED demonstrated clearance of previously obstructing granulation tissue. Past Medical History: - severe mental retardation - CP - quadraplegia - Sz Dz (last 3 months ago) - chronic trach not vented; on 2.5 L trach mask - s/p PEG - scoliosis - chronic anemia - recent LLL PNA as above Social History: Lives at home with mother, spanish speaking only. By report no Tob/EtOH/DU. Family History: Noncontributory Physical Exam: HEENT: NC/AT, PERRL, EOM full, no scleral icterus noted, drooling, frothy sputum Neck: scolotic, supple, no JVD appreciated, trach with granulation tissue, no crepitus Pulmonary: tachypneic, course BS thru/o with exp wheezes, decreased BS at bases, excessive upper airway sounds Cardiac: Tachy with RR, nl. S1S2, no M/R/G noted Abdomen: soft, mild ND, hypoactiveactive bowel sounds, no masses or organomegaly noted, PEG site with SS drainage around site Extremities: contracted, trace pedal edema bilaterally, 1+ radial, DP and PT pulses b/l. Skin: WWP, no rashes or lesions noted. Neurologic: Alert and moves eyes in response to voice, non-verbal, does not follow commands, extremities contracted without movement Pertinent Results: STUDIES: OSH-> WBC 28.7/HCT 39.7/PLT 813; Na 129/K 2.9 (given 40 mEq through PEG)/CO2 30/BUN 6/Cr 0.7. . EKG: sinus tach, Rate 115, poor baseline . CXR [**2153-1-25**]: tracheostomy tube, which terminates 3 cm above the carina. There is marked kyphoscoliosis of the thoracic spine, making these views non-standard in orientation. Allowing for this rotation, there is no definite pleural effusion, pneumothorax, or consolidation. The heart size is difficult to assess. There may be subtle retrocardiac density. CT ABDOMEN W/O CONTRAST [**2153-2-15**] 2:45 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Reason: Evaluate for abscess, pt intubated, Field of view: 36 [**Hospital 93**] MEDICAL CONDITION: 29 year old woman with CP MR, with pseumdomonas growing, GJ Tube placed, pt intubated REASON FOR THIS EXAMINATION: Evaluate for abscess, pt intubated, CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Cerebral palsy, mental retardation, with pseudomonas infection, status post GJ tube placement. TECHNIQUE: Multidetector CT images of the chest, abdomen, and pelvis were obtained without oral or intravenous contrast. COMPARISON: None. CHEST CT WITHOUT IV CONTRAST: There is marked thoracic deformity due to severe scoliosis. A tracheostomy tube is present with tip of the tube at the thoracic inlet. The heart and great vessels are unremarkable. There is no lymphadenopathy. No consolidations are present. There is patchy dependent atelectasis. Several vague subcentimeter tiny nodular opacities are present at the right lung base. There are no pleural effusions. ABDOMEN CT WITHOUT IV CONTRAST: The liver, gallbladder, pancreas, spleen, adrenal glands, kidneys, and abdominal vasculature is unremarkable. There is marked scoliotic deformity of the thoracolumbar spine. A gastrojejunostomy tube is present with tip in the proximal jejunum. There is a skin defect overlying the right mid abdomen, with mild soft tissue density in the underlying abdominal wall. This is likely related to prior intervention. No fluid collections are present. There is no free abdominal air or fluid. PELVIS CT WITHOUT IV CONTRAST: The distal ureters and pelvic organs are unremarkable. A Foley is present within the bladder. There is marked deformity of both hips. No fluid collections are present. IMPRESSION: 1. No fever source identified. 2. Several tiny nodular opacities at the right lung base. These are nonspecific and are likely chronic, possibly due to old infection. Reason: please change G tube to G-J tube and remove J tube. Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 29 year old woman with CP and leaking J tube REASON FOR THIS EXAMINATION: please change G tube to G-J tube and remove J tube. HISTORY: 29-year-old woman with _____ and leaking J-tube site. The J-tube has previously been removed. Our aim is to convert the G-tube to a GJ tube. PHYSICIANS: [**First Name8 (NamePattern2) **] [**Doctor Last Name 26181**] and [**First Name8 (NamePattern2) **] [**Doctor Last Name 380**] performed the procedure with Dr. [**Last Name (STitle) 380**], the attending radiologist, being present and supervising throughout the procedure. PROCEDURE: Following written informed consent from the patient's mother, the patient was positioned supine on the angiography table. The preprocedure timeout was performed to confirm patient, procedure and site. Standard sterile prep and drape of the ventral abdomen and in situ gastrostomy catheter (18 French Foley catheter). The guidewire was passed through the Foley catheter and the Foley catheter was removed. The bright-tip vascular sheath was placed over the guidewire and with the aid of a Kumpe catheter, the pylorus was intubated and the wire and catheter were advanced through the duodenum and into the jejunum. The Kumpe catheter was then exchanged for an MPA catheter and the wire and catheter were advanced to the level of the jejunostomy. The jejunostomy was then intubated and efferent limb was cannulated using the dilator from the vascular sheath and a Bentson guidewire. Contrast injection through the MPA catheter in the afferent limb of the jejunostomy was then performed and this demonstrated the course of the bowel at what appears to be a loop jejunostomy. The guidewire was then advanced around the loop in from the afferent limb to the efferent limb. A 22 French MIC catheter was then advanced over the guidewire and positioned with its tip in the jejunum distal to the jejunostomy site. The balloon was positioned in the stomach and inflated with 7 cc of sterile saline. A dressing was applied. Contrast was injected through the tube and confirmed catheter tip positioned in the jejunum beyond the jejunostomy site and the position of the balloon within the stomach. The catheter was then flushed with saline to clear the contrast. There were no immediate complications. IMPRESSION: Successful replacement of the in situ gastrostomy catheter with a 22 French MIC catheter with balloon in the stomach, gastric port in the gastric antrum, and tip of catheter within the jejunum distal to the site of the jejunostomy. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 54747**] [**Name (STitle) **] DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Approved: [**Doctor First Name **] [**2153-2-15**] 1:39 PM Brief Hospital Course: Assessment - 28yo quadraplegic woman with cerebral palsy and severe mental retardation, chronic trach (not on home ventilation), who was admitted for respiratory distress and found to have a tracheal obstruction and possible PNA. . 1. Respiratory distress - etiology most likely tracheal obstruction from granulation tissue complicated by pulmonary disease, possibly PNA vs bronchitis. PE less likely in pt with chronic immobility. In ED, trach was changed with new trach pushed past the site of obstruction by interventional pulmonary. Pt was placed on PCV with good oxygenation. Per IP recs -> inflate cuff to goal manometry 20-30 and MV [**6-21**]. 7.0 ETT at bedside; if needed in emergency, can place through stoma to 12cm. During her hospital course, during trach care where the velcro securing device was removed she coughed out her trach tube, it was promptly replaced, and IP was consulted, a cxr confirmed it was in appropriate position and the cuff was reinflated with good maintenance of her oxygen saturation. She was to be maintained on intermittent trach collar and pressure spport, with attempts to maximize trach collar time as tolerated, she was also continued on albuterol and atrovent. . ## Pneumonia/fever - Initially thought secondary to PNA, then likely due to cellulitis around J tube site. She had Central line and this was discontinued given low grade fevers. The tip was sent for culture and showed no grwoth. She was started on vanc/ceftaz flagyl initially, sputum culture grew pseudomonas and received 5 days of this, however with worsening renal insufficiency and concern for AIN and pt with persistent infiltrates from previous records antibiotics were discontinued for pneumonia. [**Doctor First Name **] likely colonizer as pt not on treatment from [**Hospital1 **]; she was given albuterol, atrovent prn. She had a bronch done in the ICU ~1 week after the admission which showed no new pathology. WBC started rising again [**2-12**]. WBC was up to 25 [**2-15**] with low grade temp of 100.9 on [**2-14**].UA/Urine cx neg, but sputum from [**2-12**] growing 4 +GNR on gram stain and pseudomonas on culture. On [**2-14**] pt had L shift with 1%bands. CXR from [**2-12**] did not reveal any new changes, however it was of poor quality and no lateral view can be easily obtained. Pt received 1 dose ceftaz on [**2-12**], however given h/o AIN on this in the past, it was discontinued. The pt was started on meropenem on [**2-14**] to cover pseudomonal PNA, and on Vanc on [**2-15**] to cover for any potential line infection. The pt was taken for CT of the torso to further eval for loculated effusions and abdominal abscess on [**2-15**]. The CT did not reveal any absces. Her vancomycin was discontinue as there were no gram positive cocci isolated on cultures. She was continued on meropenem and levaquin was added for further persistent fevers and double gram negative coverage. She was continued on flagyll for empiric C diff coverage while her cdiff cultures were negative at time of discharge and her C diff toxinb B was still pending. She was discharged to finish 2 more days of meropenem and 4 more days of levaquin and to finish a 14 day course of flagyl for presumed c. diff . # Sepsis - On presentation unable to maintain UOP, goal > 30cc/hr. IVF kept pt's MAPs up briefly, but then fell, and UOP never at goal. On levophed briefly for presumed sepsis on presentation and titrated to MAP>70. She was titrated off levophed with good control of her pressures. . # J tube dislodgement - On presentation her J tube had fallen out, this was replaced by Interventional radiology on [**2153-2-1**]. There was significant bile drainage from around site. This was likely because the tract of Jtube was probably larger than the j tube. Surgery evaluated the pateint and on [**2-7**] changed tube for Malecot (larger diameter), then performed J tube check. Initially contrast never made it into the small bowel but just leaked out around it. Repeat study showed contrast in small bowel. IR decided to [**Last Name (un) **] ther G tube to a G-J tube, however, given her anatomy and previous surgeries recommended that this would likely need to be done by surgery. Surgery has requsted records from [**Hospital1 **] regarding previous abdominal surgeries, previous anti reflux surgery?, ? why she has G and a seperate J tube as well as her aspiration risk. These records need to be obtained prior to surgery at [**Hospital1 18**]. Patient's family asked that patient be transferred to [**Hospital1 **] given all her care there previously. Tube feeds were held. On [**2-12**] the pts J tube was pulled, and on [**2-13**] a GJ tube was placed by IR. The pts J tube fistula site willl close over time and will need an ostomy bag over the site until then. Her G- tube was placed to suction. Her J-tube feedings were to be held until there was no drainaged from the J tube ostomy site. . # Erythema around J tube - Patient was noted to have erythema around the J tube site. This was thought likely inflammation from bile, expect improvement with replacement of ostomy bag. Given fevers there was concern for cellulitis she was started on vancomycin (PCN allergy) [**2153-2-2**]. This was discontinued on [**2-12**]. . # ARF - rise in Cr from 0.5 to 1.5 after admission. Urine lytes not consistent with prerenal. Rare eosinophils in urine initially and all potential meds were stopped as above, repeat showed no eos, so less likely AIN. Not post-renal by renal ultrasound. So most likely ATN from time of hypotension. Renal function improved gradually over time. . # CP, mental retardation - continue ativan prn, valium [**Hospital1 **] #. Seizures - continue phenobarbitol, topamax . FEN - Patient was on TPN while inpatient, will consider Tube feeds when J tube ostomy site is decreasing. Monitor and replete lytes prn. PPx - Zantac, sc heparin, bowel regimen Access - very difficult, finally with L subclavian CVL. Do not remove line. Communication - pt's mother, [**Name (NI) **] - [**Telephone/Fax (1) 64978**]; o/w can call brother at [**Telephone/Fax (1) 64979**], or father at [**Telephone/Fax (1) 64980**] Dispo - To rehab Code status - full, confirmed w/ pt's mother . Medications on Admission: - Phenobarb 88mg/44mg qAM/aPM - Topamax 100mg [**Hospital1 **] - Atrovent Nebs [**Hospital1 **] - Albuterol q4 - Ativan 2mg [**Hospital1 **] - Valium 4 mg [**Hospital1 **] - Zantac 150 [**Hospital1 **] - Ca-Carbonate 1259 [**Hospital1 **] - Nystatin/Myconazole/Hydrocort ointments - Neutraphos K 1 pkt tid - Miralax 17 daily - Bactroban to G-tube tid - Aveno soaks 10 min to G-tube tid Discharge Medications: 1. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours). 4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours). 5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane QID (4 times a day). 6. Lidocaine HCl 0.5 % Solution Sig: One (1) ML Injection Q1H (every hour) as needed for cough. 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 10. Topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. 12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 13. Diazepam 5 mg/mL Syringe Sig: 2.5 mg Injection [**Hospital1 **] (2 times a day). 14. Phenobarbital Sodium 65 mg/mL Solution Sig: Ninety (90) mg mg Injection QAM (once a day (in the morning)). 15. Phenobarbital Sodium 65 mg/mL Solution Sig: Sixty Five (65) mg Injection QPM (once a day (in the evening)). 16. Lorazepam 2 mg/mL Syringe Sig: Two (2) Injection [**Hospital1 **] (2 times a day) as needed. 17. Meropenem 1 g Recon Soln Sig: One (1) gm Intravenous Q8H (every 8 hours) for 2 days. 18. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Tablet(s) 19. Metoclopramide 10 mg IV Q6H 20. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 21. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 22. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. Discharge Disposition: Extended Care Facility: [**Hospital1 100**] Rehabitation Discharge Diagnosis: Respiratory Distress Discharge Condition: Stable Discharge Instructions: Please take your medications as instructed If you experience increased fevers chills nausea vomitting, please contact your doctor Followup Instructions: None [**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]

[ "369.00", "519.02", "318.1", "536.42", "780.39", "995.92", "276.52", "276.1", "519.1", "584.9", "536.41", "754.2", "518.84", "343.2", "682.2", "038.9", "482.1", "281.9", "787.03", "458.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93", "99.15", "33.21", "96.72", "44.32", "97.23", "96.04", "99.04" ]

icd9pcs

[ [ [] ] ]

17358, 17417

8664, 14905

293, 353

17482, 17491

3250, 3922

17671, 17795

2483, 2500

15341, 17335

5846, 5891

17438, 17461

14931, 15318

17515, 17648

2515, 3231

233, 255

5920, 8641

381, 2162

2184, 2374

2390, 2467

28,032

114,975

33219

Discharge summary

report

Admission Date: [**2181-6-26**] Discharge Date: [**2181-6-29**] Date of Birth: [**2103-7-24**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: 77 y/o p/w subdural hematoma. Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 77F with a h/o lung cancer s/p lobectomy and PE on lovenox since [**1-9**] who presented to ED after a CT scan this afternoon at an OSH revealed a SDH. She reports her only symptom is a left sided headache just beside the ear. Of note patient has been taking lovenox since [**Month (only) 404**] after a diagnosis of a PE. Past Medical History: 1. Hypertension 2.Ao Arch ulceration 3.Knee Arthritis 4. s/p Cataract surgery 5. Thyroid nodule 6. Meningoma 7. lung cancer s/p LUL lobectomy [**2181-4-19**] 8. Saddle embolus s/p lobectomy, now on lovenox. Social History: Born in [**Country 16573**], she has 8 children, lives with her daughter, who is a nurse. non-smoker, rare alcohol, no drug use. Prior to the winter she was walking 1.5 to 2 miles to church every day; only stopped because of the cold weather. Family History: She denies h/o of cancer, early MIs, CVAs. Physical Exam: On admission: PHYSICAL EXAM: O: T: 98.3 BP: 148/78 HR:89 RR: 16 O2Sats: 100%RA Gen: WD/WN, comfortable, NAD. HEENT: normocephalic, atraumatic Pupils:PERRL EOMs: intact Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**3-5**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3mm to 2mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-7**] throughout. No pronator drift, no dysmetria Sensation: Intact to light touch, proprioception. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Coordination: normal on finger-nose-finger. Pertinent Results: [**2181-6-26**] 05:15PM BLOOD WBC-8.3 RBC-4.42 Hgb-12.7 Hct-40.6 MCV-92 MCH-28.7 MCHC-31.2 RDW-16.6* Plt Ct-267 CT [**2181-6-26**]: FINDINGS: There is a left mixed-density frontal subdural hematoma visualized resulting in shift of midline to the right measuring 8 mm. Represents an acute on chronic subdural hematoma. There is mild effacement of the adjacent sulci visualized. The [**Doctor Last Name 352**]-white matter differentiation of the brain is well preserved. The ventricles appear normal with no evidence of hydrocephalus. The posterior fossa structures appear unremarkable. No evidence of tonsillar or uncal herniation. No osseous abnormalities visualized. There are bilateral carotid calcifications. The visualized orbits and paranasal sinuses appear normal. IMPRESSION: Left acute on chronic subdural hematoma resulting in subfalcine herniation as described above. No evidence of uncal or tonsillar herniation. MRI [**2181-6-26**]: FINDINGS: Again visualized is the midline orbital groove hemangioma in close proximity to the crista galli measuring 9 x 5 mm and is unchanged in size. There is a bifrontal subdural hematoma and left parietal subdural hematoma resulting in effacement of the adjacent left frontoparietal sulci, mass effect on the left lateral ventricle and shift of midline to the right, measuring 1 cm to the right. There is no evidence of hydrocephalus. The posterior fossa structures appear unremarkable. The visualized orbits and paranasal sinuses appear normal. The major vascular flow voids are well preserved. There is abnormal pachymeningeal enhancement visualized without evidence of the leptomeningeal enhancement. Differentials to consider would be meningitis. IMPRESSION: 1. Bifrontal subdural and left parietal subdural hematoma resulting in mass effect on the left lateral ventricle and subfalcine herniation to the right as described above. No evidence of tonsillar or uncal herniation. 2. Pachymeningeal enhancement. Differentials to consider would be meningitis. 3. Unchanged orbital groove extra-axial enhancing lesion. This likely represents a meningioma. Brief Hospital Course: Noncontrast head CT in the ED showed a 1 cm left acute on chronic subdural hematoma resulting in subfalcine herniation without evidence of uncal or tonsillar herniation. A brain MRI was also completed to assess for interval changes of her previously diagnosed and treated meningioma, which showed no significant changes. A complete neurological exam was normal. She was admitted to the SICU with neuro checks every one hour. Thoracic surgery attending agreed to discontinue her lovenox at that time as she had been treated for a prior PE for atleast 6 months. Her condition and neurologic exam was stable during her stay in the SICU. On HOD#2 she was transferred to the neurosurgical floor after a repeat head CT on [**6-27**] showed no significant interval changes. Her exam continued to remain stable during her stay on the floor. Thoracic surgery was consulted to determine her need for anticoagulation or placement of an IVC filter given her prior h/o saddle embolus s/p lobectomy. After consulting her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and negative LENIs bilaterally on HOD#2, it was decided that anticoagulation or placement of an IVC filter is not strongly indicated at this time. On HOD#4 PT recommended home services. OT cleared the patient for discharge as she is at her baseline according to her daughter. Neuro exam prior to discharge: orientated x 3 with appropriate responses to direct questions, PERRL, EOMi, CNII_XII intact, motor and sensory exam was normal. She was discharged on [**2181-6-29**]. Medications on Admission: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous Q12H (every 12 hours). 4. Lotemax 0.5 % Drops, Suspension Sig: One (1) drop Ophthalmic [**Hospital1 **] (2 times a day). 5. Triamterene-Hydrochlorothiazide 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. meds Please continue your home dose of lotemax 0.5% eye drops as prescribed. Please do not take lovenox. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Subdural hematoma Discharge Condition: neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR HEAD INJURY ?????? Take your pain medicine as prescribed ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? You have been prescribed an anti-seizure medicine, take it as prescribed. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication Followup Instructions: PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.[**Last Name (STitle) **] TO BE SEEN IN [**4-8**] WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST. Completed by:[**2181-6-29**]

[ "V12.51", "401.9", "E934.2", "432.1", "225.2", "322.9", "241.0", "285.9", "V10.11" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7198, 7247

4720, 6274

349, 355

7308, 7332

2581, 4697

8086, 8302

1231, 1276

6736, 7175

7268, 7287

6300, 6713

7356, 8063

1320, 1471

280, 311

383, 722

1763, 2562

1305, 1305

1486, 1747

744, 954

970, 1215

11,049

145,016

43520

Discharge summary

report

Admission Date: [**2132-1-14**] Discharge Date: [**2132-1-20**] Service: MEDICINE Allergies: Warfarin / Celexa / Cardura / Minipress / Ciprofloxacin / Keflex Attending:[**First Name3 (LF) 398**] Chief Complaint: hypotension and atrial fib w/ RVR Major Surgical or Invasive Procedure: none History of Present Illness: 89 yo female with hx of afib, MGUS, with recent rectopexy and loop sigmoid colostomy for rectal prolopse complicated by renal failure and then readmit to the hospital for SOB [**Date range (1) 40090**] now representing with nausea and vomiting. Pt initially presented for elective rectopexy and loop sigmoid colostomy performed on [**12-17**]. The procedure was complicated by volume overload and acute renal failure due to ATN. She was then readmitted [**Date range (1) 93659**] for worsening SOB and weight gain. This was felt to be due to CHF and hypothyroidism with synthroid dose increased and pt diuresed to her preoperative weight of 105 lbs although effusions on CXR weren't markedly improved. Of note she was also treated with a 7 day course of Zosyn for a pseudomonal UTI which she completed on [**1-6**]. She now presents with nausea and vomiting. She reports symptoms started 2 nights ago after receiving a dose of antibiotics for cellulitis. After having the medication mixed in applesauce she began having nonbilious and nonbloody vomitus. She denied associated abdominal pain, fever or chills. She was then given multiple nausea medication and felt that the medications were making her feel more nauseous. This persisted over the next day and there was concern for ileus so KUB was obtained today which revealed some dilated loops of small bowel so she was transferred to the hospital. In the ED she had a low grade temp to 100.4 with CXR read as could not rule out PNA so she was given a dose of Zosyn. She was given 12.5mg of Anzemet for nausea and tyenol for low grade temp. Due to elevated Alk phos she also underwent RUQ U/S which revealed.... She also had a large BM and nausea improved. She now reports feeling hungry and has no current complaints. . Past Medical History: Atrial fibrillation on Coumadin Valvular heart disease Hypertension Hypothyroidism Rectal prolapse Hemorrhoids Monoclonal gammopathy of undertermined significance Pernicious anemia Cholecystitis Past Surgical History; Hernia repair Eye surgery Hemorrhoid stapling procedure [**3-/2131**] Altemeier procedure [**1-/2131**] clipping for rectal prolapse Social History: Pt lives alone in an [**Hospital3 **] in [**Location (un) **]. She receives food services but is otherwise independent. [**Name (NI) 1094**] son comes to visit pt once or twice per week and talks to pt on telephone 3 times a day. Pt has friends in the [**Hospital3 **]. . Pt grew up in [**Location (un) **] with 5 brothers and 4 sisters. Pt completed high school. Pt has one son. [**Name (NI) 1094**] husband died in [**Month (only) 359**], after spending 3 years in a nursing home due to Alzheimer's disease. Pt used to visit her husband there every day. . Tobacco: denies cigarette use. smoked a pipe once/week for [**12-29**] years EtOH: denies drugs: denies Family History: father: diabetes, complicated by foot amputation; heart attack mother: HTN siblings: all deceased, cancer x 2 sisters, type unknown; Alzheimer's; heart attack son, 2 grandsons, 1 great grandson: good health Physical Exam: T 97.1 HR 108 BP 118-70 RR 18 O2Sat 96% [**Female First Name (un) **] Gen-NAD HEENT-pupil 3mm on left 2mm on rt but reactive bilat, no elev JVP, MMM, no ant or post cerv LAD, thyroid normal size Hrt-tachy irreg rhythm, nS2S2, [**1-29**] SM at LLSB Lungs-poor air movement at bases, no crackles Abd-soft, mod distended, NABS, nontender Extrem-severe kyohosis, 2+ rad but absent dp pulses bilat, no LE edema Neuro-CNII-XII intact Skin-1cm ulcer on left upper back with surrounding erythema but no induration, ecchymosis on left shin Pertinent Results: [**2132-1-14**] 05:28PM LACTATE-1.3 [**2132-1-14**] 05:27PM LD(LDH)-160 TOT BILI-0.4 [**2132-1-14**] 05:27PM GGT-188* [**2132-1-14**] 05:27PM TSH-19* [**2132-1-14**] 02:00PM GLUCOSE-112* UREA N-20 CREAT-0.9 SODIUM-138 POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-29 ANION GAP-17 [**2132-1-14**] 02:00PM ALT(SGPT)-37 AST(SGOT)-49* LD(LDH)-178 ALK PHOS-328* AMYLASE-100 TOT BILI-0.5 [**2132-1-14**] 02:00PM LIPASE-76* GGT-199* [**2132-1-14**] 02:00PM ALBUMIN-3.6 CALCIUM-10.1 PHOSPHATE-4.4 MAGNESIUM-2.5 [**2132-1-14**] 02:00PM WBC-13.8* RBC-3.05* HGB-9.9* HCT-28.9* MCV-95 MCH-32.5* MCHC-34.3 RDW-14.6 . KUB-Non-specific bowel gas pattern with mild gaseous distention of a few loops of small bowel. Extensive amount of stool throughout the colon suggests constipation. . CXR- Persistent moderate bilateral pleural effusions and atelectasis of the lower lobes, right middle lobe, and lingula. Underlying pneumonia cannot be definitively excluded. . RUQ U/S-pericholecystic fluid, gallstones, no dilated ducts but limited view with some sludge in common bile duct, unable to tell if acute or chronic so would recommended HIDA if clinically indicated per wet read . ECG- 1. Afib at 150, nl axis, low voltage, biphasic T's in v3-6 Brief Hospital Course: A/P-89 yo female with hx of afib, MGUS, with recent rectopexy and loop sigmoid colostomy for rectal prolopse [**12-17**] complicated by acute renal failure and then readmit to the hospital for SOB [**Date range (1) 40090**] now representing with nausea and vomiting. . # Sepsis: she has multiple signs of systemic inflammation with hypotension. BP has responded to early fluid resuscitation. [**Last Name (un) 104**] stim appropriate. Continues to have pressor requirement w/worsening BP and continued difficulties w/rate control. - IV fluid bolus for goal CVP 12-15 (ECHO with preserved EF) - continue phenylephrine gtt to keep MAP > 65 - f/u BCX, UCX - continued Vanc/Zosyn/Flagyl for broad coverage . # Pulm Edema/Increased oxygen requirement: Likely component of pulm edema from fluid resuscitation. Continue resuscitation as necessary for now for organ perfusion. Monitored clinically for worsening edema. . # ?Cholecystitis: Initially, concerning for this with leukocytosis, elevated alk phos, and evidence of gallbladder inflammation on exam. - GI consulted, recs re: perc drainage - [**Doctor First Name **] consulted, recs: but not to OR until HD stable - Biliary consulted, recs: no need for ERCP at this point as no evidence of ductal dilitation on RUQ U/S - continued Vanc/zosyn/flagyl . # Elevated amylase/lipase: Now trending downward. Likely [**12-28**] transient onstructive pancreatitis and hypotension from sepsis - follow amylase and lipase daily - follow LFTs . Despite above interventions, pt continued to have hemodynamic compromise. Family was notified of decompensation and pt was made CMO. Pt passed away with her family around her. Autopsy was denied. Medications on Admission: . Meds- CaCarbonate 650mg [**Hospital1 **] Docusate 100mg [**Hospital1 **] Pepcid 20mg qd Lasix 20mg qd levothyroxine 150mcg qd Losartan 50mg [**Hospital1 **] Toprol XL 125mg qd MVI Vit D Coumadin brand name Ambien 2.5mg qhs prn lactulose prn tid Tigan 200mg q6 Keflex 500mg tid Compazine 10mg prn Maalox MgHydroxide 30ml prn Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none

[ "276.51", "576.1", "427.31", "560.1", "394.1", "428.0", "518.81", "707.02", "577.0", "401.9", "584.9", "250.00" ]

icd9cm

[ [ [] ] ]

[ "38.93", "34.91", "38.91" ]

icd9pcs

[ [ [] ] ]

7306, 7315

5222, 6901

305, 311

7367, 7377

3963, 5199

7430, 7437

3188, 3396

7277, 7283

7336, 7346

6927, 7254

7401, 7407

3411, 3944

232, 267

339, 2114

2136, 2492

2508, 3172

9,005

110,274

17816+56889

Discharge summary

report+addendum

Admission Date: [**2179-5-16**] Discharge Date: [**2179-5-20**] Service: CCU CHIEF COMPLAINT: The patient was transferred to [**Hospital1 18**] from [**Hospital 4199**] Hospital for ST elevation MI. HISTORY OF THE PRESENT ILLNESS: The patient is an 85-year-old female transferred from [**Hospital 4199**] Hospital after originally being admitted there on [**2179-5-13**] for treatment of right foot fracture and left ankle sprain which she sustained during a fall at home. The patient was in the rehabilitation unit of the hospital today when she had a syncopal episode while using the commode after a brief loss of consciousness. An EKG was done and the patient was found to be bradycardiac with 5 mm ST segment elevations in V3 through V6, II, III, and aVF. The patient also complained of chest pressure and had an episode of emesis. The episode occurred at 10:20 a.m. The patient was started on heparin and was administered Retavase. The patient was also given aspirin, Percocet, and IV nitroglycerin. Her chest pressure resolved on presentation to [**Hospital1 18**]; however, the patient continued to complain of dyspnea and diaphoresis. She also reported additional nausea but had no emesis since the morning. The patient cites no history of bleeding disorders. She had an EGD two years ago which revealed mild gastritis. PAST MEDICAL HISTORY: 1. Hypothyroidism. 2. Multiple bilateral rotator cuff surgeries. 3. Total abdominal hysterectomy. 4. Right foot fracture on [**2179-5-13**]. MEDICATIONS AT HOME: 1. Synthroid 50 micrograms p.o. q.d. 2. Aspirin 81 mg p.o. q.d. MEDICATIONS ON TRANSFER: 1. Darvocet. 2. Restoril 50 mg h.s. p.r.n. 3. Synthroid 50 mg p.o. q.d. 4. Aspirin 81 mg p.o. q.d. ALLERGIES: The patient is allergic to iodine. SOCIAL HISTORY: The patient denied the use of tobacco, alcohol, or drugs. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 96.9, blood pressure 116/58, heart rate 73, respiratory rate 20, 02 saturation 95% on room air. General: The patient was mildly uncomfortable, in no acute respiratory distress, lying flat in bed. HEENT: Mucous membranes moist. Oropharynx clear. The pupils were equally round and reactive to light. Neck: No JVD, supple. Chest: Fine crackles at the bases bilaterally. No wheezes. Heart: Regular rate and rhythm, II/VI systolic murmur at the apex. No S3 or S4. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Extremities: Bilateral feet and ankles wrapped in bandages. Ecchymoses present on the lower extremities. Neurologic: Alert and oriented times three. Examination otherwise nonfocal. LABORATORY DATA FROM THE OUTSIDE HOSPITAL: CK 43, troponin less than 0.01. Hematocrit 41. The initial EKG at the outside hospital showed 5 mm ST segment elevations in V3 through V6, 2 mm ST segment elevation in II, III, and aVF. Prior to lysis, EKG disclosed 2 mm ST segment elevation in V3 through V6, 1 mm ST segment elevation in II, III, and aVF. Following the administration of thrombolytic agents, the patient had 1 mm ST segment elevation in II, III, aVF, V3 through V6. IMPRESSION: This is an 85-year-old female with ST elevation MI, status post lytic therapy with continued symptoms of chest pain. The patient was admitted to [**Hospital1 18**] for cardiac catheterization and transferred to the CCU for further management. HOSPITAL COURSE: 1. CARDIOVASCULAR: A. CAD: The patient was taken to the Cath Lab for cardiac catheterization. Coronary angiography of the right dominant circulation revealed no significant residual coronary artery disease. The LMCA was short and had no significant stenosis. The LAD had no significant narrowing but flow down the arteries seemed to pause in the midvessel. The LAD supplied a single bifurcating V1 that had no significant disease. The left circumflex was free of significant disease and gave rise to a moderate sized OM1 and a large OM2 before terminating in the AV groove. The RCA had mild luminal irregularities and supplied small PDA and PLV branches. Resting hemodynamics revealed moderately elevated left ventricular filling pressure with an LVEDP of 22 mmHg in the setting of normal systemic arterial blood pressure. There was evidence of moderate pulmonary hypertension with PA pressures of 43/13/26 mmHg. The cardiac output was preserved at 5.1 liters per minute. No significant gradient across the aortic valve was detected. Left ventriculography demonstrated anterolateral, apical, and inferior apical akinesis with a calculated left ventricular ejection fraction of 53% but a visually observed left ventricular ejection fraction of 30%, severe 3+ mitral regurgitation was seen. The patient returned to the CCU for further observation. She was administered aspirin, heparin, and beta blocker. Her cardiac enzymes were cycled and CKs peaked around 300. Lipid profile split disclosed an HDL of 66, LDL of 113. Since the patient did not have any demonstrable CAD, she was not started on a statin. ACE inhibitor was initiated when the patient's blood pressure could tolerate this. B. PUMP: The patient underwent an echocardiogram on [**2179-5-17**]. Echocardiogram disclosed resting regional wall motion abnormalities including akinesis of the lower half of the LV with a dyskinetic apex. There was a moderate resting left ventricular outflow tract gradient observed. There was no LV apical thrombus. There was moderate to moderately severe mitral regurgitation ([**3-15**]+). The patient ejection fraction was 25%. As mentioned above, the patient was started on a beta blocker and ACE inhibitors. C. RHYTHM: The patient remained in normal sinus rhythm during her hospital stay. D. ANTICOAGULATION: Due to the patient's poor ejection fraction and apical akinesis, it was decided that the patient should be started on Coumadin. The patient's goal INR is [**3-15**]. 2. HEMATOLOGIC: On [**2179-5-17**], it was noted that the patient's hematocrit dropped to 27.3. A CT scan of the abdomen did not disclose evidence of retroperitoneal bleed. A right groin ultrasound did not show evidence of hematoma. There was, however, a small AV fistula observed. The patient was given a total of 3 units of packed red blood cells during her hospital stay. 3. VASCULAR: As noted above, the right groin ultrasound disclosed a small AV fistula. There was no evidence of hematoma or pseudoaneurysm. A Vascular Surgery consult was obtained. The vascular surgeons noted that the patient had excellent distal flow with good dorsalis pedis and posterior tibial pulses. There was no indication for operative intervention. The patient will undergo follow-up right groin ultrasound in six weeks. 4. MUSCULOSKELETAL: As noted above, the patient had been admitted to [**Hospital 4199**] Hospital due to right third metatarsal fracture. An Orthopedics consult was obtained for evaluation of the patient's fracture. It was recommended that the patient wear a cast shoe on her right foot for comfort and support. She may weightbear as tolerated. In addition, the patient was noted to have a left ankle sprain. She was given an air cast for her left foot. The patient was instructed to rest, elevate, and weightbear with this foot as tolerated. The patient may walk with assistance. She will follow-up with Dr. [**Last Name (STitle) 284**] from Orthopedic Surgery in two weeks. 5. NUTRITION: The patient was maintained on a Heart Healthy Diet during her hospital stay. 6. ENDOCRINE: The patient continued on levothyroxine 50 mg p.o. q.d. 7. GASTROINTESTINAL: The patient was maintained on a bowel regimen during her hospital stay. DISPOSITION: The patient is to be discharged to a rehabilitation facility. DISCHARGE CONDITION: Good. DISCHARGE MEDICATIONS: 1. Lisinopril 2.5 mg p.o. q.d. 2. Levothyroxine 50 mg p.o. q.d. 3. Enteric coated aspirin 325 mg p.o. q.d. 4. Lopressor 12.5 mg p.o. b.i.d. 5. Coumadin 5 mg p.o. q.d. DISCHARGE INSTRUCTIONS: 1. The patient will follow-up with Dr. [**Last Name (STitle) 284**] from Orthopedic Surgery in one to two weeks, phone number is [**Telephone/Fax (1) 49447**]. 2. The patient is to undergo a right femoral groin ultrasound on [**2179-7-9**] at 10:30 a.m. Ultrasound is required to confirm that right femoral AV fistula has resolved. The patient should follow-up with Dr. [**Last Name (STitle) **], from Vascular Surgery. The phone number is [**Telephone/Fax (1) 1784**]. 3. The patient will follow-up with her primary care physician in two weeks. The patient's primary care doctor is Dr. [**First Name (STitle) **] [**Name (STitle) 49448**] at [**Telephone/Fax (1) 49449**]. 4. The patient will be referred to a cardiologist with whom she will follow-up within two weeks. DISCHARGE DIAGNOSIS: 1. Nerve-limiting coronary artery disease. 2. Moderate systolic and diastolic ventricular dysfunction. 3. Moderate pulmonary hypertension. 4. Severe 3+ mitral regurgitation. 5. Acute myocardial infarction. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Last Name (NamePattern1) 5092**] MEDQUIST36 D: [**2179-5-19**] 03:43 T: [**2179-5-19**] 16:02 JOB#: [**Job Number 49450**] Name: [**Known lastname 9153**], [**Known firstname **] Unit No: [**Numeric Identifier 9154**] Admission Date: [**2179-5-16**] Discharge Date: [**2179-5-20**] Date of Birth: [**2094-4-12**] Sex: F Service: ADDENDUM: Upon further discussion of the patient's fall risks, it was decided that the patient will not be started on Coumadin, so this medication will be discontinued. Furthermore, it was decided that the patient will be started on Atorvostatin 10 mg p.o. q.d. The patient will have a right groin ultrasound on [**Last Name (LF) 3032**], [**2179-7-9**], at 10:30 a.m. She will follow-up with Dr. [**Last Name (STitle) 4107**] in the Vascular Surgery Clinic on [**2179-7-13**] at 1:00 p.m. The patient will follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 677**] from Cardiology on [**2179-6-1**] at 10:40 a.m. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1729**], M.D. [**MD Number(1) 6268**] Dictated By:[**Last Name (NamePattern1) 4047**] MEDQUIST36 D: [**2179-5-20**] 11:02 T: [**2179-5-20**] 11:15 JOB#: [**Job Number 9155**]

[ "416.8", "998.12", "244.9", "410.71", "V58.61", "E878.8", "V54.16", "424.0", "997.2" ]

icd9cm

[ [ [] ] ]

[ "37.23", "88.56", "88.54" ]

icd9pcs

[ [ [] ] ]

7774, 7781

7804, 7977

8802, 10473

3403, 7752

8001, 8781

1543, 1610

107, 1354

1899, 3385

1635, 1787

1376, 1522

1804, 1884

20,374

133,497

4211+4212

Discharge summary

report+report

Admission Date: [**2100-8-16**] Discharge Date: [**2100-8-20**] Date of Birth: [**2044-7-18**] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF THE PRESENT ILLNESS: The patient is a pleasant 56-year-old white male with a history of insulin-dependent diabetes mellitus, multiple sclerosis, hypertension, and peripheral vascular disease, with gangrenous left third toe, who underwent angiogram for his left foot which revealed a long SFA occlusion and significant tibial disease. The patient was scheduled to have popliteal bypass and needed cardiac clearance prior to surgery. The patient underwent an echocardiogram on [**2100-7-28**] which revealed infiltrative cardiomyopathy. A Persantine MIBI revealed a reversible anterior apical defect. Cardiac catheterization was done on [**2100-8-5**] and revealed LM CAD three vessel coronary artery disease with normal EF. The patient subsequently was referred to Cardiothoracic Surgery for coronary artery bypass grafting. The patient denied ever having chest pain, shortness of breath, nausea, vomiting, or diaphoresis. PAST MEDICAL HISTORY: 1. Hypertension. 2. Insulin-dependent diabetes mellitus with retinopathy. 3. Multiple sclerosis times nine years with limited movement of his right side. 4. Peripheral vascular disease with left third toe gangrene. 5. Hypercholesterolemia. 6. Status post cataract surgery in [**2099**]. 7. Status post right retinal surgery [**10**] years ago. 8. Cardiomyopathy. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: Positive tobacco, one pack per day times 40 years, rare alcohol. The patient lives with his wife in [**Name (NI) 1439**], [**State 350**]. ADMISSION MEDICATIONS: 1. Humalog insulin 4 units q.a.m. 2. NPH insulin 3 units q.a.m. 3. Avonex 10 cc intramuscularly q. week for MS [**First Name (Titles) **] [**Last Name (Titles) 4085**]. FAMILY HISTORY: The patient's father died at 75 of a stroke. Mother died at 70 of pancreatic cancer. All but one sibling, a total of seven, have diabetes. REVIEW OF SYSTEMS: General: The patient was feeling mildly anxious, pain-free from a cardiac standpoint with complaints of pain in his left foot. HEENT: Positive right eye cataract surgery. Positive right eye retinal surgery. Positive diabetic neuropathy. Negative dentures. Positive [**Location (un) 1131**] glasses. Respiratory: Negative cough. Negative hemoptysis. Negative shortness of breath. Negative dyspnea on exertion. Negative PND. Negative recent URI. Cardiac: Negative chest pain. Negative palpitations. Negative MI history. GI: Negative ulcers. Negative GERD. Mild constipation with decreased appetite over the past few weeks, negative melena. GU: Positive increased length of urination. Decreased urinary flow strength. Negative prostate disease. Vascular: Positive peripheral vascular disease with gangrenous left third toe, negative varicose veins. Positive occasional claudication recently. Endocrine/hematology: Positive IDDM. Negative thyroid. Negative anemia and bleeding disorders. Neurologic: Negative stroke or TIA. Negative headache. No lightheadedness. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient was afebrile. The vital signs were stable on admission. General: The patient was a well-dressed, well-nourished male in no acute distress, appearing stated age. HEENT: The pupils were equal, round, and reactive to light and accommodation. Extraocular muscles were intact. Negative dentures. Normal buccal mucosa and dentition. Neck: Supple without JVD, without lymphadenopathy, without thyromegaly. Chest: Clear to auscultation bilaterally. Negative wheezing, rhonchi, or rales. Cardiac: Regular rate and rhythm without murmurs, rubs, or gallops. Positive S1 and S2. Abdomen: Soft, nontender, nondistended, normoactive bowel sounds, negative guarding, rebound, or rigidity. Extremities: Cold left foot with gangrenous left third toe. Negative edema. Negative varicosities. Carotid pulses, right and left, were 2+ without bruits. Radial were 2+. Femorals 2+ bilaterally. DP and PT were nonpalpable bilaterally. Neurologic: Cranial nerves II through XII were grossly intact. Positive left tender foot which made ambulation difficult, uses a walker at home. The right side of the body was limited motion due to MS. LABORATORY/RADIOLOGIC DATA: On admission, white count 14.1, hematocrit 42.7, platelets 560,000 with PT of 12.5, PTT 30.8, INR 1.0. The U/A was negative. Chemistries were 135, 4.1, 95, 29.6, and 270 for sodium, potassium, bicarbonate, BUN, creatinine, and glucose respectively. ALT 11, AST 11, alkaline phosphatase 102, amylase 7, total bilirubin 0.5, albumin 4. Cardiac catheterization showed LMCA 50%, proximal LAD 80%, left circumflex moderate distal RCA with 80% right PDA, EF 70%, negative MR. Echocardiogram showed marked concentric left ventricular hypertrophy with markedly thickened walls suggestive of amyloid involvement without regular wall motion abnormalities without AS. Chest x-ray on [**2100-8-4**] showed no active lung disease, biapical fibronodular opacities. Lungs were clear. Without heart or mediastinal abnormalities. HOSPITAL COURSE: The patient was taken to the Operating Room on [**2100-8-16**] with the diagnosis of coronary artery disease and coronary artery bypass graft times five was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] and first assistant [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12373**], M.D. LIMA grafts were LIMA to LAD, saphenous vein graft to PDA, saphenous vein graft to D3, saphenous vein graft to OM with sequential to D1. Mediastinal and left pleural tube were placed postoperatively. The patient was transferred to the unit on a Neo-Synephrine, insulin, and propofol drip. Vascular Surgery followed the patient throughout the hospital course to discharge. The patient did well postoperatively. On postoperative day number one, the patient was started on Lopressor 25 mg b.i.d. and drips were weaned off. By postoperative day number two, the patient's left foot had worsened with gangrene of toes two to four. The patient was continued on antibiotics of levofloxacin and Flagyl and TMA with left fem-[**Doctor Last Name **] was noted to require a salvage procedure. On postoperative day number two, the patient was on the floor and continued to do well. By postoperative day number three, the patient had slight increases in Lopressor dosages to 75 b.i.d. secondary to increased heart rate but the patient was in sinus rhythm. The patient had vein mapping of upper extremities on postoperative day number three showing patent right and left basilic and cephalic vein and was discharged on [**2100-8-21**] postoperative day number five in good condition. FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **] in clinic in one to two weeks. The patient is to return for vascular procedure. The patient was also instructed to follow-up with primary care physician in one to two weeks, a cardiologist in two to three weeks and Dr. [**Last Name (STitle) 1537**] in three to four weeks for further follow-up. DISCHARGE MEDICATIONS: 1. Flagyl 500 mg p.o. t.i.d. times one week. 2. Lasix 40 mg p.o. b.i.d. times one week. 3. Lopressor 75 mg p.o. b.i.d. 4. Levofloxacin 500 mg p.o. q.d. times one week. 5. Potassium chloride 20 mg p.o. b.i.d. times one week. 6. Colace 100 mg p.o. b.i.d. 7. Percocet one to two tablets p.o. q. four hours for pain. 8. Aspirin 325 mg p.o. q.d. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Hypertension. 3. Hypercholesterolemia. 4. Status post coronary artery bypass graft. 5. Peripheral vascular disease with left foot gangrene. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern4) 7013**] MEDQUIST36 D: [**2100-8-20**] 04:01 T: [**2100-8-20**] 16:55 JOB#: [**Job Number 18314**] Admission Date: [**2100-8-16**] Discharge Date: [**2100-8-26**] Date of Birth: Sex: Service: VASCULAR SURGERY ADDENDUM HOSPITAL COURSE: The patient was scheduled to be discharged home on [**2100-8-20**], following his coronary artery bypass grafting times five by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] on [**2100-8-16**]. The patient was to see Dr. [**Last Name (STitle) **] in the office after discharge to arrange left lower extremity bypass graft and amputation of his gangrenous left toes. At discharge, the patient requested left lower extremity revascularization during current admission. Dr. [**Last Name (STitle) **] agreed to proceed on [**2100-8-23**]. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Cardiology, cleared the patient for left leg bypass graft. The patient continued on Levofloxacin and Flagyl. On [**2100-8-23**], the patient underwent an uneventful left common femoral to above-the-knee popliteal artery bypass graft with PTFE. Postoperatively the patient had a warm leg with a palpable popliteal pulse and Doppler signals at the pedal pulses bilaterally. The right second to fifth toes remained dry, gangrenous and erythema at the base of the toes. The patient was evaluated by Physical Therapy on [**2100-8-17**]. They recommended that the patient have physical therapy if he was discharged home rather than to [**Hospital 3058**] rehabilitation. At the time of discharge, the patient's sternal incision was cleaned and dry and intact. There was no erythema. Steri-Strips were in place. Right saphenectomy incisions were clean, dry, and intact. Steri-Strips were placed. The left leg bypass graft incision was clean, dry, and intact. The patient was to continue on Levofloxacin for two more weeks. He was started on beta-blocker postoperatively, as well as ACE inhibitor per Dr. [**Last Name (STitle) **] of Cardiology. .................. 100 mg p.o. b.i.d. was started. The patient was to follow-up with Dr. [**Last Name (STitle) **] in the office on [**8-31**] to evaluate his gangrenous toes and to schedule a TMA. The patient was instructed to follow-up with Dr. [**Last Name (STitle) 1537**] of Cardiothoracic Surgery. Dr. [**Last Name (STitle) **] asked the patient to follow-up with him in the office in [**2-28**] weeks. DISCHARGE MEDICATIONS: 1. Pletal 100 mg p.o. b.i.d. 2. Metoprolol 25 mg p.o. b.i.d. 3. Lisinopril 5 mg p.o. q.d. 4. Aspirin 325 mg p.o. q.d. 5. Colace 100 mg p.o. b.i.d. 6. NPH Insulin 25 U subcue q.a.m. 7. Humalog sliding scale q.i.d. 8. Percocet [**11-26**] tab p.o. q.4-6 hours p.r.n. pain. 9. Levofloxacin 500 mg p.o. q.d. x 4 weeks. CONDITION ON DISCHARGE: Satisfactory. DISPOSITION: Home with services. PRIMARY DIAGNOSIS: 1. Unstable coronary artery disease; coronary artery bypass grafting times five on [**2100-8-16**], by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. 2. Ischemic gangrene, left foot; left femoral to above-the-knee popliteal PTFE bypass graft on [**2100-8-23**], by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. SECONDARY DIAGNOSIS: 1. Blood loss anemia status post transfusion. 2. Diabetes. 3. Hypertension. 4. Hypercholesterolemia. 5. Multiple sclerosis times nine years with limited movement on the right side. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**] Dictated By:[**Last Name (NamePattern1) 3954**] MEDQUIST36 D: [**2100-9-21**] 19:52 T: [**2100-9-21**] 19:54 JOB#: [**Job Number 18315**]

[ "440.24", "414.01", "357.2", "362.01", "250.61", "250.51", "425.7", "340", "277.3" ]

icd9cm

[ [ [] ] ]

[ "39.29", "89.68", "39.61", "36.15", "36.14", "99.62" ]

icd9pcs

[ [ [] ] ]

1915, 2056

10562, 10887

7686, 8320

8338, 10539

1725, 1898

2076, 3189

11369, 11829

10981, 11348

3204, 5218

1118, 1544

1561, 1702

10912, 10962

10,207

145,781

7446

Discharge summary

report

Admission Date: [**2142-2-5**] Discharge Date: [**2142-2-6**] Date of Birth: [**2062-9-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5827**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 79 yo M w/ hx vascular dementia, aphasia w/ G-tube for [**Last Name (un) **] aspiration, chronic foley transferred from NH for BRB in mouth. Pt then had another episode of "large amount" ~ [**11-26**] cup of bright red blood total of both times of hemoptysis in the ED after arrival. . In ED s/p G-tube lavage w/ old clot, easily cleared. S/p levofloxacin, flagyl, 2L IV NS, protonix. In ED discussion w/ pt's wife and [**Name (NI) **] [**Last Name (NamePattern1) **], MD and wife wants "everything done." Pt full code status confirmed. . Past Medical History: Renal/GU: 1. Nephrolithiasis/Uretolithiasis/Urosepsis a.Proteus urosepsis secondary to obstructing uretal stone, relieved by percutaneous nephrostomy tube, complicated by perinephric hematoma. Hospitalized [**2141-3-29**] x14d. b.Hematuria from nephrostomy secondary to renal stone. Hospitalized [**2141-4-16**] x5d. c.Tube dislodged [**2141-5-25**] and was replaced d.Klebsiella urosepsis secondary to uretrolithiasis. Hospitalized [**2141-8-7**] x2d e.Uretal stone was passed during hospitalization [**2141-8-7**]. f. Percutaneous nephrostomy tube removed CV: 1.Hypertension. 2.Descending thoracic aortic aneurysm. GI: 1.G tube placement 2.Dysphagia secondary to CVA, plus aspiration pneumonia status/precautions 3.Cholelithiasis 4. History of elevated liver function tests. PULM: 1.Aspiration pneumonia. Hospitalized [**6-/2136**] MSK: 1.S/p Proteus abscess. Hospitalized [**7-27**]. Status post incision and drainage. Neuro/Psych: 1.Cerebrovascular accident leading to dementia and aphasia. Nonverbal. 2.Depression 3.Atypical Psychosis FEN: 1.H/o of hypernatremia Social History: The patient is not verbal. He lives at [**Hospital3 2558**]. His family is involved in his care. Family History: N/C Physical Exam: PE: Tm 101.8, Tc 98 HR 89 (100-115) BP 112/55 (100-133/60-80's) 21 (18-24) 100% 2L NC Gen: Thin cauc M lying in stretcher in NAD, missing 2 front teeth, not cooperative w/ exam, nonverbal. HEENT: anicteric with dried blood at corners of mouth Heart: RR, S1, S2, no m/r/g no AI murmus Lungs: no rales, no crackles, no wheezing ABd: G tube in place dressing c/d/i, mildly Distended, NT, no masses Ext: no edema GU: chronic indwelling foley in place, clear yellow urine in bag Rectal: guaiac positive per ED Pertinent Results: [**2142-2-5**] 11:30PM WBC-9.8 RBC-3.14* HGB-9.4* HCT-28.4* MCV-90 MCH-29.8 MCHC-33.0 RDW-14.4 [**2142-2-5**] 11:30PM PLT COUNT-202 [**2142-2-5**] 11:30PM PT-13.1 PTT-26.9 INR(PT)-1.1 [**2142-2-5**] 12:50PM LACTATE-1.2 [**2142-2-5**] 12:40PM WBC-14.8* RBC-3.62* HGB-11.1* HCT-31.4* MCV-87 MCH-30.6 MCHC-35.2* RDW-14.0 [**2142-2-5**] 12:40PM NEUTS-80.8* LYMPHS-15.9* MONOS-2.3 EOS-0.9 BASOS-0.1 [**2142-2-5**] 12:40PM PLT COUNT-176 [**2142-2-5**] 06:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2142-2-5**] 06:50AM URINE BLOOD-SM NITRITE-POS PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2142-2-5**] 06:50AM URINE RBC-0-2 WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-0-2 [**2142-2-5**] 06:00AM GLUCOSE-125* UREA N-42* CREAT-1.1 SODIUM-142 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-28 ANION GAP-14 [**2142-2-5**] 06:00AM ALT(SGPT)-21 AST(SGOT)-30 ALK PHOS-70 TOT BILI-0.5 [**2142-2-5**] 06:00AM WBC-16.9*# RBC-4.35* HGB-12.8* HCT-38.2* MCV-88 MCH-29.3 MCHC-33.4 RDW-14.1 [**2142-2-5**] 06:00AM NEUTS-71.8* LYMPHS-24.9 MONOS-2.0 EOS-1.2 BASOS-0.2 [**2142-2-5**] 06:00AM PLT COUNT-283 Brief Hospital Course: 79 yo M NHR w/ hx CVA, chronic aspiration, UTI, dementia, CAD a/w hemoptysis, descending aortic pseudoaneurism and fever. . # HEMOPTYSIS - 2x/12h of ~ [**11-26**] cup of hemoptysis. Given his pseudoaneurism, worry about erosion into bronchus, however pt evaluated by CT surgery who feel that pt is too high risk for OR. Additionally, pt could have another etiology for hemoptysis as more bleeding would be expected from an aortopulmonary fistula. The differential diagnosis is long esp bronchiectasis in this pt w/ hx of recurrent asp pna, TB (given his NHR status), PE, bronchitis, pulm AVM, bronchogenic ca (chronic retrocardiac opacity concerning for post-obstructive lung collapse), and pna. He is HD stable w/ good resp status and would not intubate at this time. Should he hemoptysize more, he should lie on the abnormal lung (likely L lung given CXR) in the Left lateral decubitus position w/ plans for intubation to protect the good lung. Hct 38---31 at 1:00pm - appreciate CT surgery input - admit to ICU for BP control and closer monitoring - plan for bronchoscopy to evaluate site of bleeding - epistaxis not completely ruled out as a cause for "hemoptysis" - plant PPD: not coughing - con't levo for h/o quinolone sensitive UTI - con't hold anticoagulants - BP control - hold antihypertensives for BP <130 given worry re: bleeding - s/p T&Cross, 2PIV's . # FEVER - likely UTI given prior + Urine cultures for hightly-resistent pseudomonas (was only sensitive to [**Month/Day (2) **]/Gent/[**Last Name (un) **]. Finished 2 week course of Levo 250 during last admission)Was finishing course of Augmentin and Bactrium for "UTI" -Try to get cultre data at NH for this UTI - c/w Levo renal dosed. Await culture data. - f/u BCx x2, UCx, check sputum Cx -CT of chest without postobstructive PNA. levo should cover atypicals. Will add Vanc if fever/leukocytosis returns and zosyn. . #Hypertension (and relaive Hypotension): On HCTZ/Lisinopril as outpatient: Currently, relatively hypotensive as c/w baseline. -Lopressor 5mg IV q6 (for only BP >160) -Hold standing antihypertensive agents given hemorrage risk -Lactate normal: . Dementia: Has h/o of "atypical psycosis" only on Zoloft 50 qd. -Haldol 1 mg prn . Asthma: C/W PRN Ipr/Albuterol . # Contact - wife [**Telephone/Fax (1) 27297**]; #[**Name2 (NI) **]s: Has Right hand 14 guage and 16 guage. #FEN/GI: IVF/Blood/Lytes/PPI/NPO for likely bronch #Prophylaxis: Bowel reg. Pneumoboots/ Hold SQ Hep given risk for Bleed. # Code - full per discussion by PCP coverage [**Name9 (PRE) **] attending (Dr.[**Last Name (STitle) **],[**First Name3 (LF) **]) and ED Sr. Resident (Dr. [**Last Name (STitle) **], [**First Name3 (LF) **]). Overnight: Patient received 1 u PRBC with stable HCT checks. No further episodes of hemoptysis and remained hemodynamically stable overnight. Given his presentation, lack of further HCT decline or bleeding, and stable CT scan of aorta, felt that hemoptysis was best explained by tongue [**Last Name (un) 20694**] event or epitaxis and not herald bleed of a bronchial-aortic fistula. Given his poor functional status and proceedureal risk, bronchoscopy was defered. Patient remains full code at this time, but code status should be continued to be addessed in light of his aneurysm. Medications on Admission: MEDS: famotidine 20mg po q24h hctz 12.5mg po q24h lisinopril 20mg po q24h zoloft 50mg po q24h albuterol prn tylenol prn ipratropium prn Bactrim DS 1 tab po q12h x 3 days d1 = [**2142-1-12**] augmentin 500mg po q8h x 10days [**2142-1-31**] for UTI Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO once a day. 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Zoloft 50 mg Tablet Sig: One (1) Tablet PO once a day. 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day for 6 days: to complete a 7d course. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Hemoptysis from epistaxis v. tongue bite. Discharge Condition: Demented, stable. Discharge Instructions: Please resume all medications as previously prescribed. Followup Instructions: Please follow-up with PCP as needed

[ "438.11", "V55.1", "784.7", "441.2", "V13.01", "294.8", "401.9", "311", "599.0", "786.3", "438.82", "493.90" ]

icd9cm

[ [ [] ] ]

[ "96.07", "99.04" ]

icd9pcs

[ [ [] ] ]

8090, 8160

3857, 7127

324, 331

8246, 8265

2674, 3834

8369, 8408

2127, 2132

7425, 8067

8181, 8225

7153, 7402

8289, 8346

2147, 2655

274, 286

359, 905

927, 1996

2012, 2111

50,197

187,767

36097

Discharge summary

report

Admission Date: [**2192-11-6**] Discharge Date: [**2192-11-20**] Date of Birth: [**2128-5-9**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 4282**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Flexible sigmoidoscopy History of Present Illness: 64 year old Male who with recently diagnosed hepatocellular carcinoma who presented to the emergency room severe RUQ abdominal pain. The patient states the pain started 5 weeks prior to admission. He had a workup at [**Hospital6 34976**] and was found to have a large right hepatic lobe mass, consistent with hepatocellular carcinoma on biopsy. He was scheduled for outpatient oncology, but was unable to tolerate the pain, and so presented to the [**Hospital1 18**] ED for further pain management. The pain is stabbing, waxing and [**Doctor Last Name 688**], alleviated by lying on the right side, worsened by lying on his left side. He notes he was taking oxycodone at home, but this was not providing relief. At 5mg he was OK for side effects, but this did not cover his pain, but when this was increased up to 20mg, he stated he had GI upset. He is able to ambulate up two flights of stairs before he has to rest due to dyspnea. Following admission to Medicine service, he was found to be unresponsive on routine nurse exam at around 2 pm. His vitals were BP 94/62 HR 84 RR 16 82% on 2LNC. He was placed on 5L NC which improved the sats to 91% and NRB which improved to 97%. He was given 1L NS. He received 0.2 mg of IV nalaxone which improved his mental status in less than one minute. He coughed up approx 30 ml blood after this. His BP improved to 120s/60s. His blood pressure transiently decreased to 94/60 and responded to 100/48 after another 1L of NS. He received 30 mg of MS Contin at 8 am with another dose of 30 mg at 10 am. He has also received 15 mg of immediate release at 8 am and 10 am. . On arrival to ICU his vitals were T 98.2 HR 85 BP 61/48 which improved to 108/75 without intervention, 10 97% on 15L facemask. He was alert and oriented x 3. He denied any discomfort. He denies any chest pain, shortness of breath, nausea, vomitting, fever, chills, nightsweats, cough, cold, constipation, diarrhea, blood in stool, hematuria, or dysuria. He still has abdominal discomfort. Dyspnea on exertion was noted in the chart. . In the MICU, mental status improved with a total of 2 doses of Narcan. He was also treated with Lactulose for component of hepatic encephalopathy. Palliative care and Oncology were consulted for management of hepatic mass. . Past Medical History: Hepatitis C cirrhosis Hepatocellular carcinoma Diabetes Type II Benign Hypertension CAD: CABG x 3 in [**2185**] Osteoarthritis h/o IVDA Chronic Stable Asthma ?COPD IBD [**Doctor First Name **] hx: laprascopic cholecystectomy Left wrist surgery bilateral common iliac artery stents Social History: - ETOH, - TOB, -IVDU (history of all 3), Wife died in [**2-4**] of Brain Cancer Lives with stepdaughter, who is his primary caregiver and takes care of all his medications Family History: Non-Contributory Physical Exam: REVIEW OF SYSTEMS GEN: - Fevers, - Chills, - Weight Loss, - Weight Gain EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum Bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: - Nausea, - Vomitting, - Diarhea, + Abdominal Pain, - Constipation, - Hematochezia, - Melena PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - Hematuria, - Incontinence SKIN: - Rash, - Ulcers ENDO: - Heat/Cold Intolerance, - Polyuria, - Polydypsia MSK: - Myalgia, - Arthralgia, - Back Pain NEURO:- Weakness, - Vertigo, - Headache, - Neuropathy VASC: - Claudication, - Raynauds PHYSICAL EXAM: On presentation: VS: Tcurr 97.7, BP 116/64 , HR 72, RR 20, SAO2 92% GENERAL: Well Apearing, obese, No Apparent Distress Pain: [**6-7**] CRANIAL: Atruamatic, Normocephalic NECK: - Bruits ENT: Moist, - Oropharynx Lesions OPHTHO: Pinpoint Pupils, EOMI PUL: Clear to Auscultation B/L COR: Regular Rate and Rhythm, normal S1/S2, - MRG ABD: RUQ Tenderness with voluntary guarding, firm, + Bowel Sounds, - fluid wave, - Rebound EXT: - Cyanosis, - Clubing, - Edema NEURO: CAOx3, Non-Focal Pertinent Results: [**2192-11-6**] 12:05AM BLOOD WBC-7.8 RBC-4.87 Hgb-14.9 Hct-43.1 MCV-89 MCH-30.7 MCHC-34.7 RDW-13.9 Plt Ct-211 [**2192-11-6**] 12:05AM BLOOD Neuts-57.5 Lymphs-25.7 Monos-14.0* Eos-2.2 Baso-0.6 [**2192-11-6**] 12:05AM BLOOD PT-14.4* PTT-28.6 INR(PT)-1.3* [**2192-11-6**] 12:05AM BLOOD Glucose-77 UreaN-13 Creat-0.8 Na-139 K-4.3 Cl-105 HCO3-26 AnGap-12 [**2192-11-6**] 12:05AM BLOOD ALT-13 AST-37 CK(CPK)-30* AlkPhos-172* TotBili-PND [**2192-11-6**] 12:05AM BLOOD Albumin-3.1* Phos-4.1 [**2192-11-6**] 12:12AM BLOOD Lactate-2.0 [**2192-11-6**] 02:54AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2192-11-6**] 02:54AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-6.0 Leuks-NEG Time Taken Not Noted Log-In Date/Time: [**2192-11-6**] 12:13 am BLOOD CULTURE VENIPUNCTURE #2. Blood Culture, Routine (Pending): . CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2192-11-6**] 1:45 AM IMPRESSION: 1. No evidence of aortic dissection or pulmonary embolism. However, the subsegmental pulmonary arteries cannot be fully evaluated on this phase of contrast. 2. Infiltrating hepatic lesion involving the majority of the right lobe with relative sparing of segment VI. However, phase of contrast is not optimized for full evaluation of the liver and optimal evaluation with triphasic CT versus MRI recommended. Further progression of portal vein thrombosis involving the right portal vein with new extension into the main portal vein. 3. Coronary artery calcifications. Calcification of the aortic valve of unknown hemodynamic significance. 4. Emphasematous changes. . CHEST (PORTABLE AP) Study Date of [**2192-11-5**] 10:57 PM IMPRESSION: No evidence of acute cardiopulmonary process detected. No evidence of free intra-abdominal air. . [**2192-11-6**] CT ABD/Pelv: IMPRESSION: 1. No evidence of aortic dissection or pulmonary embolism. However, the subsegmental pulmonary arteries cannot be fully evaluated on this phase of contrast. 2. Infiltrating hepatic lesion involving the majority of the right lobe with relative sparing of segment VI. However, phase of contrast is not optimized for full evaluation of the liver and optimal evaluation with triphasic CT versus MRI recommended. Further progression of portal vein thrombosis involving the right portal vein with new extension into the main portal vein. 3. Coronary artery calcifications. Calcification of the aortic valve of unknown hemodynamic significance. 4. Emphasematous changes. . [**2192-11-8**] MRI Abdomen: IMPRESSION: 1. Large infiltrating and enlarging right hepatic mass, consistent with hepatocellular carcinoma. 2. Right portal vein thrombosis. 3. Cirrhosis. . [**2192-11-12**] EEG: IMPRESSION: This is an abnormal routine EEG due to the presence of a slow and abnormal background indicative of a mild encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. Nevertheless, there were no areas of focal slowing and there was no evidence of focal epileptiform discharges. . [**2192-11-12**] CT HEAD W/O contrast: IMPRESSION: No evidence of acute hemorrhage or shift of normally midline structures. Small, subcm hypodensity in left temporal lobe of uncertain significance- can relate to volume averaging or less likely a focus of ischemic or neoplastic etiology. Please note that MRI is more accurate for better assessment and can be considered. . [**2192-11-13**] CT ABD PELVIS: IMPRESSION: 1. Thickening of the hepatic flexure and sigmoid colon with fat stranding and fluid in the mesentery. These findings are new compared to most recent CT examination from [**2192-11-6**]. These findings are concerning for either an infectious or an ischemic process. Given patients history of inflammatory, an IBD flare is also a consideration. The terminal ileum and small bowel are normal in appearance. 2. Large heterogeneous mass occupying the right lobe of the liver with a clot in the right portal vein consistent with hepatocellular carcinoma. 3. Bibasilar atelectasis, right greater than left. 4. Infrarenal abdominal aortic stent graft with left and right iliac stents in apparently normal position. 5. Patent celiac artery, SMA, and SMV 6. Status post cholecystectomy. . [**2192-11-14**] ECHOCARDIOGRAM: The left atrium is moderately dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. 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. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. FLEXIBLE SIGMOIDOSCOPY: Multiple ulcers with mucosal erythema and friability, partially covered with yellowish membranes were found in the descending colon and proximal sigmoid colon. Brief Hospital Course: A/P: 64M who with history of Hepatitis C, recent diagnosis of hepatocellular carcinoma, diabetes mellitus type 2, CAD presented to the emergency room with 10/10 RUQ abd pain, with course complicated by altered mental status in the setting of opioid overdose. Patient's pain was controlled. He had a colonoscopy that showed multiple ulcers with mucoasl erythema and friability of descending and poximal sigmoid colon. He was started on po vancomycin with excellent effect and resolution of abdominal pain and diarrhea. He was discharge home in stable condition with a 6 week vancomycin taper and GI followup. # Abdominal pain/distention/BRBPR: Patient had small amount of BRBPR on [**2192-11-11**]. Hct was stable throughout hospital stay. Has recent history of Proctocolitis in [**2192-7-23**] was started on Asacol. Bowel thickening and mesenteric stranding in sigmoid on CT abd. Vancomycin po was started after flex sigmoidoscopy showed multiple ulcers with mucosal erythema and friability, partially covered with yellowish membranes were found in the descending colon and proximal sigmoid colon. Stool studies were negative. Cytology was pending at time of discharge. Patient to complete 6 week taper of po vancomycin and has follow up with his gastroenterologist. # Hepatocellular carcinoma: Diagnosed by biopsy 6 weeks ago, by biopsy. Currently the patient has thrombosis in the R portal vein with possible tumor invasion. At this time, patient is not a cancidate for surgical resection or palleative XRT/cyberknife. Pain treated with oxycodone. Patient has follow up with Dr. [**Last Name (STitle) 81885**], possible discussion of palliative chemo. Palliative care followed while in patient. # Altered mental status: Triggered for hypoxia and somnolence on [**2192-11-12**]. He had gotten 5mg morphine PO and symtoms mildly reversed with narcan administration (more alert, breathing more comfortably). ABG [**11-12**] shows chronic CO2 retention. Mental status resolved and appeared to be at baseline upon discharge. # Emphysematous changes/Blood tinged sputum: Patient reported to have coughed up 30 ml blood during MICU course. NG sunction was only trace guaic positive - Hct normal. CT chest without PE but was notable for insterstial lung abnormalities -> no clear explanation for blood tinged sputum. Pulm consult stated likely iatrogenic or multifactorial. He is a long-standing smoker, likely with underlying emphysema. Discharged on albuterol prn and standing ipratroprium inhalers. # Acute renal failure: Was likely [**12-31**] to ATC, also has contrast for PE-CT on [**2192-11-6**]. Also received ketorolac. Was resolved prior to discharge. # Diabetes: Home metformin held while in house and covered on sliding scale. Oral medication restarted upon discharge. # Hypertension: Was well controlled during hospital stay. Continued on home metoprolol and isosorbide. # CAD: Continued on home beta blocker. ASA held in setting of scope and restarted upon discharge. # IBD: Continued home asacol # ? Schizophrenia: Continued home depakote & citalopram # PPx - Patient received heparin # Code - Full Code Medications on Admission: asacol 1200mg tid asa 81mg daily isosorbide 30mg prn B12 amlodipine 10mg daily simvastatin 80mg daily neurontin 800mg tid divelproex 2000mg qhs atenolol 100mg daily citalopram 60mg daily lisinopril 5mg daily metformin 500mg daily, Levaquin (completed 7day course for UTI per patient) Discharge Medications: 1. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Mesalamine 1.2 g Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO three times a day. 4. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 5. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*2* 7. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*0 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. 9. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO once a day. 10. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 12. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for pain. 13. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 14. Vancomycin 125 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 1 weeks: Please follow this taper: Week [**11-30**]: 2 pills four times a day Week 3: 1 pill 4 times a day Week 4: 1 pill three times a day Week 5: 1 pill 2 times a day Week 6: 1 pill once a day. Disp:*190 Capsule(s)* Refills:*0* 15. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day. Disp:*1 inhaler* Refills:*2* 16. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*2* 17. Miconazole Nitrate 2 % Powder Sig: One (1) application Topical four times a day: apply to affected area. keep affect area clean and dry. Disp:*1 bottle* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 6138**] Home Care Services Discharge Diagnosis: Primary: Hepatocellular carcinoma Enteritis Hepatic cirrhosis COPD Secondary: CAD s/p CABG Diabetes type 2 COPD Discharge Condition: Good, VSS, on room air, tolerating PO Discharge Instructions: You came to the hospital for abdominal pain and to see Dr. [**Last Name (STitle) **] for your new diagnosis of hepatocellular cancer. You were sent to the ICU because you recieved too much morphine and were unresponsive but did not required intubation. The surgical service and radiation oncology state that your tumor is too big for either surgery or palleative radiation. You developed a distended abdomen and diarrhea while in the hospital and a CT scan showed inflammation of you colon. Stool tests were negative for C. diff or other bacteria. The gastroenterologist did a scope which showed colitis concerning for a c. diff infection. You were started on oral vancomycin which you will take for 6 weeks following tapered doses: - week [**11-30**]: 2 pills (250mg) every 6 hours - week 3: 1 pill (125mg) every 6 hours - week 4: 1 pill (125mg) every 8 hours - week 5: 1 pill (125mg) every 12 hours - week 6: 1 pill (125mg) once a day Medication changes: -Please take oxycodone as prescribed -Please take the vancomycin (the antibiotic for your diarrhea) as above -The dose of your Depakote and Neurontin have been changed. -Please take your other medications as prescribed. Please be sure to keep your appointment with you GI doctor as below. pain, fevers, chills, shortness of breath, nausea, vomitting, constipation, numbness/tingling, gait instability or other concerns. Followup Instructions: Please call your PCP [**Name9 (PRE) 81886**],[**Name9 (PRE) 81887**] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 81888**] for an appointment in the next 2-4 weeks. A message has been left for the office to call you to schedule an appointment. You have an appointment on [**2192-12-6**] at 2:30pm with your gastroentrologist, Dr. [**Last Name (STitle) 65193**]. Pleae call ([**Telephone/Fax (1) 50234**] if you need to change your appointment.

[ "250.00", "799.02", "070.54", "556.9", "584.9", "493.20", "401.1", "295.90", "414.00", "571.5", "155.0", "E935.2" ]

icd9cm

[ [ [] ] ]

[ "45.23" ]

icd9pcs

[ [ [] ] ]

15352, 15426

9818, 11538

307, 332

15583, 15623

4500, 5355

17058, 17511

3143, 3161

13298, 15329

15447, 15562

12990, 13275

15647, 16592

3903, 4481

5389, 9795

16612, 17035

253, 269

360, 2633

11554, 12964

2655, 2938

2954, 3127

12,113

163,258

4727

Discharge summary

report

Admission Date: [**2145-2-10**] Discharge Date: [**2145-2-16**] Service: MEDICINE Allergies: Augmentin / Penicillins / Moxifloxacin Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Dyspnea, LE edema, leg redness Major Surgical or Invasive Procedure: None History of Present Illness: 86M with history of HTN, DM, CAD, SVT, pAib, PVD, CKD, and recent hospitalization in the ICU from [**Date range (2) 19889**] requiring pressors/intubation presents from home with worsening symptoms of CHF and concern for cellulitis of L LE. History is gathered from the patient and his 2 daughters. They report that since discharge from rehab on [**1-19**], the patient has had gradually worsened SOB. Lately, he has been unable to sleep in bed (even when head of bed is elevated) and has preferred sleeping in his wheelchair. He has been on 2L continous nc at home since [**1-19**], but over the past 2 weeks, has noticed increasing dyspnea. No cough above baseline, no fevers. + sick contacts at home ([**Name (NI) **]) in his grandson and great-grandchildren. Family also has noted increased ankle swelling and edema in the patient's thighs. They report that his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], increased his dose of Lasix from 40 mg PO qday to 60 mg qday about 1 month ago and then to 80 mg PO qday about 1.5 weeks ago with little improvement. He was scheduled to see his PCP in clinic today, but the family decided to bring him to the ED instead. . In the ED, initial VS were 97.8 77 148/86 20 94% on 4L (on [**1-27**].5L home O2). Exam was notable for LE edema and rales; and small wounds on L LE. CXR showed no definite effusion, pulmonary edema, and possible pneumonia in RLL. Otherwise, labs significant for HCO3 39, Trop 0.25, lactate 1.5. R LENI was negative for DVT. The patient was treated with Lasix 80 mg IV to which he responded well - oxygen requirement decreased to 2L. Ceftriaxone 1g/azithromycin 500 mg were started to treat CAP. . Of note, the patient was hospitalized from [**Date range (2) 19889**] for respiratory failure and sepsis requiring intubation and pressors. He was treated for pneumonia, pulmonary edema; course was complicated by SVT and ATN. The patient was discharged to a rehab facility. He left the rehab facility for home on [**1-19**] at the request of his family. At home, the patient is wheelchair-bound and requires 2-2.5L of home O2. . Currently, VS 98.9 80 110/60 20 92% on 3L. The patient appears mildly dyspneic but is able to speak in short sentences. He is alert and oriented x 3. Exam reveals rales 1/2 up posterior lung fields, 2+ pitting edema up to thights and lower extremity venous stasis changes but no obvious cellulitis or infection. He does report PND and has not been sleeping well for the past few nights. His family reports that his diet is poor - meals on wheels helps with many meals and that he does not monitor his salt intake. . Endorses diarrhea 2 weeks ago (has ostomy [**1-27**] rectal cancer) and occasional urinary hesitancy . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: # CHF -- LVEF on [**2144-6-5**] with LVEF 50% # CAD -- Cardiac Cath on [**2137-3-26**] -- Three vessel coronary artery disease -- Successful stenting (Express2 DES) of the proximal and mid-LAD # Peripheral [**Date Range 1106**] disease -- s/p multiple LLE revascularization procedures # Paroxysmal atrial fibrillation # Diabetes Mellitus Type 2 # Hypertension # Hyperlipidemia # Pulmonary fibrosis # Endocarditis # SVT # BPH # Osteoarthritis # Chronic Back Pain # Allergic rhinitis # Anemia # Septic arthritis # Urosepsis # Colon polyps # Rectal carcinoma -- T3, distal within 2 cm of the dentate line -- Diagnosed by colonoscopy on [**11/2141**] -- Abdominal perineal resection on [**2142-2-9**] -- Multiple subsequent surgeries # Bilateral Inguinal Hernias -- Laparoscopic repair with mesh on [**2141-12-21**] # Left Spigelian Hernia # Left CIA aneurysm Social History: Widower. He lives in a 3 family home with his daughter below and son above. His grandson lives with him in the same apartment and helps him - grandson's girlfriend and child also live with them. His family helps him manage his medications. Mostly wheelchair-bound since d/c from rehab. Needs help with all IADLs. Tobacco: Smoked in his teens, but quit at least 43 years ago. Alcohol: None Drugs: None Family History: Mother and brother with diabetes. Multiple other family members with cancer history. Father died from cancer when patient was young, unsure of type. Sister died from cancer, unsure of type, either melanoma or gynecological cancer Physical Exam: On admission: VS - 98.9 80 110/60 20 92% on 3L GENERAL - chronically-ill appearing man, sitting with head of bed at 75 degrees, speaks in short sentences, some labored breathing after talking HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, elevated JVP to mid neck, no carotid bruits CHEST: L-sided port LUNGS - Significant bibasilar rales and 1/2 up posterior lung fields, no wheezing, some labored breathing after talking; HEART - RRR, [**1-31**] murmur heard throughout precordium, nl S1-S2 ABDOMEN - NABS, ostomy appears healthy, soft/NT/ND EXTREMITIES - multiple toes amputated from L foot, [**1-28**]+ pitting edema up to thighs; 1+ pulse on R, diminished on L; venous stasis dermatitis bilaterally; (appears unchanged since ICU on R and worsened on L) NEURO - awake, A&Ox3, muscle strength 4/5 throughout, sensation grossly intact throughout, cerebellar exam intact Pertinent Results: On admission: [**2145-2-10**] 12:58PM BLOOD WBC-6.1 RBC-3.67* Hgb-10.2* Hct-32.0* MCV-87 MCH-27.8 MCHC-31.9 RDW-15.5 Plt Ct-229 [**2145-2-10**] 12:58PM BLOOD Neuts-73.9* Lymphs-16.9* Monos-5.1 Eos-3.7 Baso-0.4 [**2145-2-10**] 12:58PM BLOOD PT-12.6 PTT-25.7 INR(PT)-1.1 [**2145-2-10**] 12:58PM BLOOD Glucose-197* UreaN-32* Creat-1.0 Na-141 K-3.5 Cl-93* HCO3-39* AnGap-13 [**2145-2-10**] 12:58PM BLOOD CK-MB-11* MB Indx-13.3* proBNP-462 [**2145-2-10**] 12:58PM BLOOD Calcium-9.3 Phos-3.4 Mg-2.4 [**2145-2-10**] 11:05PM BLOOD Type-ART pO2-73* pCO2-77* pH-7.37 calTCO2-46* Base XS-14 . Blood culture: negative Sputum culture: cancelled due to contamination . TTE: Conclusions The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. The pulmonary artery is not well visualized. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2144-12-21**], no obvious change but the technicalloy suboptimal nature of both studies precludes definitive comparison. . Admission CXR: IMPRESSION: Low lung volumes and pulmonary edema. No definite pleural effusion seen on the lateral view. Bibasilar opacities, which may relate to atelectasis from low lung volumes and overlying edema. In the appropriate clinical setting, consolidation from aspiration or infection would be difficult to exclude. . R LE Doppler: negative for DVT . Brief Hospital Course: 86M with history of HTN, DM, CAD, SVT, pAib, PVD, CKD, IPF and recent hospitalization in the ICU from [**Date range (2) 19889**] requiring pressors/intubation presents from home with worsening symptoms of CHF and concern for cellulitis of L LE . # Acute decompensated heart failure (diastolic): On admission to the floor, the patient appeared volume overloaded with elevated JVP, rales throughout posterior lung fields, and 2+ pitting edema in LE. He was diuresed with 80 mg IV Lasix in the ED and again on the floor the night of admission due to mild dyspnea at rest. He continued to be diuresed with 80 mg IV daily with good response (~1L negative per day) while on the floor. Electrolytes were closely followed and were repleted as necessary. He was kept on a low Na diet and 1.5L fluid restriction. Toprol 100 mg qday was continued prior to bradycardic episode on [**2-13**] at which time Toprol was held for 24 hours. While patient was in MICU on [**3-31**] he was on a furosemide drip with fluid balance of -3L while in MICU and was transitioned back to bolus furosemide 80 mg IV prior to transition back to the medical floor on [**2-14**]. While in house TTE showed EF > 55% with mild AS. . # Symptomatic bradycardia: On [**2-13**] AM, the patient had 2 episodes of symptomatic bradycardia - code blue was called for the second episode. Patient had transient hypotension with each episode. Was attributed to vagal episode by cardiology evaluation. After transfer to ICU on [**2-13**] was monitored on telemetry with no further bradycardia. . # Hypercarbia/hypoxia: Repeat ABGs showed persistent hypercarbia and hypoxia. Pulmonary was consulted due to the patient's known interstitial pulmonary fibrosis. He was initially kept on oxygen 2L on the floor and was diuresed as above; however, following bradycardic event on [**2-13**], patient's oxygen requirement climbed to 5L NC despite diuresis. Was witnessed to be aspirating thin liquids by MICU nurse, thus dietary orders were modified and speech/swallow evaluation was ordered. Aspiration causing vagal episodes as well as hypoxemia is a possible unifying diagnosis for reason for transfer to the MICU on [**2-13**]. Palliative care was consulted. He and his family expressed wishes to go home with hospice. On the morning of [**2-15**], after the patient had been anxious most of the night for persistent SVT, the patient was became more confused and somnolent. ABG was 7.22/111/177. The patient had been on a non-rebreather for much of the night and was also given 0.5 mg lorazepam, which likely both contributed in part to hypercarbia. The patient was again transferred to the ICU and BiPap was initiated with improvement in ABG to 7.35/79/60. His respiratory status improved and he was sat-ing in the high 80s to low 90s on nasal canula. After further discussion with the family, it was decided to discharge Mr. [**Known lastname 19800**] home with hospice. . # Elevated troponin/CAD: Troponins were flat. Patient denied CP. CK-MB remained elevated at 11,10, and 10. There was concern for persistent ischemia [**1-27**] diastolic dysfunction. Aspirin 81 mg, plavix 75 mg qday, and simvastatin 80 mg qhs were continued. The patient's outpatient cardiologist, Dr. [**First Name (STitle) 437**] was contact[**Name (NI) **]. . # SVT: Patient had known history of SVT. He went into SVT on [**2-12**] AM. He appeared to be in increased respiratory distress. He was re-positioned back in bed and during the movement, broke the rhythm spontaneously. Toprol 100 mg qday was continued on the floor until the patient's episode of symptomatic bradycardia on the floor. Toprol was then held for <24 hours while patient was in ICU and metoprolol 25 mg [**Hospital1 **] was started prior to patient transfer back to medical floor. Telemetry was continued. In the early morning on [**2-15**], the patient had 3 episodes of SVT - first episode lasted 1.5 hours. Vagal manuever was attempted with no response; repositioning was also tried. Rate eventually responded to 5 mg IV metoprolol x 2. He was managed on oral metoprolol thereafter. . # Venous stasis dermatitis: No ulcer was present. Changes thought to be [**1-27**] venous stasis and PVD (on left). No obvious signs of cellulitis or infection. Compression socks were used and patient's legs were kept elevated when possible. . # CXR opacity: Pt without leukocytosis, cough, fever. He received ceftriaxone/azithromycin in the ED. Antibiotics were discontinued on transfer to the floor. . # BPH: Continued home flomax/finasteride. . # DM: Type II. On glyburide at home. Continued SSI and diabetic diet during admission. . # Communication was with daughter [**Name (NI) 2048**] (h: [**Telephone/Fax (1) 19890**]; c: [**Telephone/Fax (1) 19891**]) and other daughter [**Name (NI) **]. . # Goals of care: Discussions were held with the family on the floor, with the primary team, palliative care team, and MICU team. Code status was changed to DNR/DNI. Mr. [**Known lastname 19800**] requires an ambulance for transportation. Medications on Admission: ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for Nebulization - use via(s) nebulizer once a day as needed for severe sob CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once daily FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE - 20 mg Tablet - 2 Tablet(s) by mouth once a day GLYBURIDE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth twice a day IPRATROPIUM BROMIDE - 21 mcg Spray, Non-Aerosol - 2 sprays to nostrils twice a day METOPROLOL SUCCINATE - 100 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth once a day TAMSULOSIN [FLOMAX] - 0.4 mg Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth once a day . Medications - OTC ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily MULTIVITAMIN WITH IRON-MINERAL [CENTRUM] - (Prescribed by Other Provider) - 400 mcg-162 mg-18 mg-300 mcg-250 mcg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. Medical Equipment Semi-electric Bed -patient with diagnosis of congestive heart failure and interstitial pulmonary fibrosis 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day. 4. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 7. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 2.5-5.0 mg PO q1h as needed for shortness of breath or wheezing. Disp:*30 ml* Refills:*0* Discharge Disposition: Home With Service Facility: seasons hospice & palliative care Discharge Diagnosis: Primary Diagnosis Congestive Heart Failure Bradycardia Hypercarbic Respiratory Failure Supraventricular Tachycardia Secondary Diagnosis Type 2 Diabetes BPH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "424.1", "428.0", "414.01", "V10.06", "515", "584.9", "427.81", "E928.9", "600.00", "E939.4", "E944.4", "585.9", "285.29", "459.81", "411.89", "867.0", "428.33", "V44.3", "V12.72", "427.31", "276.4", "V45.82", "V49.86", "250.70", "787.20", "V46.2", "715.90", "443.81", "403.90", "518.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14555, 14619

7729, 12756

284, 290

14820, 14820

5787, 5787

4598, 4830

13809, 14532

14640, 14799

12782, 13786

4845, 4845

214, 246

318, 3281

5801, 7706

14835, 15116

3303, 4161

4177, 4582

27,327

129,921

32285

Discharge summary

report

Admission Date: [**2147-1-30**] Discharge Date: [**2147-2-2**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: dyspnea, increased oxygen requirement Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] yo F with COPD, chr back pain, with recent concern for broncioloalveolar carcinoma (based on radiographic imaging) presented with SOB and dropping SaO2 to 81% on RA at [**Hospital **] skilled nusring facility. She did not have fever at that time. She was sent to the ED for evaluation . In the ED the pt was febrile to 102 and SaO2 measuring low 80s on RA. the CXR showed persistent patchy multifocal opacities. She received levoflox and ceftaz. she also received solu medrol x 1 and albuterol and atrovent nebs. her SaO2 improved to low 90s on 6L by NC. No elevation in wbc count and UA was wnl. . Pt is [**Name (NI) **] x 2. She says she is here because she has back pain which is [**6-3**]. she denies SOB, CP, palpitations, pain in abd, N/V/D. She c/o dizziness on sitting up. For many questions she answers "I don't know" and "someone takes care of me". Past Medical History: anxiety back pain COPD CAD (unclear history, pt denies prior MI) PVD Concern for bronchoalveolar carcinoma based on radiographic imaging during last admission. Social History: denies tobacco and EtOH, lives at [**Hospital3 **] Family History: non-contributory Physical Exam: VS: 98.1 108 125/57 32 91/40% O2 by face mask GEN: in moderate respiratory distress, [**Hospital3 **] x 2 HEENT: PERRL, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: b/l coarse crackles and rhonchi, no wheezes, using accesory muscles of respiration CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: AAOx2. moving all 4 extremities Pertinent Results: [**2147-1-30**] 05:15PM WBC-9.3 RBC-4.24 HGB-12.1 HCT-36.3 MCV-86 MCH-28.6 MCHC-33.4 RDW-14.9 [**2147-1-30**] 05:15PM NEUTS-64 BANDS-7* LYMPHS-22 MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-5* [**2147-1-30**] 05:15PM PLT SMR-VERY HIGH PLT COUNT-624* [**2147-1-30**] 05:15PM PT-14.1* PTT-32.5 INR(PT)-1.2* [**2147-1-30**] 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2147-1-30**] 05:15PM URINE RBC-0 WBC-[**3-29**] BACTERIA-MOD YEAST-NONE EPI-[**3-29**] [**2147-1-30**] 05:15PM URINE GRANULAR-[**3-29**]* HYALINE-[**3-29**]* [**2147-1-30**] 05:15PM GLUCOSE-107* UREA N-48* CREAT-1.4* SODIUM-139 POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-24 ANION GAP-20 [**2147-1-30**] 05:15PM CK(CPK)-35 [**2147-1-30**] 05:15PM cTropnT-0.01 [**2147-1-30**] 10:04PM TYPE-ART PO2-67* PCO2-36 PH-7.41 TOTAL CO2-24 BASE XS-0 Brief Hospital Course: A/P: [**Age over 90 **] yo F w/recent finding of persistant bilateral consolidation c/w BAC vs COP presenting with dyspnea and increasing O2 requirements, positive nasopharyngeal aspirate for influenza B, change in overall goals of care to DNR/DNI with focus on comfort. . Initial issues by problem were as follows (with additional hospital course below): . # SOB: On arrival this was judged most likely secondary to exacerbation of underlying lung disease attributed to influenza B. Etiology of underlying lung disease unkonwn, most likely diagnoses based on radiographic appearance are pneumonic bronchoalveolar cancer vs. cryptogenic organizing pneumonia. She was treated for possible nosocomial pneumonia as well; a sputum sample was contaminated by oropharyngeal flora. She had increasingly frequent episodes of desaturation yesterday, improved with morphine gtt as pt was able to tolerate face mask. We continued vancomycin and levofloxacin, as well as albuterol and atrovent nebulizer treatments. We continued methylprednisolone also. She tested positive for influenza B. Blood and urine cultures were negative. . #Back pain - had lumbo-sacral xray [**2147-1-2**] which showed chronic compression fractures of L3 and L4. She is requiring significant quantities of pain medications and in light of possible pulmonary malignancy could be concerning for bony involvement. We continued outpatient regimen of fentanyl patch, lidocaine patch. She was also on morphine gtt. There was no further work up at this point given change in goals of care, focus on comfort and pain management. . # Acute Renal failure: baseline Cr 0.9, on review of medical records she often has ARF on hospital admission responsive to IVF. Creatinine decreased from 1.4 to 1.1 with gentle hydration. . # Depression: d/c'd mirtazapine as not taking po's . # Hyperlipidemia: d/c'd statin . # HTN: d/c'd amlodipine, propranalol, lasix and hctz . # F/E/N: continued with maintenance IVF as not taking PO intake. . # PPx: sq Heparin was given . # Access: PIV . # Communication and goals of care: We discussed code status early with both the patient and the health care proxy, [**Name (NI) **] [**Name (NI) 27953**] (h:[**Telephone/Fax (1) 75464**] w:[**Telephone/Fax (1) 75465**] or [**Telephone/Fax (1) 75466**]). All agreed that DNR/DNI was the appropriate code status. . # Hospital course. Ms [**Known lastname 21883**] had worsening respiratory status which did not improve with antibiotics or optimized COPD regimen, including corticosteroids. She was kept on droplet precautions and ruled in for influenza B. She demonstrated continued clinical decline over the next 2 hospital days. After discussion with her healthcare proxy, it was agreed that she should not be intubated. She was kept comfortable with morphine drip, and she died quietly and comfortably in the early morning of [**2-2**]. . Mr [**Name13 (STitle) 27953**] agreed on a limited autopsy and this showed diffuse metastatic adenocarcinoma of the lung with superimposed pneumonia. . Medications on Admission: 1. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*5 Patch 72 hr(s)* Refills:*0* 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 7. Clonazepam 0.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six (6) hours. 11. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day. 12. Vitamin B-1 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 14. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 15. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 16. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 17. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO once a day. 18. Propranolol 20 mg Tablet Sig: One (1) Tablet PO twice a day. 19. Prednisone 10 mg Tablet Sig: 1-4 Tablets PO once a day for 16 days: Take 4 tablets on [**1-12**] tablets [**Date range (1) **], 2 tablets [**Date range (1) 70177**], then 1 tablet [**Date range (1) 75462**]. Disp:*30 Tablet(s)* Refills:*0* Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Autopsy showed diffuse adenocarcinoma of the lungs with associated pneumonia. Discharge Condition: Expired. Discharge Instructions: N/A Followup Instructions: N/A [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "272.4", "733.13", "491.21", "162.8", "401.9", "584.9", "276.2", "487.0", "300.00", "518.81", "311" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7778, 7787

3015, 6041

299, 305

7908, 7918

2090, 2992

7970, 8102

1481, 1500

7750, 7755

7808, 7887

6067, 7727

7942, 7947

1515, 2071

222, 261

333, 1213

1235, 1396

1412, 1465

51,203

193,364

25035

Discharge summary

report

Admission Date: [**2150-1-21**] Discharge Date: [**2150-1-30**] Date of Birth: [**2087-5-24**] Sex: F Service: MEDICINE Allergies: Gemfibrozil / Ranitidine / Aloe / Lipitor / Avandia Attending:[**First Name3 (LF) 4365**] Chief Complaint: chest pain, shortness of breath, rigors Major Surgical or Invasive Procedure: Incision and Drainage of left foot ulcer Central venous line placement Left foot hardware removal and wash out PICC line placement History of Present Illness: This is a 62 year old female with history of recent NSTEMI, type II diabetes mellitus, s/p revision Charcot LLE([**9-29**]) prior pseudomonas, and MRSA infections that presents with left lower extremity plantar purulent ulceration, chest pain, and rigors. The patient reported that she was recently discharged from rehab on [**1-14**], and on [**1-19**] noticed a pin-sized hole with bloody discharge at the site of her prior Charcot surgery. That night the pt reported + nightsweats, frontal headaches, chills, and shortness of breath. In the ED, her initial vitals were 97.7 88/38 96 16 96%RA. The patients blood pressure subsequently fell to 70/50, with a HR in 70s. The pt received 3L NS with BP improvement to 110/50 with her heart rate in the 80s. A LIJ was placed and the pt was given ASA, Vanc, Zosyn. Podiatry was called for incision and drainage of noted left foot ulcer. The patient denied any fevers, chills, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, orthopnea, lower extremity, cough, urinary frequency, urgency, dysuria, lightheadedness, focal weakness, vision changes, rash or skin changes. Past Medical History: # Coronary artery disease status post myocardial infarction x 4 per patient with multiple PCIs in [**2131**], performed at [**Hospital3 15054**], anatomy unknown) # s/p Removal of external fixator left foot ([**2149-12-30**]) # s/p Bilateral Charcot reconstruction [**2149-10-14**] # H/o MRSA ([**2149-10-14**]) from skin wounds # H/o Pseudomonas ([**2149-7-31**]) from skin wounds # Diabetes mellitus, type 2, since [**2133**] # Hypercholesterolemia # Hypertension # Neuropathy # B/l charcot s/p RLE recon ([**1-28**]) # H/o sepsis, in MICU [**4-/2147**] # Rheumatic fever at age 7 or 8 Social History: Is divorced and lives by herself in [**Hospital1 1559**], MA. [**Name (NI) **] mother lives nearby and helps out. Patient has one daughter who also helps her. Denies smoking or drinking. Family History: Family H/O CAD; no Family H/O DM or Charcot joints Physical Exam: PHYSICAL EXAM ON ADMISSION: Vitals: T: 98.6 BP: 102/43 HR: 96 RR: 16 96% 2L NC GEN: Caucasian female, obese, NAD, Sitting upright speaking in full sentences HEENT: PERRL, EOMI, Sclera Anicteric, MMM, OP Clear NECK: LIJ in place, Obese neck, unappreciable neck veins, carotid pulses brisk, no cervical lymphadenopathy, trachea midline COR: S1 S2, [**2-27**] ejection murmur radiating to axilla, radial pulses +2 PULM: Lungs CTAB,no wheezes or crackles ABD: Soft, Obese, NT, ND, +BS, no HSM, no masses EXT: Left plantar wound packed, approximately 0.5 cm vertical incision. Draining both purulent, and serosangionous fluid. Left medial plantar ulceration granulation tissue at the base without drainage. No crepitus appreciated. NEURO: AOx3. Moving all 4 extremities. Strength 5/5 in upper and lower extremities. SKIN: Without rashes. Pertinent Results: LABS ON ADMISSION: [**2150-1-21**] 03:00PM BLOOD WBC-12.3*# RBC-3.69* Hgb-10.0* Hct-30.3* MCV-82 MCH-27.0 MCHC-32.9 RDW-16.7* Plt Ct-294 [**2150-1-21**] 03:00PM BLOOD Neuts-87.0* Lymphs-8.5* Monos-3.2 Eos-1.0 Baso-0.2 [**2150-1-21**] 03:00PM BLOOD Glucose-255* UreaN-18 Creat-1.2* Na-135 K-3.6 Cl-103 HCO3-18* AnGap-18 [**2150-1-21**] 08:46PM BLOOD Calcium-7.5* Phos-2.8# Mg-1.5* [**2150-1-21**] 03:09PM BLOOD Glucose-136* Lactate-3.4* Na-136 K-3.6 Cl-102 calHCO3-18* CARDIAC ENZYMES: [**2150-1-21**] 03:00PM BLOOD cTropnT-0.02* [**2150-1-22**] 06:13AM BLOOD CK-MB-2 cTropnT-0.01 INFLAMMATORY MARKERS: [**2150-1-27**] 05:22AM BLOOD ESR-142* [**2150-1-26**] 04:40AM BLOOD CRP-123.3* [**2150-1-27**] 05:22AM BLOOD CRP-83.5* LABS ON DISCHARGE: [**2150-1-29**] 06:32AM WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 6.7 3.01* 8.3* 24.6* 82 27.5 33.6 16.8* 450* [**2150-1-29**] 06:32AM Glucose UreaN Creat Na K Cl HCO3 AnGap 218* 19 1.6* 139 4.5 105 25 14 Vanco [**2150-1-29**] 06:32AM 22.3* ---------- MICROBIOLOGY: [**2150-1-21**] 3:00 pm BLOOD CULTURE #1. **FINAL REPORT [**2150-1-24**]** Blood Culture, Routine (Final [**2150-1-24**]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S -------------------\\\\\\\\\\\\\\\\ [**2150-1-21**] 4:05 pm BLOOD CULTURE #2. **FINAL REPORT [**2150-1-24**]** Blood Culture, Routine (Final [**2150-1-24**]): STAPH AUREUS COAG +. SENSITIVITIES PERFORMED ON CULTURE # 264-7543R [**2150-1-21**]. Anaerobic Bottle Gram Stain (Final [**2150-1-22**]): GRAM POSITIVE COCCI IN CLUSTERS. Aerobic Bottle Gram Stain (Final [**2150-1-23**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. -------------------- Blood Cultures Negative [**1-22**], [**1-23**], [**1-24**] -------------------- [**2150-1-23**] 12:30 pm SWAB LEFT FOOT. **FINAL REPORT [**2150-1-27**]** GRAM STAIN (Final [**2150-1-23**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final [**2150-1-27**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 264-7759R ([**2150-1-21**]). PSEUDOMONAS AERUGINOSA. RARE GROWTH. ANAEROBIC CULTURE (Final [**2150-1-27**]): NO ANAEROBES ISOLATED. [**2150-1-26**] 3:54 pm CATHETER TIP-IV Source: Left IJ. **FINAL REPORT [**2150-1-29**]** WOUND CULTURE (Final [**2150-1-29**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies. COAG NEG STAPH does NOT require contact precautions, regardless of resistance Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 8 I LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S ECG [**2150-1-21**] Sinus rhythm. There are Q waves in the inferior leads consistent with prior inferior myocardial infarction. There are Q waves in the anterior leads consistent with prior myocardial infarction. Low voltage in the precordial leads. Compared to the previous tracing there is no significant change. ECHO [**2150-1-23**] IMPRESSION: No obvious masses/vegetations seen suggestive of endocarditis. Moderate aortic stenosis. Normal left ventricular systolic function, EF >55%. The right ventricle appears mildly depressed with depressed free wall contractility (the base contracts normally). TEE [**2150-1-28**]: Impression: No mass/thrombus seen in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No valvular mass/vegetation seen. Mild (1+) aortic regurgitation. Moderate (2+) mitral regurgitation. Overall LVEF is normal. -------------------- IMAGING STUDIES: Left Foot XRay 3 Views: IMPRESSION: 1. No definite new areas of cortical destruction to suggest osteomyelitis. 2. Status post Charcot reconstruction without evidence of hardware failure or change in alignment. 3. Diffuse soft tissue swelling about the foot and ankle. No soft tissue gas identified. MRI Right Calf [**2150-1-27**] IMPRESSION: 1. No evidence for osteomyelitis. 2. Focal defect in cortex of anterior mid shaft tibia, likely due to prior instrumentation. Please correlate clinically. 3. Diffuse muscle atrophy, greatest in tibialis anterior. 4. Achilles tendon thickening. Brief Hospital Course: This is a 62 year-old female with a history of type II diabetes mellitus, bilateral charcot joints with recent LLE reconstruction who presents with a draining ulcer on her left foot and hypotension who was found to have MRSA bacteremia and and required LLE hardware removal. # Sepsis/Hypotension: The patient presented with tachycardia, leukocytosis and hypotension. She was found to be bacteremic and suspected source was a left foot ulcer at her previous surgical site that was incised and debrided of purulent material upon admission by podiatry. She was initially admitted to the MICU where she received IVF and required pressors for only a few hours. She was started on Vancomycin and Zosyn for empiric coverage. Her vital signs stabilized with these interventions. She went to the OR for LLE harware removal where she had a screw removed and washout. Following this procedure patient's vital signs remained stable and she was transferred to the floor. #MRSA Bacteremia/Osteomyelitis (MRSA + Pseudomonas): MRSA bacteremia likely secondary to chronic ulcerations of the left plantar foot. Blood cultures from [**1-21**] grew MRSA. Wound culture from left lower extremity (intraoperative) also positive for MRSA and Pseudomonas. Patient had both a TTE and TEE to rule out endocarditis. Patient followed by infectious disease service during this hospitalization. As noted above, patient was initially started on a course of Vancomycin, Zosyn and Cipro. Zosyn stopped after 5 days and patient continued on Vancomycin/Cipro. Cipro was stopped after 8 days and switched to meropenem giving finding on R calf MRI that showed tendon thickening. Surveillance cultures from [**1-22**], [**1-23**], and [**1-24**] all negative. Patient's CRP trending down. On discharge, she remained afebrile, stable hemodynamics, left foot with two clean surgical sites without erythema. Patient will require a 6 week course of antibiotics (starting [**2150-1-23**]) given osteomyelitis and high grade bacteremia. She will be discharged on vancomycin 1 gram Q24hrs for MRSA and meropenem 1 gram Q12 hours (may need to be adjusted as renal function improves) for pseudomonas. The last dose both BOTH medications is [**2150-3-5**]. Patient should have the following laboratory monitoring: CBC/diff, chem 7, LFTs, ESR/CRP, vancomycin trough weekly. Creatinine and vancomycin trough should be checked within a couple days of discharge. All laboratory results should be faxed to Infectious disease RNs at ([**Telephone/Fax (1) 432**]. All questions regarding outpatient antibiotics should be directed to the infectious disease RNs at Patient has a follow up appointment in infectious disease clinic on [**2150-2-20**] with Dr. [**Last Name (STitle) 111**]. # Left Lower Extremity Hardware Removal: Patient taken to OR by podiatry on [**2150-1-23**]. The lateral screw was removed and the site was debrided and irrigated. The wounds were initially left open and packed. These wounds were closed at the bedside on [**2150-1-27**]. Patient's has not complained of significant pain post-op. Patient will require daily dressing changes to LLE. Patient is to avoid weight bearing on the LLE for at least 3 weeks. She should follow up with Dr.[**Last Name (STitle) **] in podiatry clinic on [**2150-2-5**]. # Right Lower Extremity Shin Ulcer: Pt noted to have ulcer where external fixator had been in place. An MRI of this area did not indicate evidence of osteomyelitis. # Type II Diabetes Mellitus: Prior to hospitalization patient on regimen consisting of metformin and glyburide, though for the past few months was only taking glyburide. Her most recent Hgba1C of 7.9 in [**2149-9-22**]. Glipizide held while an inpatient. Patient started on Lantus in addition to an insulin sliding scale given to finger stick blood sugars in the 200's-400's. Given difficulty controlling blood sugars in spite of titrating up lantus Josline endocrinology service consulted. At time of discharge patient on Lantus 30 units qHs and the humalog sliding scale attached to this discharge summary. It is likely that the patient's lantus will continue to be titrated to achieve adequate glycemic control. She is scheduled to follow up at [**Hospital **] Clinic with Dr. [**First Name (STitle) 7582**] on [**2150-4-8**]. # Acute Renal Failure: Following surgery patient's creatine increased to as high as 2.2 likely secondary to transient hypotension with operative anesthesia. Creatinine continues to improve and is 1.6 at time of discharge. As noted above, her creatinine should be rechecked within a few days of discharge and weekly thereafter. # Coronary Artery Disease: Stable during this admission. Given patient presented with chest pain she was ruled out for ACS with two sets of negative cardiac enzymes. ECG unchanged. She was continued on aspirin, statin, plavix. Her metoprolol was held on admission due to hypotension and restarted at time of discharge (this medication had been started on a previous admission-she was previously on atenolol). # Nephrolithiasis: Stable during this admission. Patient was on a dose of Allopurinol 350 mg daily which was decreased to 150 mg daily. Can titrate backup to 350 mg daily and renal function improves. Patient was a FULL code during this admission. Medications on Admission: ASA 81 mg PO Daily Vitamin C 500mg [**Hospital1 **] Metoprolol (Dose Unknown) Calcium Carbonate 500mg [**Hospital1 **] Colace Glipizide 5mg PO Daily Lactulose 30mL q6hr PRN Lorazepam 2mg qhs PRN Magnesium Oxide 140mg [**Hospital1 **] Glucophage 850mg QAM Glucophage XR QHS MVI Quinine Sulfate 325mg QHS Senna 2 Tabs PO Daily Vitamin D 400mg PO Daily Vitamin E Zinc Sulfate Motrin 800mg PO TID PRN Allopurinol 100mg PO Daily Fluvastatin 80mg PO QHS Oxycodone (Dose Unknown) Protonix Nitro Glycerin SL Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 10. Pravastatin 20 mg Tablet Sig: Four (4) 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. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection Q8H (every 8 hours). 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 18. Lantus 100 unit/mL Solution Sig: Thirty (30) Subcutaneous at bedtime. 19. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous per sliding scale attached. 20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 21. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 22. Magnesium Oxide 140 mg Capsule Sig: Two (2) Capsule PO twice a day. 23. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual as needed as needed for chest pain. 24. Meropenem 1 gram Recon Soln Sig: 1g Intravenous every eight (8) hours: last dose on [**2150-3-5**]. 25. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 26. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 27. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every twenty-four(24) hours: last dose on [**2150-3-5**]. Discharge Disposition: Extended Care Facility: holy trinity Discharge Diagnosis: Primary: Methicillin Resistant Staphylococcus aureus bacteremia, Osteomyelitis, Acute renal failure, status post hardware removal in left lower extremity Secondary: Type II Diabetes Mellitus, Coronary Artery Disease Discharge Condition: stable Discharge Instructions: You were admitted to the hospital because you were found to have a low blood pressure in the emergency department. You were admitted to the ICU where you received intravenous fluids, medications to support your blood pressure and intravenous antibiotics. You were determined to have a bacterial infection in your blood stream which was likely caused by an infection that started in your left foot. You went to the operating room and had hardware removed from your left lower extremity. Intra-operative cultures confirmed that your have a bacterial infection in your left foot. Your vital signs stabilized following surgery and continuation of antibiotics and you were able to be transferred to a medical floor. You will need to complete a total of 6 week course of antibiotics for this infection. You have follow up scheduled with an infectious disease doctor as listed below. In regards to your left foot, you cannot weight bear for a minimum of 3 weeks. You have an appointment to follow up with your podiatrist, Dr. [**Last Name (STitle) **] 1 week after discharge. During your hospitalization your blood sugars were found to be very high. You were seen by the endocrinology service from [**Last Name (un) **] and you were started on a new regimen with both long and short acting insulin. It is very important to control your blood sugars. You have an appoinment to follow up at the [**Hospital **] Clinic in [**Location (un) 86**]. You have been started on the following NEW medications: -Lantus: this is a long acting insulin that you should take before bedtime -Humalog sliding scale: this is short acting insulin. You will need to check your blood sugar before meals and give yourself insulin injections based on the sliding scale (you have been on a sliding scale in the past) -Meropenem: this is an antibiotic for your bone infection -Vancomycin: this is an antibiotic for your blood infection -Oxycodone: this is a pain medication. you should not drive or operate heavy machinery while taking this medication. The following CHANGES were made to your antibiotic regimen: -Allopurinol was decreased from 350 mg daily to 150 mg daily given your current kidney function. Your doctor will let you know when it is safe to increase the dose. If you experience fevers, chills, chest pain, shortness of breath, drainage from your surgical site or worsening pain in your left lower leg please contact your primary care physician or go to the emergency department for evaluation. Followup Instructions: Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM (podiatrist) Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2150-2-5**] 4:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (infectious disease) Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2150-2-20**] 11:00 You are also scheduled to see Dr. [**First Name (STitle) **] (endocrinologist) at [**Last Name (un) **] Diabetes Center on [**2150-4-8**] at 12:00. You can try and call the office to see if there are cancellation so that you could be seen sooner. The office number is [**Telephone/Fax (1) 2384**] You should follow up with your primary care physician [**Name Initial (PRE) 176**] [**1-23**] weeks following discharge from rehab. Completed by:[**2150-1-30**]

[ "280.9", "592.0", "995.92", "250.62", "996.67", "414.01", "038.12", "584.9", "272.0", "707.15", "357.2", "401.9", "412" ]

icd9cm

[ [ [] ] ]

[ "78.69", "38.93", "86.22" ]

icd9pcs

[ [ [] ] ]

17694, 17733

9400, 14666

352, 484

17993, 18002

3414, 3419

20534, 21330

2492, 2544

15217, 17671

17754, 17972

14692, 15194

18026, 20511

2559, 2573

3901, 4141

273, 314

4160, 8766

512, 1659

3434, 3884

1681, 2271

2287, 2476

8784, 9377

72,327

156,958

50357

Discharge summary

report

Admission Date: [**2115-12-31**] Discharge Date: [**2116-1-8**] Date of Birth: [**2049-2-11**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1384**] Chief Complaint: HCV cirrhosis Major Surgical or Invasive Procedure: [**2116-1-1**] - Orthotopic Liver Transplantation History of Present Illness: 66 yo M with PMH HCV and HCC s/p RF ablation in [**1-20**] presents pre-operatively for a possible liver [**Date Range **]. Since the last time we saw him in [**Month (only) **], the pt has been in his usual state of health. Took the motorcycle out for a ride the other day. Has been enjoying the winter with his wife, who is present with him today. No recent illnesses, fevers, cough, n/v/d, melena or hematochezia. The remainder of his review of systems is negative. His last MELD score was 29 in the end of [**Month (only) **]. Past Medical History: HCV HCC Cirrhosis Last MELD 28 [**2115-8-6**] Social History: Lives in [**Location **], has a daughter Enjoys gardening, motorcycling, boating Quit smoking 30 years ago Quit drinking 25 years ago No illicits Family History: Mother died of MI at 61 Physical Exam: Gen: NAD HEENT: MMM no lesions CV: RRR no MRG RESP: CTAB no WRR ABD: soft, appropriately tender over incision, no guarding or rebound WOUND: abdominal incision and JP sites clean and dry with no drainage or erythema EXT: no LE edema Pertinent Results: [**2116-1-8**] 04:50AM BLOOD WBC-9.4 RBC-3.28* Hgb-10.1* Hct-29.1* MCV-89 MCH-30.9 MCHC-34.8 RDW-17.2* Plt Ct-130* [**2116-1-3**] 03:43AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-1+ Polychr-OCCASIONAL Schisto-OCCASIONAL Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 16494**] [**2116-1-8**] 04:50AM BLOOD Glucose-82 UreaN-48* Creat-1.9* Na-138 K-4.2 Cl-105 HCO3-28 AnGap-9 [**2116-1-8**] 04:50AM BLOOD ALT-195* AST-54* AlkPhos-75 TotBili-1.9* [**2116-1-8**] 04:50AM BLOOD Albumin-3.4* Calcium-8.5 Phos-2.6* Mg-1.7 [**2116-1-7**] 04:40AM BLOOD tacroFK-7.1 Liver Duplex [**1-1**] FINDINGS: Difficult study due to the patient's recent postoperative state, nonetheless diagnostic images were obtained. No focal or textural abnormality seen in the liver. The portal vein and its major branches are patent with normal flow. The main hepatic artery and its major intrahepatic branches are patent with normal flow demonstrated. The three hepatic veins are patent with normal flow seen. No biliary duct dilatation seen. The spleen is enlarged measuring 17.7 cm. No intra-abdominal free fluid seen. IMPRESSION: Patent hepatic vasculature post-liver [**Month/Year (2) **]. Splenomegaly. Liver Duplex [**1-7**]: CLINICAL INDICATION: Hep C, status post liver [**Month/Year (2) **], [**12-31**] now with elevated LFTs. The liver shows some increase in echogenicity in a patchy distribution suggestive of patchy fatty infiltration. There are no focal liver lesions seen nor is there any evidence of bile duct dilatation. A 4 x 5 cm right subhepatic hematoma is noted. Splenomegaly is also again noted with the spleen measuring 16.3 cm in length. Color flow and pulse Doppler assessment of the [**Month/Year (2) **] was performed. All portions of the portal and hepatic venous system are well visualized and showed normal color flow and pulse Doppler characteristics. The inferior vena cava was fully patent with normal pulse Doppler. The left, right, and main hepatic arteries show normal waveforms with resistive indices ranging from 0.67-0.71. CONCLUSION: Normal liver Doppler and no bile duct dilatation. Heterogeneous hyperechoic regions consistent with fatty infiltration. Small-to-moderate right subhepatic hematoma also noted. Brief Hospital Course: Pt was admitted for OLT on [**2116-1-1**]. The operation went well with no complications. He was transferred to the SICU in stable condition. His POD0 liver duplex was found to be normal. He was extubated on POD 1, and then transferred to the inpatient floor in good condition. Initially his serum blood sugars were difficult to control and the patient was placed on an insulin drip. He was stabilized on a sliding scale regimen by POD3, and his diet was advanced to clears. Of note, the patient was found to be hypertensive, and this was initially managed with IV lasix and PRN IV hydralazine. As the patient's volume status normalized and he was able to take PO's, he was given amlodipine which seemed to normalize his hypertension. The patient progressed very well through his post operative course. On POD6, the patient underwent a liver duplex which showed patent vasculature with normal waveforms as well as a patent biliary system without dilatation. On POD7 the patient's pain was well controlled on oral medication, was ambulating and voiding without difficulty, and had received all of his instruction regarding meds and blood sugar recording. Due to persistent drain output from his lateral JP, he was to be sent home with drain teaching. He was then deemed ready for discharge. Medications on Admission: COLCHICINE - 0.6 mg''METOPROLOL SUCCINATE - 50 mg'. URSODIOL 500 mg'' CALCIUM CARBONATE-VITAMIN D3 - 600 mg-400U'', MULTIVITAMIN, VITAMIN E 200 unit'' 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). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): While taking narcotic pain medication. Disp:*60 Capsule(s)* Refills:*2* 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 10. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital1 **] [**Location (un) 5087**] Discharge Diagnosis: HCV cirrhosis and HCC s/p liver [**Location (un) **] Discharge Condition: Ambulating and AOx3 Discharge Instructions: You were admitted for an elective liver transplantation. Your operation went well with no complications. You were ready to go home seven days later. Please take all medications as prescribed, and don't drive while on pain medication. You should make sure to keep all of your follow up appointments, and let your [**Location (un) **] team know of any changes in your health. Please call the [**Location (un) **] clinic at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, diarrhea, inability to take or keep down food, fluids or medications, increased drain output or if the drainage apears bloody or develops a foul odor. You may shower, do not allow the drain to hang freely. Place a new drain sponge around the drain site following your shower or daily. No tub baths or swimming until further notice. Drain and record your drain outputs twice daily and more often as necessary. Bring copy of record with you to your clinic visits. No heavy lifting or straining. Labs every Monday and Thursday Followup Instructions: Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2116-1-16**] 8:00 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2116-1-29**] 1:00 Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2116-1-29**] 3:40

[ "416.8", "V15.82", "E930.5", "733.00", "070.54", "584.5", "572.3", "401.9", "571.5", "424.1", "V58.65", "155.0" ]

icd9cm

[ [ [] ] ]

[ "00.93", "50.59", "38.93" ]

icd9pcs

[ [ [] ] ]

6321, 6393

3792, 5096

317, 369

6490, 6512

1481, 3769

7577, 7961

1187, 1213

5297, 6298

6414, 6469

5122, 5274

6536, 7554

1228, 1462

264, 279

397, 936

958, 1007

1023, 1171

27,481

100,440

8479

Discharge summary

report

Admission Date: [**2103-7-21**] Discharge Date: [**2103-7-26**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Chest pain and shortness of breath Major Surgical or Invasive Procedure: 1)Cardiac catheterization with thrombectomy and balloon angioplasty of a bare metal stent in a venous graft to the obtuse marginal artery. . 2) Intubation/Ventilation . 3) Right subclavian central line History of Present Illness: CHIEF COMPLAINT: Chest pain . EVENTS / HISTORY OF PRESENTING ILLNESS: [**Age over 90 **] year old male with CAD (s/p CABG and multiple stents to the venous grafts), hypertension, type II diabetes, and chronic renal insufficency who presented with suddent onset chest pain and respiratory distress starting at 6a.m. on day of admission. The patient felt this was the same type of pain as his past myocardial infarction. The patient did not have nausea or vomiting. . In the ED, vital signs were as follows: HR-108-120, BP: 128-254/100-164, RR: 32, O2sat: 93-100% on CPAP at 5cm H20. On exam, patient was diaphoretic with cool extremities, there was JVD, bibasilar rales, and bilateral pedal edema. EKG showed ST elevations in aVR and V1-V3. Cardiac enzymes showed a CPK of 125, MB-8, and Trop T 0.21. The patient was given morphine, Aspirin 325mg, metoprolol, Plavix 600mg, integrillin, heparin drip, nitro drip, Lasix 40mg. The patient continued to have respiratory distress an arterial blood gas showed a ph of 7.15, pC02 of 54, and a pO2 of 74 and was therefore intubated with an 8.0 ETT with ventilator settings of Assist control mode with a respiratory rate of 12, tidal volume of 550ml, and PEEP of 7.5, and FiO2 of 100% and an NG tube was placed. He was then brought urgently to the catheterization lab. On review of symptoms, he was intubated/sedated and unable to obtain history. Past Medical History: 1. CAD s/p CABG with 3 venous grafts(SVG->LAD, SVG->LCx, SVG->PDA '[**86**].) Status post stent in [**2099**] (3.5 x 23 mm and 3.5 x 8 mm Cypher in SVG->PDA). Status post stent in [**2103**](3.5 x 18mm Vision RX bare metal stent in the SVG-OM with TIMI 3 flow.) Cath [**2-7**] with: Three vessle coronary disease. 90% mid-vessel stenosis of the SVG to OM with TIMI 2 flow. 40% stenosis of the SVG to PDA prior to the Taxus stent. Total occlusion of the SVG to LAD graft. LVEDP of 26mm Hg. Moderate left ventricular diastolic dysfunction. Successful stention of the SVG-OM graft with a 3.5x1 8mm bare metal stent. ECHO ([**2101-12-8**]): Elongated LA. Normal LV wall thickness and cavity size. LVEF of 50% with mild hypokinesis of the anterior septum, anterior free wall, and apex. Dilated RA. Normal RV chamber size and free wall motion. No AS, or AR. 1+ MR and1-2+ TR. There was moderate pulmonary artery systolic hypertension. 2. HTN 3. Hyperlipidemia 4. Peripheral vascular disease status post bypass [**2088**] 5. DM Type II (not on oral hypoglycemics) 6. Chronic renal insufficiency- baseline Cr of 1.7-2.0 7. Gout 8. Status post right cataract surgery Social History: The patient lives with daughter and wife. [**Name (NI) **] 8 children. Ambulates at home. Denies tobacco, alcohol, and illegal drug use. Family History: Non contributory. Physical Exam: VS: T: 99.0 , BP: 135/68 , HR: 65 , RR: 100% O2sat on AC/16/500/5/50% Wt: 68kg Gen: Slender elderly male who is intubated and sedated. HEENT: Normal cephalic and atraumatic. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of less than 10cm. CV: PMI located in 5th intercostal space, midclavicular line. regular rate, normal S1, S2. No S4, no S3. No murmurs. Chest: No chest wall deformities, scoliosis or kyphosis. Bibasilar crackles. Abd: Soft, non-tender and non-distended, No hepatosplenomegally or tenderness. No abdominal bruits. Ext: Warm, 2+ pedal edema bilaterally. Skin: Minimal stasis dermatitis, No ulcers, scars, or xanthomas. Pulses: Right: Carotid 1+ without bruit; DP 1+; PT 1+ Left: Carotid 1+ without bruit; DP 1+; PT 1+ Neur: Opens eyes to painful stimulus. Moving all four extremities. Pertinent Results: EKG ([**2103-7-21**]): Sinus Tachycardia with a rate of 117bpm. Nml PR and QRS intervals. Mildly prolonged QT interval. Nml axis. LVH. ST elevations in aVR, V1-V3. ST depressions in I, II, aVF, V5-V6. T wave inversions in I, and aVL. Compared to prior EKG: Sinus Tachycardia, worsening of ST elevation in aVR and V1-V3. Though, in the past, minimal ST elevations were present in those leads. . CXR ([**2103-7-21**]): The cardiac silhouette size remains borderline enlarged but stable. Extensive degenerative changes are noted throughout the thoracic spine. There is mild cardiogenic hydrostatic edema with small bilateral pleural effusions. . CARDIAC CATHETERIZATION ([**2103-7-21**])SVG-RCS with 40% stenosis. SVG-OM with previous stent occluded and thrombus. SVG-OM thrombectomy with balloon angioplasty (22atms)resulting in normal flow. LVEDP 25. Right renal artery with no critical lesions. Left renal artery with mild ostial disease. . ECHO ([**2103-7-21**]): Dilated LV with LVEF depressed (20%) Inferior akinesis/hypokinesis, anterior hypokinesis, septal akinesis/hypokinesis, and apical akinesis/dyskinesis. Nml RV size with depressed RV funcion. No AS. No pericardial effusion/tamponade. . ECHO ([**2103-7-23**]): Mild LA enlargement. Mild symmetric LVH with normal cavity size. There is mild hypokinesis of the distal septum and distal inferior wall. Left ventricular ejection fraction of 30-35%. Mild RA dilation. Normal RV chamber size and mild RV hypokinesis. Trace AR, ([**1-2**]+) MR, (1+) TR. Compared to study on [**2103-7-21**], there is improvement in LV function. . [**2103-7-21**] WBC-14.4*# RBC-4.99 Hgb-16.4 Hct-51.2 MCV-103* MCH-32.9* MCHC-32.0 RDW-16.0* Plt Ct-212 [**2103-7-26**] WBC-7.5 RBC-3.43* Hgb-11.3* Hct-33.3* MCV-97 MCH-32.8* MCHC-33.8 RDW-15.7* Plt Ct-189 . [**2103-7-21**] PT-11.4 PTT-26.3 INR(PT)-1.0 [**2103-7-26**] PT-11.8 PTT-27.1 INR(PT)-1.0 . [**2103-7-21**] Glucose-201* UreaN-28* Creat-2.0* Na-140 K-4.4 Cl-104 HCO3-24 AnGap-16 [**2103-7-26**] Glucose-134* UreaN-35* Creat-2.0* Na-138 K-4.2 Cl-101 HCO3-27 AnGap-14 . [**2103-7-21**] ALT-53* AST-40 AlkPhos-145* Amylase-29 TotBili-0.8 [**2103-7-22**] ALT-39 AST-57* . [**2103-7-21**] CPK-125 [**2103-7-21**] CPK-95 [**2103-7-21**] CPK-773* [**2103-7-21**] CPK-603* [**2103-7-22**] CPK-354* . [**2103-7-21**] CK-MB-8 [**2103-7-21**] cTropnT-0.21* [**2103-7-21**] CK-MB-95* MB Indx-12.3* cTropnT-3.10* [**2103-7-21**] CK-MB-49* MB Indx-8.1* [**2103-7-22**] CK-MB-23* MB Indx-6.5* cTropnT-1.88* . [**2103-7-21**] 08:15AM BLOOD Triglyc-153* HDL-37 CHOL/HD-3.5 LDLcalc-62 . [**2103-7-21**] Blood gas in ED: pO2-54* pCO2-74* pH-7.15* calTCO2-27 Base XS--4 [**2103-7-21**] Blood gas before extubation: pO2-90 pCO2-40 pH-7.45 calTCO2-29 Base XS-3 . [**2103-7-21**] %HbA1c-5.8 . [**2103-7-21**] HIV AB - negative, HCV Ab - negative . [**2103-7-21**] Urine Culture. Enterococcus greater than 100,000 organisms. Sensitive to ampicilln, nitrofurantoin, and vancomycin. Resistant to tetracycline. Brief Hospital Course: ASSESSMENT AND PLAN, AS REVIEWED AND DISCUSSED IN MULTI DISCIPLINARY ROUNDS : Mr. [**Known lastname **] is a [**Age over 90 **] year old man with a history of CAD (s/p CABG and mult. stent placements), type II diabetes, hypertension, and hyperlipidemia who presented with chest pain and shortness of breath and found to have an ST elevation myocardial infarction based on EKG and cardiac enzymes. Status post cardiac catheterization with thrombectomy and balloon angioplasty of the SBG-OM graft. . CAD/STEMI: Patient is s/p cardiac cath with thrombectomy and balloon angioplasty of the SBG-OM graft. Cardiac enzymes were cycled with a peak CPK of 773 and a peak CK-MB of 95. The fact that the patient had thrombosis of a bare metal stent in the SBG-OM graft while on a home dose aspirin and Plavix is concerning for some sort of hypercoagulable state. The patient was therefore started on Plavix 75mg PO BID. The patient was continued on aspirin 325 mg daily, continued on Integrilin for 18 hours after catheterization, atorvastatin 80 mg, and a nitro drip (which was later weaned.) Metoprolol was titrated up to 75 mg PO TID. The patient was also started on isosorbide 30mg TID. An ACE inhibitor was held until hospital day 4 because of the history of chronic renal insufficiency and the recent cardiac catheterization dye load. The lisinopril then was started and titrated up to 20mg Daily. A lipid panel showed and HDL of 37 and LDL of 62, . Pump/CHF: Patient has history of LVEF of 50% with diastolic dysfunction repeat ECHO showed and an ejection fraction of 20% with inferior, septal, and anterior hypokinesis. On admission exam, the patient had bilateral crackles and pedal edema. Admission chest x-ray showed infiltrates. Therefore the patient was given Lasix 20mg IV for three days. The patient was 4.5 liters negative for the length of stay with decreasing oxygen requirement (now on room air) and resolved pedal edema. The patient will be discharged on his home dose of Lasix 20mg PO Daily. The patient was maintained on a beta blocker and an ACE inhibitor was started on hospital day 4. . Rhythm: Patient stayed in normal sinus rhythm. Occasional premature atrial beats. . Resp: On admission to the CCU, the patient was intubated/sedated. The ventilator setting were weaned and the patient passed a pressure support trial. An arterial blood gas before extubation showed a ph of 7.45, pCO2 of 40, and pO2 of 90. On the evening of admission, the patient was extubated successfully. Since that time the patient has had decreasing oxygen requirement and was discharged on room air. . Hypotension: On transport from the cath lab, the patient became bradycardic and hypotensive (SBP to the 80's.) The patient was given atropine with good response. The patient was also started on a neosynephrine drip which was quickly weaned. This episode was thought to be due to a post-cath vaso-vagal event or recent administration of propofol. There was concern from a cardiac tamponade and/or ACS an ECHO was rapidly performed and ruled this out. The patient did not have any more hypotensive episodes. . Respiratory Acidosis: ABG on admission showed a ph of 7.20 pCO2 of 58, and pO2 of 314 consistent with respiratory acidosis. The respiratory rate was increased and repeat ABG showed a pH of 7.47, pCO2 of 29, and pO2 of 193. . DM type II: A HbA1c was 5.8%. The patient was maintained on an insulin sliding scale. The patient was restarted on his home dose of glipized before discharge. . ID/Fever: On [**2103-7-21**], the patient had rectal temperature to 102.4. The patient was started on a course of levofloxacin for possible pneumonia (equivocal infiltrate on CXR). Blood cultures were negative and and urine cultures grew enterococcus sensitive to ampicillin, nitrofuratoin, and vancomycin. The patient was started on a 10 day course of amoxicillin on [**2103-7-24**] and remained afebrile throughout the rest of his stay. . Renal Function: Patient has history of chronic renal insufficiency with a baseline Cr of 1.8-2.0, and received Acetylcysteine x2 after catheterization. His renal function remained stable and he is discharged on lisinopril 20mg. . Hematuria: Mr. [**Known lastname **] developed hematura on aspirin, Plavix, heparin, and Integrilin. Because of clots, urology was consulted and a 3 way catheter was placed and irrigated. The catheter was removed the next day w/o complication and he was urinating wihtout difficulty on discharge. . Prophy: The patient was maintained on a bowel regimen, proton pump inhibitor, and Heparin SQ. . Access: Right SCV line was placed on [**2103-7-21**] and removed on [**2103-7-23**]. Patient had peripheral IV access at that time. . Code: Full . Contact: [**Name (NI) 29880**], [**Telephone/Fax (1) 29881**]. Granddaughter, [**Name (NI) **], [**Telephone/Fax (1) 29882**]. . Dispo: The patient was discharged to the floor on [**2103-7-25**]. The patient was seen by physical therapy and sent home with services. The patient will follow up with his cardiologist and primary care doctor. Medications on Admission: 1. Colchicine 0.6 mg po qod 2. Allopurinol 100 mg po qod 3. Lisinopril 40 mg po daily 4. Atorvastatin 20 mg po daily 5. Aspirin 325 mg po daily 6. Hexavitamin po daily 7. Glipizide 5 mg po daily 8. Furosemide 20 mg po daily 9. Clopidogrel 75 mg po daily 10. Nitroglycerin 0.3 mg Tablet sl prn 11. Isosorbide Dinitrate 30mg po tid 12. Metoprolol Tartrate 75 mg po bid 13. Ferrous Sulfate 325mg po daily 14. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours) for 8 days. Disp:*32 Capsule(s)* Refills:*0* 10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual once a day as needed for chest pain. 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day. 14. Isosorbide Dinitrate 30 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: 1) ST elevation myocardial infarction 2) Congestive heart failure 3) Hypoxic respiratory failure 4) Urinary tract infection Discharge Condition: good; stable/normal vital signs, tolerating po, ambulating with assistance. Discharge Instructions: During this hospitalization, you were diagnosed with a heart attack. The type of heart attack you had is called an ST elevation myocardial infarction. You underwent a cardiac catheterization to help open up the vessels in your heart. . It is very important that you take all of your medications. It is especially important that you take your Plavix and aspirin. You should take your aspirin once a day and your Plavix twice a day. Under no circumstance should you stop taking these medications without speaking to your cardiologist. If you become sick and vomit and are not able to take your aspirin or plavix, please contact your cardiologist. . If you have chest pain, shortness of breath, dizziness, or feel hot/sweaty, please call your doctor or go to the nearest emergency room. Please call your doctor if you have any other concerns. We also found that you have a urinary tract infection for which you will need to finish about 1 week of antibiotics. If you develop fevers, chills, nausea, vomiting, abdominal pain and diarrhea, or any other problems then please seek medical advice. Followup Instructions: Please follow up with your cardiologist. You have an appointment with Dr. [**Last Name (STitle) **] on [**2103-8-1**] at 11:30am at [**Hospital3 29818**] [**Apartment Address(1) 29883**]. Please call [**Telephone/Fax (1) 5985**] if you have any questions. . Because you were in the hospital, you should follow up with your primary care doctor. You have an appointment with DR. [**First Name (STitle) **] [**Name8 (MD) 29884**], MD on [**2103-7-25**] at 2:15pm. Please call [**Telephone/Fax (1) 7976**] with any questions. . You also have an appointment with [**First Name5 (NamePattern1) 6811**] [**Last Name (NamePattern1) 29885**] [**Doctor Last Name **] on [**2103-8-6**] at 11:00am. Please call [**Telephone/Fax (1) 7976**] with any questions.

[ "410.01", "274.9", "V45.81", "458.29", "599.0", "250.00", "996.72", "272.4", "428.0", "276.2", "518.81", "414.01", "599.7", "585.9", "403.90" ]

icd9cm

[ [ [] ] ]

[ "99.20", "00.40", "88.56", "96.71", "88.57", "96.04", "88.45", "00.66", "38.93", "36.09", "37.23", "88.53" ]

icd9pcs

[ [ [] ] ]

14054, 14111

7218, 12294

297, 501

14279, 14357

4201, 7195

15502, 16258

3276, 3295

12783, 14031

14132, 14258

12320, 12760

14381, 15479

3310, 4182

546, 1919

529, 529

1941, 3105

3121, 3260

24,573

114,472

1115

Discharge summary

report

Admission Date: [**2126-5-25**] Discharge Date: [**2126-6-2**] Date of Birth: [**2070-7-15**] Sex: M Service: CME CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: This is a 55-year-old male with longstanding diabetes, CAD status post CABG on [**2126-3-6**], and peripheral vascular disease who presented after 2 days of nausea/vomiting with notable coffee-ground emesis on the morning of admission. He has had 2 days of epigastric pain and 2 days prior to admission was informed by PCP to start on PO vancomycin for positive C. difficile. The patient reported nausea immediately following initiation of vancomycin, which progressed to vomiting. He had 2 days of sharp, constant, abdominal pain and diarrhea, which was improving. No blood per rectum or black/tarry stools. The patient also complained of chest pain/left arm pain x 2-3 months, tender to palpation and worse with movement. He also has shortness of breath associated with the pain though different from prior angina. In ED, the patient was hypertensive with right arm 218/147, left 240/98, tachycardia to 103. EKG showed no T-wave inversions in V2 to V4 and lead I compared to that of [**2126-3-19**]. He was treated with sublingual nitroglycerin, IV Lopressor, and labetalol as well as morphine with response of decreasing chest pain and blood pressure. He was noted to vomit coffee-grounds and was NG lavaged clear with 600 cc. He was given IV Protonix at that time. PAST MEDICAL HISTORY: Hypertension. Left lower lobe collapse. Hypercholesterolemia. Insulin-dependent diabetes. CHF with EF of 30-35 percent on [**2126-2-27**]. Chronic renal insufficiency, baseline creatinine 1.5-1.9. CAD status post CABG x 4 in [**2-28**] with LIMA to LAD, SVG to RCA to PDA, SVG to OM1. PVD/claudication. Tracheomalacia. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg a day. 2. Lipitor 20 mg p.o. q.d. 3. Amitriptyline 25 mg q.h.s. 4. Lopressor 75 mg p.o. b.i.d. 5. Lasix 40 mg p.o. b.i.d. 6. Protonix 40 mg p.o. q.d. 7. Pletal 100 mg p.o. b.i.d. 8. Glargine 20 units q.a.m. 9. Atacand 16 mg p.o. q.d. ALLERGIES: CEFEPIME, WHICH GIVES FLUSHING AND TACHYCARDIA. SOCIAL HISTORY: A 20-pack-year tobacco history. No ETOH. No IVDU. Spanish-speaking from [**Country 7192**]. Lives with brother's family. Not married. No kids. FAMILY HISTORY: Father with CAD. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Afebrile, heart rate 90s, blood pressure 122/60, respirations 17, oxygen saturation 100 percent on 5 liters, decreasing to 97 percent on room air. GENERAL: Hispanic male, appearing older than stated age, resting, in no acute distress. HEENT: PERLA and EOMI. Moist mucous membranes. Clear oropharynx with poor dentition. NECK: Supple, bilateral carotid bruits. JVP about 8 cm at 45 degrees. CARDIOVASCULAR: Regular rate and rhythm. Normal S1, S2. Early systolic murmur over right upper sternal border and left upper sternal border radiating to carotids bilaterally. LUNGS: Clear to auscultation bilaterally. No egophony. Slight decreased breath sounds to left lower lung. ABDOMEN: Normoactive bowel sounds, soft, nondistended, tender in midepigastrium without rebound or guarding, audible bruit, midline abdomen with well-healed surgical scar. EXTREMITIES: Faint PT pulses bilaterally, but good flow with Doppler. Chronic venous stasis changes bilaterally. Sensation to touch and position intact bilaterally. No palpable cords or edema. RECTAL: Guaiac negative. NEURO: Cranial nerves II-XII grossly intact. LABORATORY DATA: Significant on admission for white count 12.4, hematocrit 35.1, and platelets 549. BUN 25, creatinine 1.5, CK 138, MB 6, troponin 0.04. Next set, CK 103 with MB of 4 and troponin of 0.02. RADIOGRAPHIC STUDIES: Chest x-ray, elevation of left hemidiaphragm, blunting of the right and left CPAs, no pulmonary vascular condition, no pneumothorax, persistent bibasilar atelectasis. MRA showing atherosclerotic changes of infrarenal abdominal aorta without evidence of aneurysmal dilatation. High-grade stenosis of right proximal common iliac and diffuse disease of left common iliac, severe disease of left superficial femoral artery. Bilateral disease of anterior tibial arteries. HOSPITAL COURSE: GI bleed: The patient had EGD on [**2126-5-26**], showing nonbleeding [**Doctor First Name **]-[**Doctor Last Name **] tear from vomiting in the gastric cardia. EGD also showed mild esophagitis and multiple erosions possibly consistent with NSAID-associated gastropathy and gastritis. The patient was started on Protonix b.i.d. with no further rebleeding from this tear. His hematocrit has remained stable, so he did require a few blood transfusions. He was guaiac negative later during admission. He also was treated with Carafate 4 times a day and was instructed to follow all pills with soft bread. Per GI fellow, he will need IV PPI b.i.d. x 8 weeks followed by PPI q.d. Clostridium difficile colitis: Because of abdominal upsets on oral vancomycin, he was switched to oral Flagyl to complete a 14-day course. Although, he experienced continued dyspepsia, he tolerated this medication well with no further nausea/vomiting. His diarrhea also had resolved by hospital discharge. CAD: The patient was status post CABG and ruled out for MI earlier on initial presentation. He experienced 1 further episode of chest pain for which he received 4 sublingual nitroglycerin with decrease in the pain. He had no EKG changes at that time, and repeat enzymes were sent, which were negative. He will be continued on aspirin, beta- blocker, and statin with re-adding of his ACE inhibitor as an outpatient once his creatinine is fully stable. His hematocrit was kept greater than 30 during admission. Hypertension: For extremely elevated blood pressure, the patient was started on nitroglycerin gtt and once this was weaned off, started on hydralazine and Isordil. His hydralazine was gradually weaned off during admission. The patient required increasing doses of his beta-blocker during admission with occasional persistent hypertension to systolic of 150s-160s. His ACE inhibitor was not restarted during admission secondary to chronic renal insufficiency issues, but should be restarted on discharge. CHF: The patient had an EF of 30-35 percent. Initially, gentle fluids were given with holding of Lasix secondary to renal failure, but Lasix was re-added at home dose later in admission. Because he developed crackles later in admission, he was also given 2 doses of IV Lasix with good response of urine output. Acute renal failure: After admission, creatinine noted to bump up to the mid-2 range. He was gently hydrated with holding of his Lasix, and creatinine decreased to baseline by discharge. His ACE inhibitor was held during admission. Right hand cellulitis: The patient was noted to have increase in white count with erythema, tenderness, and warmth on the dorsum of his right forearm, where his former IV site had been. Given that patient was diabetic, he was started on Augmentin for a 7-day course. Peripheral vascular disease: The patient has chronic claudication and was to be scheduled for outpatient bypass procedure by Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **]. Given that he was already an inpatient, the patient was taken to lab for bilateral iliac stent placement prior to discharge, which he tolerated well. He will need to return in the next 3 weeks for full bypass procedure once his renal issues are resolved. IDDM: The patient continued on Lantus and RISS. Urinary retention: The patient was noted to have urinary retention late during admission without administration of narcotics or other medications causing this. He was started on Flomax. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: Hypertensive emergency. Diabetes mellitus, insulin-dependent. Clostridium difficile colitis. Coronary artery disease. Status post coronary artery bypass surgery. Peripheral vascular disease status post bilateral iliac stent. Urinary retention. DISCHARGE MEDICATIONS: 1. Sucralfate 1 tablet p.o. q.i.d. 2. Pantoprazole 40 mg p.o. b.i.d. 3. Isosorbide dinitrate 40 mg p.o. t.i.d. 4. Simethicone p.r.n. 5. Atorvastatin 20 mg p.o. q.d. 6. Amlodipine 10 mg p.o. q.d. 7. Aspirin 81 mg by p.o. q.d. 8. Metoprolol 100 mg p.o. t.i.d. 9. Plavix 75 mg by p.o. q.d. 10. Furosemide 40 mg p.o. b.i.d. 11. Glargine 20 units subcutaneous q.h.s. 12. Tamsulosin 0.4 mg p.o. q.h.s. 13. Amoxicillin/clavulanate 500 mg/125 mg p.o. q.12 hours x 6 additional days. 14. Ibuprofen as needed. FOLLOW-UP PLANS: The patient will call PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], who was also in-patient attending, for follow-up appointment in the next 2-3 weeks and will also arrange to have full vascular surgery with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] in the next 3 weeks. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] Dictated By:[**Last Name (NamePattern1) 7193**] MEDQUIST36 D: [**2126-6-3**] 11:21:45 T: [**2126-6-4**] 02:34:32 Job#: [**Job Number 7194**]

[ "530.7", "996.62", "447.1", "428.0", "401.0", "682.4", "V45.81", "584.9", "788.20" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.13", "88.42", "39.90", "39.50" ]

icd9pcs

[ [ [] ] ]

7833, 7871

2355, 2394

7893, 8144

8167, 8697

1857, 2172

4276, 7811

8715, 9255

153, 170

199, 1480

2409, 4258

1503, 1831

2189, 2338

13,329

138,079

51848

Discharge summary

report

Admission Date: [**2184-7-30**] Discharge Date: [**2184-8-9**] Date of Birth: [**2112-8-23**] Sex: F Service: MEDICINE Allergies: A.C.E Inhibitors / Neurontin Attending:[**First Name3 (LF) 3624**] Chief Complaint: SOB and Malaise Major Surgical or Invasive Procedure: Patient was placed on BiPAP after respiratory distress History of Present Illness: HPI: 71 YOF with ESRD s/p trx in [**2180**] presents with 1 week of malaise, sob, and cough. . In the ED, vital signs initially were 97.7 67 124/58 16 98 RA. Patient c/o of dry persistent cough for 1 week, CXR negative. Given Albuterol, combivent, Azythromycin 500 mg, CTX 1 gram IV, Solumedrol 125 IV and sent urine Cx and legionella antigen. . Currently, patient endorses 1 week h/o dry cough and diaphoresis, though no chills or fevers. Stated she had two episodes of coughing spells leading to vomiting last week. Denies CP or abdominal pain. Denies any sick contacts, recent travel or h/o Tb. She received pneumovax and influenza vaccine in [**2182**]. Past Medical History: 1. ESRD [**12-27**] NSAID induced nephropathy, s/p living related donor transplant in [**9-/2181**], on tacrolimus, cellcept, and bactrim prophylaxis. 2. HTN 3. CAD s/p cath [**2177**] with no intervention and 99% RCA blockage; MIBI [**8-29**] - Fixed defect of the base of the inferior wall & a calculated left ventricular ejection fraction is 59%. 4. COPD 5. chronic aortic dissection 6. enteroccocus line infx 7. s/p TAH/BSO 8. s/p appy 9. anemia 10. GERD 11. s/p ventral hernia repair [**3-30**] Social History: Lives at home by herself, but temporarily living with daughter while her apartment is getting renovated, ambulates with assistance of cane. Tobacco h/o [**11-26**] ppd x >40+ years. No EtOH or illicits. Family History: non-contributory Physical Exam: vitals:97.9 92/64 73 24 98 2L General: uncomfortable, coughing HEENT: PERRL, EOMI, OP clear Neck: Supple, no LAD, no JVD CV: RRR, though difficult to appreciate given lung sounds Lungs: b/l wheezes and rhonchi with coarse breath sounds Abdomen: +BS, NTND, soft, no guarding or rebound Ext: no edema, 2+ pulses bilaterally Neuro: AAOx3, 5/5 strength Pertinent Results: [**2184-7-30**] 02:20PM LACTATE-0.8 K+-5.6* [**2184-7-30**] 01:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2184-7-30**] 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2184-7-30**] 01:00PM GLUCOSE-108* UREA N-50* CREAT-2.3* SODIUM-135 POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-14* ANION GAP-21* [**2184-7-30**] 01:00PM estGFR-Using this [**2184-7-30**] 01:00PM CK(CPK)-197* [**2184-7-30**] 01:00PM CK-MB-4 cTropnT-0.03* [**2184-7-30**] 01:00PM WBC-9.1 RBC-3.25* HGB-9.4* HCT-29.4* MCV-90 MCH-28.9 MCHC-32.0 RDW-17.2* [**2184-7-30**] 01:00PM NEUTS-77.3* LYMPHS-13.4* MONOS-6.0 EOS-2.6 BASOS-0.6 [**2184-7-30**] 01:00PM PLT COUNT-372 [**2184-7-30**] 09:20AM WBC-9.1 RBC-3.04* HGB-8.8* HCT-27.8* MCV-91 MCH-29.0 MCHC-31.7 RDW-16.9* [**2184-7-30**] 09:20AM PLT COUNT-331 Brief Hospital Course: #SOB/cough-s/p respiratory distress and MICU course on BiPAP -Azithromycin-discontinued/CTX began [**2184-7-30**] discontinued and will start PO Augmentin for 2 days-discontinued [**2184-8-5**] -Steroid taper 40 mg PO for 2 days(completed), today 20 mg for 2 days(completed), then 10 mg for 2 days-begin today -ECHO from yesterday, normal EF with some pulmonary HTN Last ECHO from [**2181**] demonstrated hyperdynamic EF, with diastolic dysfunction -mycoplasma urine, IgM, IgG-pending -legionella negative -F/u blood cx-[**11-28**] pos for GPC-micrococcus/stomatococcus -guaifenisin/codeine PRN -Albuterol/Ipratropium nebs changed to inhaler today, to see if patient tolerates better. -tessalon pearls -Sputum Cx-sample not obtained yet as cough not productive, will order chest PT -discontinued diuresis today, but will continue fluid restriction -RSV aspirate-pending -Appreciate pulmonary consult, will need outpt f/u in [**1-27**] weeks -continue Benadryl QHS for sleep -Furosemide 20 mg QDay []Patient will need follow up arranged with PCP and transplant this week # ARF-in trx patient-(1.6-2.0 baseline) 2.1 today -hydration with bicarb on initial admission at 100 cc/hr for total 1 L-improved Cr to baseline, will continue to monitor, will discontinue hydration as is taking PO *follow tacrolimus level 6.3 yesterday, pending today -Will cont tacro to 5 mg [**Hospital1 **] -Continue prograf/azathioprine -Continue Sensipar -continue cinacalet to 30 mg and add CaCarbonate QID with meals . #Leukocytosis- could represent steroid use, could represent setting of infection, patient has had some frequent stooling, but has now resolved. She is incontinent at times per baseline, and was noted to have yeast in her urine. -Repeated CXR-[**2184-8-6**]-L lung atelectasis, small L pleural effusion -obtain repeat UA-+LE, few bact, few yeast, culture grew >100K -Fluconazole 200 mg PO for 2 days started [**2184-8-7**] -WBC 12.2, down from 14.6 . #Hyperkalemia -on kayexalate, but does not take reliably due to side effects of diarrhea -redraw in AM and restart -K stable-will continue to hold Kayexalate and monitor again in AM, will give kayexalate if K >5.8 . #Hyperphosphatemia -on phosphate binders . #Hypocalcemia-albumin normal -Given calcium gluconate during hospitalization 7.3 to 7.7 -Added 800 U Cholecalciferol QD -F/u vitamin D level-pending . #Hyperglycemia -Will add 4 units of NPH in the morning to ISS #HTN -Continue labetolol . #GERD -Continue PPI [**Hospital1 **] . #CAD -Continue ASA . # FEN: electrolyte repletion prn . # PPX: heparin SQ for DVT ppx, bowel regimen, eating . # Dispo: Likely home today . # Code: FULL Code after reversal on [**2184-8-4**] Medications on Admission: Procrit [**Numeric Identifier 389**]/ Q 2 weeks Protonix 40 mg QD Sensipar 60 mg [**Hospital1 **] Tylenol-Codeine 300-30 [**11-26**] PRN hand pain ASA 81 QD Lasix 10 mg QD Nitro SL Vita D [**Numeric Identifier 1871**] QD Kayexalate 15 PO QD Azathioprine 50 mg QD Labetalol 200mg [**Hospital1 **] Albuterol IH Prograf 5 mg [**Hospital1 **] Ipratropium 2 puffs Q 6 hours Discharge Medications: 1. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:*15 Capsule(s)* Refills:*0* 2. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 3. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for cough. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for cough. Disp:*15 Tablet(s)* Refills:*0* 9. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours. 10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours). Disp:*1 inhaler* Refills:*2* 11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation every six (6) hours. 12. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*0* 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QID (4 times a day). 15. 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* 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. SOB with respiratory distress requiring MICU course 2. Urinary yeast infection 3. Acute on chronic renal insufficiency 4. Leukocystosis 5. Hyperphosphatemia 6. Hyperkalemia 7. Hypocalcemia 8. Hyperglycemia Discharge Condition: Hemodynamically stable, tolerating PO, ambulating Discharge Instructions: During your hospital stay you were found to have shortness of breath. It is unclear what the cause is, whether it was infection, or an exacerbation of a lung process. Therefore you should follow up with the appointments scheduled for you to make sure it resolves. You should return if you notice increased shortness of breath, decreased urine output, fevers, chills, sweating, worsening of your symptoms or other symptoms concerning to you. Followup Instructions: Provider: [**Name Initial (NameIs) **] (covering for your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4026**] Date/Time: [**2184-8-12**] 10:15 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2184-8-13**] 9:30 Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2184-9-28**] 9:40 Provider: [**First Name8 (NamePattern2) 2206**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2184-10-1**] 10:30 [**Hospital Ward Name 23**] [**Location (un) **]-DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2184-8-26**] 11:00 [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**] Completed by:[**2184-8-9**]

[ "414.01", "584.9", "530.81", "E878.0", "996.81", "275.41", "585.3", "288.60", "403.90", "275.3", "276.7", "486", "112.2", "518.82", "518.4", "491.21" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8009, 8067

3124, 5806

304, 361

8320, 8372

2215, 3101

8864, 9867

1813, 1831

6226, 7986

8088, 8299

5832, 6203

8396, 8841

1846, 2196

249, 266

389, 1052

1074, 1576

1592, 1797

64,969

105,543

42301

Discharge summary

report

Admission Date: [**2108-8-27**] Discharge Date: [**2108-8-31**] Date of Birth: [**2057-8-11**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Coronary artery bypass grafting times three (left interior mammary artery to left anterior descending, saphenous vein graft to diagonal, saphenous vein graft to PLV), placement of synthes sternal plates [**8-27**] History of Present Illness: Mr. [**Known lastname 3265**] is a 51 year male who has had a one year history of exertional chest tightness. He had a pulmonary workup and used an inhaler and prednisone, which did not relieve symptoms. He was referred for a stress test on [**2108-8-13**] by his primary care physician which elicited [**4-3**] chest tightness with exercise and ST changes. Echo images revealed a moderately hypokinetic apex and severely hypokinetic inferior apex with consistent with likely apical ischemia. Ejection fraction was 55-60%. After his stress echo on [**2108-8-13**] he was started on baby aspirin and metoprolol. He was referred for left heart catheterization. He was found to have two vessel coronary artery disease upon cardiac catheterization and is now being referred to cardiac surgery for revascularization. Past Medical History: Hypercholesterolemia Cystic hygroma removed from abdomen age 6 Right knee surgery Tonsillectomy Social History: He lives with his wife and 8 children. He is an unemployed carpenter. He denies smoking or alcohol use. He reports drinking more than 8 alcoholic beverages per week. Family History: His father was diagnosed with heart disease at age 71 Physical Exam: Pulse:87 Resp:16 O2 sat:97/RA B/P Right:137/91 Left:134/89 Height:5'[**07**]" Weight:204 lbs General: Skin: Dry [] 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 [] _None____ 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: cath site Left:+2 Carotid Bruit Right:None Left:None Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 91661**] (Complete) Done [**2108-8-27**] at 9:49:35 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2057-8-11**] Age (years): 51 M Hgt (in): 71 BP (mm Hg): 112/62 Wgt (lb): 204 HR (bpm): 68 BSA (m2): 2.13 m2 Indication: Intraoperative TEE for CABG ICD-9 Codes: 745.5, 424.0 Test Information Date/Time: [**2108-8-27**] at 09:49 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2011AW-:1 Machine: us2 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Left Ventricle - Lateral Peak E': 0.12 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 3 < 15 Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: 3.0 cm <= 3.6 cm Aorta - Ascending: 2.9 cm <= 3.4 cm Aorta - Arch: 2.3 cm <= 3.0 cm Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm Aortic Valve - LVOT diam: 2.3 cm Mitral Valve - E Wave: 0.4 m/sec Mitral Valve - A Wave: 0.5 m/sec Mitral Valve - E/A ratio: 0.80 Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). Doppler parameters are most consistent with Grade I (mild) LV diastolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild to moderate ([**11-27**]+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data Conclusions PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. A patent foramen ovale is present, confirmed by bubble study. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-27**]+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results at time of surgery. POST-BYPASS: The patient is on no inotropes. Biventricular function is unchanged. Mitral regurgitation is unchanged. The aorta is intact post-decannulation. [**2108-8-31**] 05:47AM BLOOD WBC-7.6 RBC-3.64* Hgb-11.2* Hct-32.4* MCV-89 MCH-30.8 MCHC-34.5 RDW-12.9 Plt Ct-209# [**2108-8-27**] 12:53PM BLOOD WBC-11.5*# RBC-4.11* Hgb-12.5* Hct-36.5* MCV-89 MCH-30.5 MCHC-34.3 RDW-12.7 Plt Ct-174 [**2108-8-28**] 12:36AM BLOOD PT-13.9* PTT-32.7 INR(PT)-1.2* [**2108-8-27**] 07:58AM BLOOD PT-12.0 INR(PT)-1.0 [**2108-8-31**] 05:47AM BLOOD UreaN-16 Creat-0.8 Na-140 K-4.1 Cl-101 [**2108-8-27**] 12:53PM BLOOD UreaN-15 Creat-0.8 Na-143 K-4.1 Cl-111* HCO3-25 AnGap-11 Brief Hospital Course: On [**8-27**], Mr. [**Known lastname 3265**] [**Last Name (Titles) 1834**] a coronary artery bypass grafting times three (left interior mammary artery to left anterior descending, saphenous vein graft to diagonal, saphenous vein graft to PLV), placement of synthes sternal plates performed by Dr. [**Last Name (STitle) 914**]. CARDIOPULMONARY BYPASS TIME:71 minutes.CROSS-CLAMP TIME: 57 minutes. Please see the operative note for details. He tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit on a levophed infusion. He extubated but then post-operatively he had high chest tube output and returned to the operating room for re-exploration. He returned again to the intensive care unit and was extubated again on the following evening after diuresis. He was started on Beta-Blocker/Statin/Aspirin and diuresis. On post-operative day two his chest tubes were removed and he was transferred to the step down floor. Physical therapy was consulted for evaluation of strength and mobility. He was started on an ACE-I for more aggressive blood pressure control, beta-blocker optimized. The remainder of his hospital course was essentially uneventful. He continued to progress and on POD#4 he was dicharged to home with VNA. All follow up appointments were advised. Medications on Admission: DESIPRAMINE 10 mg Tablet one Tablet by mouth once a day METOPROLOL SUCCINATE 25 mg Tablet Extended Release 24 hr - one Tablet by mouth once a day SIMVASTATIN 20 mg Tablet 1 Tablet by mouth once a day ASPIRIN 81 mg Tablet, Delayed Release one Tablet by mouth once a day MV-MIN-FOLIC ACID-LUTEIN [CENTRUM SILVER] Dosage uncertain OMEGA-3 FATTY ACIDS-FISH OIL [OMEGA 3 FISH OIL] Dosage uncertain Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. desipramine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 14 days. Disp:*28 Tablet Extended Release(s)* Refills:*0* 8. 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* 9. metoprolol tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). Disp:*225 Tablet(s)* Refills:*2* 10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: coronary artery disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] 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) 914**] [**Telephone/Fax (1) 170**] on [**10-2**] at 3:15pm Cardiologist: Dr.[**First Name (STitle) **] [**Name (STitle) 2257**], on [**9-19**] at 10:30am Please call to schedule appointments with your Primary Care Dr.[**Last Name (STitle) 59223**],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 6803**] in [**2-28**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2108-8-31**]

[ "E878.2", "998.11", "414.01", "272.0" ]

icd9cm

[ [ [] ] ]

[ "36.15", "34.03", "36.12", "39.61" ]

icd9pcs

[ [ [] ] ]

10476, 10525

7372, 8703

320, 536

10593, 10804

2454, 7349

11727, 12330

1698, 1753

9147, 10453

10546, 10572

8729, 9124

10828, 11704

1768, 2435

270, 282

564, 1377

1399, 1497

1513, 1682

1,915

189,437

30044

Discharge summary

report

Admission Date: [**2137-4-7**] Discharge Date: [**2137-4-23**] Date of Birth: [**2061-5-13**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: Patient returns from rehab w/ fever, chills and light green draiange from abd drain -placed near pancreas at time of esophagogastectomy and partila pancreatic resection on [**2137-3-13**] Major Surgical or Invasive Procedure: C-line placement x2 Drain placement for para- pancreatic fluid collection History of Present Illness: 75M s/p transhiatal esophagectomy (for adenocarcinoma), pyloroplasty, J-tube placement c/b resection of distal pancreas, splenectomy ([**2137-3-13**]) returns with fevers. Past Medical History: GERD, HTN, hyperlipidemia, distal esophageal adenoCA transhiatal esophagectomy (for adenocarcinoma), pyloroplasty, J-tube placement c/b resection of distal pancreas, splenectomy ([**2137-3-13**]) , Pulmonary embolism . Social History: Tobacco: 7-pack-year smoking history, quit 35 years ago. EtOH: one to two alcoholic beverages a day. Has 3 adult children, healthy. He works as a clothing presser Family History: HTN, hypercholesterol. His mother lived to age [**Age over 90 **]. His father died in a drowning accident, and his children remain healthy. Physical Exam: On Admit: general: tacypneic VS: 99.8, 116, 110/63, 978% on NRB HEENT: unremarkable chest: decreased at the bases bilat w/ rhonchi. COR: tachy S1, S2 ABD: soft, NT, ND, +BS. Abd drain draining pale green thick drainage . On Discharge: 98.3 73 121/68 20 97ra wd, wn, nad a&o x3, mae slight decreased BS at bases, good inspiratory effort rrr, no m/r/g soft, nt, nd, tubes in place no surrounding erythema bilateral LE warm, no c/c/e Pertinent Results: RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2137-4-21**] 04:45AM 168* 19 0.8 141 4.5 105 29 12 COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2137-4-21**] 04:45AM 9.3 3.45* 9.1* 28.9* 84 26.4* 31.5 16.4* 933* CXR [**2137-4-18**] There is persistent atelectasis/consolidation in the left lower lobe with associated small pleural effusion. There is a small right pleural effusion. The left upper abdomen pigtail drainage catheter is again noted. Illdefined opacity consistent with atelectasis at right lung base. No pneumothorax. residual contrast in leftsided colonic diverticula. CT [**2137-4-16**] IMPRESSION: Successful CT-guided placement of a 10-French catheter into the loculated fluid collection in the splenectomy bed, which revealed approximately 20 mL of purulent hemorrhagic material, which was sent for microbiology and amylase levels. Brief Hospital Course: pt was admiited to the SICU from rehab after one month post op from /p transhiatal esophagectomy (for adenocarcinoma), pyloroplasty, J-tube placement c/b resection of distal pancreas, splenectomy ([**2137-3-13**]). He presented w/ fever, chills and pale thick greenish drainage from abd drain placed at the neck of the pancreas at the time of surgery. WBC 26. CT scan w/o signif change in collection, no free air. Drain fluid sent for culture:1+ gram neg rods and amylase of 9000. Started on broad spectrum antibiotics-vanco, zosyn. Made NPO w/ IVF pending need for intervention. Required IVF boluses for decreased u/o w/ good reponse. Lovenox d/c'd and placed on heaprin gtt for known pulmonary embolism. Picc line was d/c'd and tip sent for culture. Was transfused 2 units PRBC for anemia. Was diuresed for vol overload. Deferevesed on HD#5, leukocytosis improved. Drain culture revealed Ecoli-antibiotics tapered to cipro. based on culture data vanco d/c'd. After being off Vanco x 1 dose - WBC increased and had temp spike. vanco resumed. Afeb and leucocytosis resolving. CXR revealed left effusion which was tapped under ultrasound for 750cc. Oxygen requirement decreased and tachynpea improved. IR was consulted to place drain in second pancreatic fluid collection. Percutaneous drain was placed in IR for small amount of old bloody fluid. Pt was transferred out of the ICU on HD#7. IR was consulted to place drain in second pancreatic fluid collection. On [**2137-4-18**] Percutaneous drain was placed in IR for small amount of old bloody fluid- culture data neg. Vanco d/c'd and mainatined on po cipro. Remained afeb w/ normalizing WBC, HCT. Ambulating well on roomair, [**Last Name (un) 1815**] reg diet, TF cycled to decrease fullness and encourage po's. d/c to [**Hospital1 1501**] for multiple medical needs that were unable to be managed by pt and wife despite [**Name (NI) 269**] support. Medications on Admission: lansoprazole 30", atenolol 25', atorvastatin 10', HCTZ 12.5' . Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 weeks. Disp:*56 Tablet(s)* Refills:*0* 4. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q 12 HRS. () for 2 weeks: consult w/ Dr. [**Last Name (STitle) 4120**] discontinuation of this medicine. Disp:*14 doses* 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. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Outpatient Lab Work have your INR checked on wednesday and then as directed by DR. 8. finger stick check you glucose level by finger stick before meals and at bedtime. dose your insulin per the sliding scale 9. regular insulin regular insulin per sliding scale disp one vial 2 refills 10. insulin syringes 1unit per cc insulin syringes disp one box 3 refills 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): follow-up with your PCP regarding checking your INR. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay - [**Hospital1 392**] Discharge Diagnosis: GERD, HTN, hyperlipidemia, distal esophageal adenoCA, unclear depth, 1 FDG-avid paraesophageal node on PET that was FNA-neg. Pulmonary embolism, sepsis, anemia, volume overload Discharge Condition: good Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you experience chest pain, shortness of breath, fever, chills, nausea, vomiting, diarrhea, or abd pain,redness or drainage from around your drain sites. If your feeding tube sutures become loose or break, please tape tube securely and call the office [**Telephone/Fax (1) 170**]. If your feeding tube falls out, save the tube, call the office immediately [**Telephone/Fax (1) 170**]. The tube needs to be replaced in a timely manner because the tract will close within a few hours. Do not put any medication down the feeding tube unless they are in liquid form. Flush your feeding tube with 50cc every 8 hours if not in use and before and after every feeding. Please empty the abd drains daily and record the output. Bring a record of the drainage to your clinic appointment. Any questions reguarding the drain, please call [**Telephone/Fax (1) 170**]. You drains in your back and abdomen will stay in until you are seen in the office by DR. [**Last Name (STitle) **]. Followup Instructions: You have a follow up appointment with Dr. [**Last Name (STitle) **] on thursday [**2137-5-2**] at 10am in the [**Hospital Ward Name **] Clinical center [**Location (un) **]. Please arrive 45 minutes prior to your appointment and report to the [**Hospital Ward Name 23**] Clinical Center [**Location (un) **] radiology for a follow up CXR.

[ "038.9", "995.91", "041.4", "401.9", "276.6", "511.9", "998.59", "V10.03", "567.22", "272.4", "V44.4", "V12.51", "530.81", "285.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "54.91", "38.93", "34.91", "96.6" ]

icd9pcs

[ [ [] ] ]

6054, 6134

2752, 4658

508, 584

6355, 6362

1839, 2729

7455, 7797

1225, 1369

4772, 6031

6155, 6334

4684, 4749

6386, 7432

1384, 1605

1619, 1820

281, 470

612, 785

807, 1028

1044, 1209

4,891

125,220

43172

Discharge summary

report

Admission Date: [**2105-1-24**] Discharge Date: [**2105-1-30**] Service: ORTHOPAEDICS Allergies: Sulfonamides Attending:[**First Name3 (LF) 3190**] Chief Complaint: Lower exstremity weakness with acute onset of low back pain Major Surgical or Invasive Procedure: 1. T5 to L1 posterior fusion 2. T10 transpedicular decompression 3. Multiple thoracic laminotomies 4. Vertebroplasty of T10 History of Present Illness: The patient is an 83y old man with past history of prostate cancer treated with resection 12 years ago, HTN, hyperlipidaemia, hypothyroidism, aortic stent and a pacemaker. He presents now with 2-3 days of lower thoraco-lumbar back pain with lower extremity numbess and collapse on the way to the toilet overnight. This was followed by sudden onset severe weakness affecting the R>L legs. There had been no significant urinary or bowel symptoms. In addition to the weakness he had decreased reflexes in the lower extremities worse R>L and altered sensation, with reductions in LT, PP and JP, with change to normal at the groin bilaterally. Abdominal reflexes were absent. ER staff noted reduced rectal tone but absence of saddle anaesthesia. Past Medical History: Hypothyroid Elevated cholesterol AAA Prostate CA CAD s/p pacemaker Hydrocele Zoster Social History: Denies alcohol and tobacco Family History: N/C Physical Exam: O: T: 97.5 HR: 69 BP: 171/79 R 18 O2Sats 98 Gen: Lying in bed, distressed with movement, tearful briefly talking about family HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM Back: Thoracic kyphosis, lumbar lordosis. Exquisite tenderness over lower thoracic spine. CV: RRR, Nl S1 and S2 +nil Lung: Clear to auscultation bilaterally aBd: Distended, +BS soft, nontender, unable to appreciate AAA. ext: no edema, thickened nails Skin: Rough area about 3x4cm over thoracolumbar area, not fully seen due to pain and need to support patient with additional help. Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Speech is fluent with normal comprehension and repetition. No dysarthria. No right left confusion. No evidence of neglect. Cranial Nerves: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1-V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone reduced in LE. No observed myoclonus or tremor No pronator drift [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF R 5- 5- 5- 5- 5- 4+ 5- 0 0 0 2 3 3+ 3 L 5- 5- 5- 5- 5- 4+ 5- 2 2 2 2 4- 4 4- Sensation: Intact to light touch, pinprick, vibration and proprioception throughout. No extinction to DSS. Pertinent Results: [**2105-1-27**] 06:10AM BLOOD WBC-16.0* RBC-3.44* Hgb-9.9* Hct-28.5* MCV-83 MCH-28.7 MCHC-34.7 RDW-16.0* Plt Ct-140* [**2105-1-26**] 01:44AM BLOOD WBC-13.6* RBC-3.43* Hgb-9.7* Hct-28.3* MCV-83 MCH-28.2 MCHC-34.1 RDW-15.9* Plt Ct-120* [**2105-1-24**] 11:31PM BLOOD WBC-14.3* RBC-4.28* Hgb-12.1* Hct-35.6* MCV-83 MCH-28.2 MCHC-33.9 RDW-16.1* Plt Ct-153 [**2105-1-24**] 07:09PM BLOOD WBC-14.5* RBC-5.31 Hgb-14.4 Hct-41.7 MCV-79* MCH-27.2 MCHC-34.6 RDW-15.7* Plt Ct-215 [**2105-1-24**] 08:42AM BLOOD WBC-13.6* RBC-5.26 Hgb-14.2 Hct-42.0 MCV-80* MCH-27.0 MCHC-33.8 RDW-15.3 Plt Ct-226 [**2105-1-26**] 01:44AM BLOOD Glucose-131* UreaN-28* Creat-1.0 Na-137 K-3.8 Cl-107 HCO3-24 AnGap-10 [**2105-1-25**] 02:16AM BLOOD Glucose-155* UreaN-29* Creat-1.0 Na-143 K-3.9 Cl-110* HCO3-23 AnGap-14 [**2105-1-24**] 07:09PM BLOOD Glucose-110* UreaN-25* Creat-1.1 Na-140 K-4.3 Cl-104 HCO3-23 AnGap-17 [**2105-1-26**] 01:44AM BLOOD Calcium-7.9* Phos-2.2*# Mg-1.9 [**2105-1-25**] 02:16AM BLOOD Calcium-8.0* Phos-4.8* Mg-2.0 Brief Hospital Course: Ms. [**Known lastname 1728**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**]. His scans revealed a lytic destruction of the T10 vertebral body posterior elements with soft tissue density minimally enhancing mass lesion. He was informed and consented for a posterior decompression and fusion and agreed to proceed. Please see Operative Note for procedure in detail. Post-operatively Mr. [**Known lastname 1728**] was given antibiotics and pain medication. His incision was clean and dry throughtout his hospital course. Neurology and Heme/Onc consults were sought and recommendations followed. He failed to regain significant lower extremity function but continued to work with physical therapy. He was screened for rehab and was discharged when medically stable. He will follow up in clinic in [**7-21**] days. Medications on Admission: Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection TID (3 times a day). 11. 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 Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: T10 soft tissue mass Discharge Condition: Good Discharge Instructions: Please continue to take your pain medication with an over the counter laxative. Call the clinic if you notice any redness or discharge from the incision site. Call the clinic for any additional concerns. Physical Therapy: Activity: Out of bed to chair Thoracic lumbar spine orthotic: when OOB Treatments Frequency: Please continue to change the dressing daily with dry, sterile gauze. Followup Instructions: Please follow up in the Orthopedic Spine Clinic in [**7-21**] days. Call [**Telephone/Fax (1) 11061**] for an appointment. Provider: [**Name10 (NameIs) 3833**] Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2105-2-18**] 10:15 Please follow up with your Primary Care Physician regarding the coordination of your remaining medical care. Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] at ([**Telephone/Fax (1) 8683**]. Completed by:[**2105-1-30**]

[ "737.19", "199.1", "V45.01", "198.5", "V10.46" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "81.63", "81.08", "03.09" ]

icd9pcs

[ [ [] ] ]

6267, 6337

4054, 4931

284, 410

6402, 6409

3028, 4031

6849, 7338

1348, 1353

5234, 6244

6358, 6381

4957, 5209

6433, 6639

1368, 1964

6657, 6733

6755, 6826

185, 246

438, 1181

2238, 3009

2003, 2222

1988, 1988

1203, 1288

1304, 1332

19,371

135,033

52882

Discharge summary

report

Admission Date: [**2196-6-15**] Discharge Date: [**2196-6-19**] Date of Birth: [**2118-11-15**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfonamides / Enalapril / Zocor Attending:[**First Name3 (LF) 2485**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 77F copd on home O2, metastatic CA with presumed lung primary opting for palliative care, DNR/DNI, T3 lung Ca s/p R pneumonectomy, dm2, who now p/w SOB. Of note, she was recently admitted [**Date range (1) 80833**] to [**Hospital1 18**] for PNA. She had recently been found to have metastatic disease to bone and liver of undetermined origin. After a non-diagnostic liver biopsy during a previous admission, she ultimately decided to pursue palliative care and eschew further efforts at biopsy to obtain a diagnosis. This is now her fourth admission since [**Month (only) **]. She was living at home with services since her discharge on [**6-7**]. She states that she is mostly bed bound, never leaves her home. She has DOE at her baseline and is on home O2 of 3L. She states that over the past couple of days her breathing has been worse. She denies f/c, cough. She does endorse abd pain and nausea. She was brought to the ED by ambulance from home. In the ED initial VS: T 99.1 109 112/69 36 98 4L NC. She was noted to be in a-fib. She was given nebulizers, solumedrol 125 IV x1 to treat copd flare, Vanc/levo to treat possible PNA. She was given dilt 120 mg PO x1 to treat the a-fib which had increased in rate to 140s. She briefly required non-invasive ventilation in the ED for roughly one hour. Initial gas 7.25/101/99 improved to 7.33/81/62. she was admitted to MICU for further evaluation. Past Medical History: 1. Lung cancer: - T3 N0 large cell s/p R pneumonectomy in [**2191-12-20**] 2. Breast cancer: - Ductal carcinoma in situ (left breast) s/p lumpectomy in [**2177**] 3. Chronic obstructive pulmonary disease 4. ?CAD --> negative MIBI [**2189**] 5. Diabetes mellitus 6. Hypercholesterolemia 7. Cartaract Social History: Lives with her niece in [**Location (un) 669**] who helps with most of her ADLs. Her significant other frequently visits. Occasional alcohol use, smoked 2 packs per day x 30 yrs prior to lung Ca Family History: Mother with breast cancer 74, diabetes in mother Physical Exam: VS: Temp: 98.4 BP: 126/68 HR: 83 RR: 22 O2sat: 92 50% VM GEN: awake, alert, comfortable appearing on face mask oxygen HEENT: PERRL, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, RESP: Absent breath sounds on R, prolong exp phase on L with minimal wheezing. CV: irreg irreg, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e Pertinent Results: Labs: see below . EKG: a-fib at 145, LAD, narrow QRS, no ischemic changes . Imaging: . Portable abdomen: IMPRESSION: Non-obstructive bowel gas pattern. Patient is apparently undergoing oral prep for CT scan. . CXR: Impression: Nonspecific findings are consistent with lymphangitic spread of carcinoma left lung. Less likely differential diagnosis would include chronic fluid overload in emphysematous patient. Appearances are not typical for infectious etiology. Brief Hospital Course: 77F copd on home O2, metastatic CA with presumed lung primary opting for palliative care, DNR/DNI, T3 lung Ca s/p R pneumonectomy, dm2, who now p/w SOB likely COPD flare. . 1. Resp distress: Likely [**1-22**] COPD flare in setting of very tenuous baseline status. Pt had FEV1 of 0.5 preop before the pneumonectomy. On 3L home 02. CHF was believed less likely. PNA is unlikely given pt is afebrile and without leokocytosis. Lymphangitic spread of tumor is a possibility. PE is a consideration particularly given the risk factor of CA, although although with treatment of COPD the patient returned to her home O2 requirement so CTA chest deferred as alternative Dx more likely. Treated initially with solumedrol then transitioned to prednison to complete 5 day course (40-30-20-10-5-off), azithromycin day [**3-24**], nebulizers as needed. She also responded well to morphine for subjective dyspnea. . 2. Afib/flutter: No known prior history. Hemodynamically stable. CHADS 3 so would benefit from anticoagulation but risk of bleeding likely outweighs mortality from metastatic lung CA so coumdain not started. Continued on ASA 81mg daily and diltiazem for rate control. TSH mildly decreased (0.15) but difficult to interpret in setting of acute illness; could consider repeating as an outpatient. . 3. Lung CA with liver and bone Lesions: These likely represent metastases. Pt has decided in the past not to pursue further diagnostics given that she had no intentions of undergoing chemotherapy, radiation or surgery except for palliation. Code status is DNR/DNI. Palliative care consulted. . 4. Abd pain: Rapidly resolved. KUB and exam unremarkable. No further symptoms. . 5. Diabetes mellitus: Was recently discharged with increased glargine (8 -> 10units), and this was uptitrated in setting of steroids. [**Month (only) 116**] need to decrease as taper steroids. RISS. . # Hypertension: c/w bp regimen . # ?UTI: Urinalysis dirty. Remains afebrile but with rising WBC count. Will recheck U/A and send culture, consider starting antibiotics if positive however asymptomatic. . 7. Episcleritis: Complained of eye pain and was seen by optho during her last admission who felt she had episcleritis; started on Polyvinyl Alcohol-Povidone and Erythromycin treatments. . FEN: Regular diet Access: PIVs PPx: Hep SQ, ppi DISPO: Call out to floor Medications on Admission: 1. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). [**Month (only) **]:*60 Capsule, Sustained Release(s)* Refills:*2* 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-22**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 6. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-22**] Drops Ophthalmic QID (4 times a day). [**Month/Day (2) **]:*1 bottle* Refills:*0* 8. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic HS (at bedtime) for 1 weeks: Apply to affected eye. [**Month/Day (2) **]:*5 strips* Refills:*0* 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. [**Month/Day (2) **]:*8 Tablet(s)* Refills:*0* 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 8 days. [**Month/Day (2) **]:*24 Tablet(s)* Refills:*0* 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Home With Service Facility: Hospice of the Good [**Doctor Last Name 9995**] Discharge Diagnosis: respiratory failure metastatic lung cancer Discharge Condition: expired Discharge Instructions: pt expired Followup Instructions: n/a Completed by:[**2196-7-12**]

[ "250.00", "198.5", "427.31", "401.9", "197.7", "599.0", "491.21", "V10.3", "379.00", "518.81", "V10.11", "272.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7120, 7198

3319, 5661

328, 334

7285, 7295

2827, 3296

7354, 7389

2326, 2376

7219, 7264

5687, 7097

7319, 7331

2391, 2808

269, 290

362, 1768

1790, 2096

2112, 2310

59,314

111,840

46036

Discharge summary

report

Admission Date: [**2114-12-18**] Discharge Date: [**2115-1-2**] Date of Birth: [**2045-12-15**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 4282**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: none History of Present Illness: HPI: The patient is a 69 yo woman with h/o recently diagnosed MDS ([**4-9**]), azacytodine chemotherapy, day 15 presently cycle 5. Presented to clinic for scheduled NP follow up visit s/p C5 Azacitidine; arrived feeling extremely weak, quite pale, shivering; describes 4 days of these sx, including diarrhea; no n/v, states taking large amounts of po fluids, non productive cough with fever to 102. She had received 3U PRBC prior to a 3 week trip in mediterranean. Presented to clinic fatigued, with non-productive cough, but has been afebrile, without evidence of respiratory distress. . Past Medical History: PAST ONCOLOGIC HISTORY: --Presented to ER in [**2114-1-1**] with shortness of breath and fever secondary to pneumonia. Hemoglobin and hematocrit levels were 4.9 mg/dl and 14.2%, respectively, with MCV = 122 at the time. Required several red cell transfusions between [**1-8**] and [**4-9**]. --Bone marrow biopsy on [**2114-4-26**] showed "hypercellular erythroid dominant bone marrow with dyserythropoiesis and ringed sideroblast consistent with myelodysplastic syndrome best classified as RARS. Cytogenetics revealed trisomy 8. IPSS intermediate-1 risk score. --Began Procrit 40,000 units weekly [**2114-5-1**] with increase of dose to 60,000 units weekly with no improvement in her red cell transfusion requirement. --Received Cycle 1 azacitidine chemotherapy [**2114-7-9**] through [**2114-7-13**]. Cycle 2 administered [**Date range (1) 97986**]; delayed by one week due to neutropenia. Cycle 3 administered [**Date range (1) 97987**]; again delayed by one week due to neutropenia. Cycle 4 administered . PAST MEDICAL HISTORY: s/p pericarditis 4 years ago Bilateral [**Hospital1 15309**] neuroma h/o migraines that resolved 2 years ago s/p plantar fasciitis L foot s/p shingles s/p multiple skin cancers removed by either dermatologists, Dr. [**Last Name (STitle) **], or Dr. [**Last Name (STitle) 22342**] s/p tonsillectomy. Pericarditis Social History: Lives alone by herself in Collidge Corner in a condominium. No known family members. [**Name (NI) **] lots of friends who live nearby. 1 pack cig per day active smoker for approx 50 years. Family History: Father passed away of PNA. Physical Exam: PHYSICAL EXAM: Vs: Tc: 98.7 hr: 100 BP: 106/51 . General: comfortable. Skin: very pale, warm, dry, without ecchymosis, erythema, petechiae or rash. HEENT: sclera anicteric, conjunctiva very pale. Oropharynx pale pink, moist, without mucositis, erythema or thrush. Lungs: breathing easily with occasional dry cough, able to talk in full sentences; dullness to percussion at L base; diminished coarse breath sounds at R base with inspiratory and expiratory crackles. Remainder of lung fields clear. Cardiac: heart rate regular in rate and rhythm, without murmur, rub or gallop. Extremities: symmetrical, trace edema bilaterally from feet to mid-calf bilaterally. No erythema or tenderness. Pertinent Results: [**2114-12-18**] 09:00PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE IgM HAV-NEGATIVE [**2114-12-18**] 09:00PM Smooth-NEGATIVE [**2114-12-18**] 09:00PM [**Doctor First Name **]-POSITIVE * [**2114-12-18**] 09:00PM HCV Ab-NEGATIVE [**2114-12-18**] 08:50AM UREA N-22* CREAT-1.1 SODIUM-130* POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-21* ANION GAP-16 [**2114-12-18**] 08:50AM ALT(SGPT)-191* AST(SGOT)-230* LD(LDH)-343* ALK PHOS-89 TOT BILI-0.7 [**2114-12-18**] 08:50AM HAPTOGLOB-176 [**2114-12-18**] 08:50AM WBC-0.8*# RBC-1.53*# HGB-4.5*# HCT-13.6*# MCV-89 MCH-29.4 MCHC-33.1 RDW-21.4* [**2114-12-18**] 08:50AM NEUTS-42.8* LYMPHS-53.5* MONOS-1.5* EOS-0.9 BASOS-1.3 [**2114-12-18**] 08:50AM PLT SMR-VERY LOW PLT COUNT-74*# [**2114-12-18**] 08:50AM RET AUT-2.5 . Micro: DIRECT INFLUENZA A ANTIGEN TEST (Final [**2114-12-19**]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2114-12-19**]): Negative for Influenza B. [**2114-12-19**]: Liver US. . IMPRESSION: 1. No intra- or extra-hepatic biliary duct dilatation. 2. Small amount of free perihepatic fluid. 3. Collapsed gallbladder with wall edema and small amount of pericholecystic fluid. These findings could be due to a variery of chronic conditions including hypoalbuminemia, chf, or can be seen in hepatitis. There is no evidence to suggest acute inflammation. . CXR: [**2114-12-18**] Very severe heterogeneous opacification has developed in the left upper lobe. Left lower lobe was collapsed in [**Month (only) 1096**], now reexpanded and densely consolidated. There may be left hilar adenopathy and small left pleural effusion. Overall, findings are consistent with extensive pneumonia though under the appropriate clinical circumstances, this could be infiltrated malignancy. Small region of ground-glass opacity in the right apex persists since the chest CT done on [**2114-1-13**]. Mild-to-moderate cardiomegaly is longstanding and right lung shows some mild vascular redistribution but I do not believe pulmonary edema is playing any role. . -[**2114-12-21**] TTE: The left atrium is mildly dilated. Left ventricular wall thicknessis is normal. There is normal cavity size and regional/global systolic function (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. -[**2114-12-24**] CT chest: 1. Multifocal pneumonia, comparable in extent to the appearance on the chest radiograph, [**12-23**], which has progressed since [**12-18**]. Small bilateral pleural effusions are also comparable and not of sufficient size to suggest empyema. There are no characteristics of the widespread pulmonary infection, to permit discriminating among possible causes: virus, bacteria, or fungus. 2. Minimal increase in size and number of mediastinal lymph nodes, presumably reactive. More substantial left hilar adenopathy cannot be excluded, but if present, is not obstructive, and is equally likely to be reactive. 3. New tiny right middle lobe lung nodule. 4. Small pleural and pericardial effusions could be sympathetic to infection, or residual from prior cardiogenic edema -[**2114-12-27**] CT head No acute intracranial hemorrhage. No acute intracranial process -[**2114-12-30**] MRI/MRA Multiple areas of restricted diffusion are seen in both cerebral hemispheres involving frontal, parietal and occipital lobes. No focal acute infarcts are seen within the posterior fossa. The distribution is in the watershed region in the left frontal lobe, but otherwise, it is in the cortical and subcortical region of both cerebral hemispheres. There is no acute hemorrhage identified. There is no mass effect, midline shift or hydrocephalus. Mild-to-moderate brain atrophy is seen. IMPRESSION: 1. Multiple small acute cortical and subcortical infarcts including infarct in the left frontal watershed distribution as described above. Mild diffuse decreased signal within the bony structures of the head could be due to marrow hyperplasia or infiltration and clinical correlation recommended. MRA OF THE NECK: Neck MRA shows normal flow in carotid and vertebral arteries without stenosis or occlusion. IMPRESSION: Normal MRA of the neck. MRA HEAD: Head MRA demonstrates normal flow in the arteries of anterior and posterior circulation. IMPRESSION: Normal MRA of the head -[**2115-1-1**] TTE Bubble Study: No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers -[**2115-1-1**] CSF: WBC: 2 (x2 tubes) TP 28 Gluc 51 LDH 31 -[**2115-1-2**] EEG: Pending at time of discharge Labs on day of discharge: WBC 4.4 Hct 21.9 Plt 221 Na 138 K 4.3 Cl 109 HCO3 26 BUN 16 Creat 0.7 Gluc 73 ALT 37 AST 81 AP 158 TBil 0.2 Alb 2.0 Brief Hospital Course: 69 yo with myelodysplastic syndrome (RARS), presently D15C5 azacitidine presenting with fever, neutropenia, profound anemia, diarrhea and cough with fever, lung exam concerning for PNA. . Respiratory Distress: Patient presented with profound anemia likely secondary to her MDS. She received 5 UPRBC with improvement of her HCT from 13.6 on admission to 23.2. She developed respitratory distress likely secondary to combined insult of her pneumonia and volume overload for which she triggered. She was found to be in flash pulmonary edema. She received supportive therapy. Her respiratory status improved and she was transferred to the floor. She was started on albuterol nebulizer treatement for possible bronchospasm, but this may not need to be continued at the rehabilitation facility. . PNA/recurrent fevers: She had presented to clinic where she was found to be febrile to 102 and neutropenic. a CXR showed a Left lower lobe pneumonia. She was started on vancomycin and cefepime. A DFA was negative. Blood cultures were negative. In the interim, the patient was managed with meropenem, voriconazole, azithromycin, and vancomcyin in the setting of recurrent fevers and night sweats. She was discharged after being afebrile for 1-2 days, with a short course of meropenem to be completed. . MDS/Anemia: She has a history of sideroblastic anemia for which she is on azacitidine. She received 5 units of pRBC over the first 2 days of her hospitalization. There was a consideration, given the recurrent fevers and night sweats, that the patient had a hematologic etiology, perhaps transformation to AML. A smear was obtained and was unremarkable, so bone marrow biopsy was deferred. She received a unit of pRBC on the day of discharge, which she completed prior to transfer to rehabilitation. . Altered mental status/right hand-wrist weakness: The patient developed right hand/wrist weakness on [**12-26**]. The patient also developed attention/cognitive deficits. An MR head was obtained which showed a likely watershed infarct in the left frontal cortex, with multiple focal lesions in both hemispheres. LP was negative for meningitis. TTE bubble study was negative for PFO or ASD. EEG was performed with results pending at time of discharge. Her mental status improved considerably and she had a clear thought process, and was consistently oriented to her name, the name of her hospital, and the month/year. . LFT elevation: Hepatitis serologies were negative, as were smooth Antibodies. She did have a positive [**Doctor First Name **] with titer pending. Hepatic US showed Small amount of free perihepatic fluid, collapsed gallbladder with wall edema, and small amount of pericholecystic fluid. LFTs were improved by day of discharge. . Neutropenic Fever: Her neutropenia was likely secondary to her chemotherapy. She was placed on neutropenic precautions and her ANC was trended. Her neutropenia resolved with periodic dosing of neupogen. She had had no fevers for 1-2 days prior to discharge. Per ID recommendations, she was discharged on meropenem, to be continued for six days following discharge. . Prophylaxis: She did not receive heparin SQ prophylactically given the contraindication posed by her azacitidine therapy. As her platelet count remained normal, and there was no evidence of intracranial hemorrhage on imaging, SC heparin was given for DVT prophylaxis. Medications on Admission: PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth every 6 hours as needed for nausea ZOLMITRIPTAN [ZOMIG] - (Prescribed by Other Provider) - Dosage uncertain Medications - OTC ASPIRIN [ASPIRIN [**Hospital1 **]] - (Prescribed by Other Provider; OTC) - 81 mg Tablet, Chewable - one Tablet(s) by mouth once a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - 1,000 unit Tablet - 1 Tablet(s) by mouth once a day MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1cap Capsule(s) by mouth once daily OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider) - Dosage uncertain VITAMIN E - (Prescribed by Other Provider) - Dosage uncertain . ALLERGIES: Codeine Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nAUSEA . 3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 4. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. 5. Meropenem 500 mg Recon Soln Sig: One (1) dose Intravenous every six (6) hours for 6 days: Last doses on [**2115-1-8**]. 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Treatment Inhalation every four (4) hours as needed for sob/wheeze. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for PRN FEVER. 8. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 9. Omega-3 Fish Oil 1,000-5 mg-unit Capsule Sig: One (1) Capsule PO once a day. 10. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Multifocal Pneumonia Febrile neutropenia Left frontal watershed cerebral infarct Myelodysplastic syndrome Secondary s/p pericarditis 4 years ago Bilateral [**Hospital1 15309**] neuroma h/o migraines that resolved 2 years ago s/p plantar fasciitis L foot s/p shingles s/p multiple skin cancers removed by either dermatologists, Dr. [**Last Name (STitle) **], or Dr. [**Last Name (STitle) 22342**] s/p tonsillectomy. Pericarditis Discharge Condition: Medically stable for discharge to rehabilitation facility. Discharge Instructions: You were admitted to the hospital because you were fatigued and having fevers. You were found to have a pneumonia treated with antibiotics. You also received blood transfusions. Your breathing initially improved, however your lungs became overloaded with fluid and you went to the intensive care unit. Your breathing improved and you came back to the regular floor. . You coninued to have difficulty with your breathing and continued to have fevers so procedures were done to sample your lung fluid to culture and remove some of the fluid, which did not show obvious infection. Your pnuemonia was treated with antibiotics. You also developed some mild confusion and right hand weakness, due to a stroke, which was seen on MRI. A lumbar puncture did not show any infection of your cerebrospinal fluid. You had an EEG exam to look for seizure activity, the final results of which were pending at the time of discharge. . The following changes were made to your medications: -You were started on MEROPENEM, an intravenous antibiotic. You will have an IV line placed at the rehabilitation facility to receive this medication. You will continue to take this for six days post-discharge, with your last doses on [**2115-1-8**]. -Added Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. -Added Benzonatate 100 mg Capsule, One Capsule by mouth 3 times a day -Added Acetaminophen 325-650 mg by mouth every eight hours as needed for fever; PLEASE DO NOT EXCEED 2000MG/ DAY -Added Albuterol 0.083% Nebulizer to be inhaled every four hours, as needed for shortness of breath or wheeze . Please return to the hospital or call your doctor if you feel faint, light headed, experience nausea, vomiting, constipation, headache, blurry vision, weight loss, night sweats, chest pain, abdominal pain, shortness of breath, muscle aches, joint aches, fever, blood in your stool or urine, or any other symptoms that are concerning to you. Followup Instructions: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3014**], RN & [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2115-1-10**] 1:30

[ "518.89", "288.03", "284.1", "790.4", "486", "355.6", "758.5", "434.91", "238.75", "518.84", "787.91", "E933.1", "518.4", "305.1", "780.61" ]

icd9cm

[ [ [] ] ]

[ "33.24", "03.31" ]

icd9pcs

[ [ [] ] ]

13642, 13708

8496, 11876

278, 284

14189, 14249

3255, 8473

16250, 16470

2499, 2527

12640, 13619

13729, 14168

11902, 12617

14273, 16227

2557, 3236

231, 240

312, 904

1962, 2276

2292, 2483

49,328

100,827

41430

Discharge summary

report

Admission Date: [**2191-3-23**] Discharge Date: [**2191-3-31**] Date of Birth: [**2125-3-4**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5790**] Chief Complaint: Sarcoma of the left lung extending to and including the main pulmonary artery, as well as the left and right pulmonary arteries. Major Surgical or Invasive Procedure: [**2191-3-23**]: 1. Left pneumonectomy with pulmonary artery reconstruction using a 20-mm Dacron tube graft. 2. Ligation and division of the patent ductus arteriosus. 3. Flexible bronchoscopy. 4. Mediastinoscopy 5. Intercostal muscle flap buttress to the left bronchial stump. History of Present Illness: Mr. [**Known lastname **] is a 66M w a recently diagnosed pulmonary artery sarcoma admitted for resection. Patient was in his usual state of good health until [**4-/2190**] when he developed a cold while traveling abroad. Since then, he has noticed a decrease in overall stamina. In [**7-/2190**], he saw his PCP and several tests were done including Holter monitor, stress test, pulmonary function tests and chest x-ray all of which reportedly were normal. A chronic dry cough developed over this time, and he was started on PPI. Cough improved some but stamina remained low. In [**11/2190**] continued complaint of cough prompted ENT evaluation. Laryngoscopy demonstrated changes consistent with PND and he was started on a nasal spray, nasal wash and a course of antibiotics. In [**1-/2191**], progressive DOE and dry cough lead to pulmonary specialist referral. Noncontrast CT scan demonstrated a 1.3 cm nodule. At this time, pt was referred to Dr. [**Last Name (STitle) **] for further evaluation of the solitary pulmonary nodule. Subsequent contrast CT scan revealed a soft tissue mass arising within the left pulmonary artery, vascular occlusion and expansion highly suggestive of pulmonary artery sarcoma. There was also extravascular extension and bronchial artery transpleural collaterals suggesting longstanding pulmonary artery obstruction. PET/CT scan later demonstrated a lobulated low-attenuation FDG avid mass which occupies an experience of left main pulmonary artery and extends beyond its wall. There was a new FDG avid left pleural effusion which developed over the 7-day interval since the CT scan suggestive of tumor spread. On [**2191-2-24**], the patient underwent bronchoscopy and biopsy of the soft tissue mass, which revealed a spindle cell neoplasm with necrosis, likely malignant. By immunohistochemistry, the tumor cells were diffusely positive for vimentin, focally positive for cytokeratin cocktail, actin and desmin; negative for S-100. The profile was suggestive of a smooth muscle phenotype. Corresponding cytology was also consistent with this diagnosis. Patient presents now for operative resection. Past Medical History: PMH: Hyperlipidemia, Hx prostate CA s/p rsxn ([**2188**]) PSH: prostatectomy for early stage prostate cancer at [**Hospital1 2025**] ([**9-/2189**]), B/L inguinal hernia repair ([**2191-1-5**]) Social History: Married, lives with wife. [**Name (NI) 1139**] never. ETOH: 1 drink per week Family History: Father died age 73 of breast cancer. Brother has prostate cancer. Physical Exam: VS: T: 99.0 HR: 88-93 SR BP: 103/76 Sats: 98% RA GEN: WD, WN M in NAD HEENT: MMM, anicteric sclerae CV: RRR, +S1S2 w no M/R/G PULM: clear breath sounds no crackles ABD: S/NT/ND EXT: WWP, no edema Incision: L. thoracotomy incision margins well approximation. R groin site mild erythema, no discharge Neuro: awake,alert oriented Pertinent Results: LABORATORIES: ADMISSION: [**2191-3-23**] 06:03PM BLOOD WBC-14.6* RBC-2.25*# Hgb-6.6*# Hct-18.8*# MCV-84 MCH-29.4 MCHC-35.2* RDW-14.1 Plt Ct-227# [**2191-3-23**] 06:03PM BLOOD PT-17.0* PTT-37.7* INR(PT)-1.5* [**2191-3-23**] 08:00PM BLOOD UreaN-17 Creat-0.9 Na-139 K-4.0 Cl-108 HCO3-25 AnGap-10 MICROBIOLOGY: MRSA Screen [**2191-3-23**]: NEG CXR: [**2191-3-30**]: The left apical air collection is unchanged. The post-surgical cavity continues to be occupied by fluid. Subcutaneous air appears to be grossly unchanged. Right lung is unremarkable, except for small amount of right pleural effusion that appears to be decreased as well. [**2191-3-23**] (postop): s/p L pneumonectomy. pneumonectomy space filled w air/min amount of fluid. mild vascular congestion on right. ET tube in standard position. tip 4.6 cm above carina. R IJ catheter tip in the mid-to-lower SVC. postoperative mediastinal widening. Cardiac size top normal. mild left chest wall subcutaneous emphysema. Elevation L hemidiaphragm is new. Left chest tube in place. PATHOLOGY: PENDING Brief Hospital Course: Mr.[**Known lastname **] is a 66M with a recently diagnosed left pulmonary artery sarcoma admitted to the thoracic surgery service on [**2191-3-23**] following: cervical mediastinoscopy, left exploratory thoracoscopy, left thoracotomy and left pneumonectomy with pulmonary artery reconstruction, cardiopulmonary bypass, intercostal muscle flap buttress to the bronchial stump, mediastinal lymph node dissection, bronchoscopy with bronchoalveolar lavage. Postoperatively, the patient was transferred to the CVICU intubated, sedated, on pressors, foley, Left chest tube and IV opoids for pain control. Neuro: Post-operatively, the patient remained intubated and sedated. Sedation was weaned and patient was extubated on POD1. Upon extubation, patient received percocet and IV morphine with good effect and adequate pain control. Analgesia was eventually adjusted to po oxycodone and tylenol RTC with improved effect. Cardiac: Required pressors initially to maintain MAP > 60 ajd was discontinued on [**2191-3-26**]. His SBP remained stable at 100-120. He remained in sinus rhythm without ectopy. Low-dose lopressor was started [**2191-3-27**] for tachycardia and increased to 25 mg tid on [**2191-3-29**] for HR 90-100. Respiratory: Patient was successfully extubated on [**2191-3-24**]. Aggressive pulmonary toilet and nebs were initiated with oxygen saturations of 95-98% on 1-2L NC. On [**2191-3-29**] he titrated off oxygen room with a saturation of 98% at rest and activity. Serial CXRs were followed postoperatively to assess status of L thorax and aeration of R lung. L thorax demonstrated expected fluid collection s/p pneumonectomy while R lung expanded well. Chest tube: immediate postoperative output large amount of heme which trended down. The chest tube was removed [**2191-3-25**] and U stitch was placed to seal chest tube tract. GI/GU: Post-operatively, the patient was given IV fluids while extubated. Upon extubation, patient's diet was advanced as tolerated to regular/heart healthy and fluids were discontinued. He was also started on a bowel regimen to encourage bowel movement. Urine output was monitored via foley catheter postoperatively. Lasix 20 iv x 1 dose given on [**3-25**] for assistance w diuresis. Foley was removed on [**3-28**] and patient voided appropriately. Intake and output were closely monitored. Patient was noted to be hyponatremic to 129 on [**3-28**] prompting free water restriction of 500cc/day. Urine electrolytes were also evaluated [**3-28**]. Electrolytes were followed [**Hospital1 **]. ID: Patient was given appropriate preoperative antibiotic prophylaxis. The patient's temperature was closely watched for signs of infection. Heme: Postop, serial HCT were done in setting of sanguinous chest tube output. He was transfused 7 units of PRBC to maintain HCT > 24. His last transfusion was [**2191-3-26**] with a stable HCT of 29. HCT remained stable throughout remainder of admission. Prophylaxis: Initially postoperatively, DVT prophylaxis was held given concern for hemorrhage. Subcutaneous heparin and ASA were started on [**3-27**] when HCT stable. Patient was also encouraged to get up and ambulate as early as possible. At the time of discharge on [**2191-3-31**] the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: pravachol 40 qhs, omeprazole 20' Discharge Medications: 1. Nebulizer Machine and equipment 2. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: Three (3) mL Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*30 vials* Refills:*1* 3. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. sennosides-docusate sodium 8.6-50 mg Tablet Sig: One (1) Tablet PO twice a day: with narcotics. hold for loose stool. Disp:*60 Tablet(s)* Refills:*2* 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO twice a day. Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2* 9. tizanidine 4 mg Capsule Sig: One (1) Capsule PO every eight (8) hours as needed for pain. Disp:*90 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] Regional VNA Discharge Diagnosis: Left main pulmonary artery sarcoma Hyperlipidemia 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 chest pain -Left thoracotomy incision develops drainage Pain -Take acetaminophen 650 mg every 6 hours for pain -Oxycodone 5-10 mg every 4-6 hours for pain. -Tazanidine 4 mg every 8 hours as needed for pain Activity -Shower daily. Wash incision with soap & water, rinse, pat dry -No tub bathing, swimming or hot tub until incision healed -No driving while taking narcotics. -No lifting greater than 10 pounds -Daily weights: keep a log. Call if you have greater than [**1-21**] pound weight gain Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] 617-632-:[**Telephone/Fax (1) 3020**] Date/Time:[**2191-4-19**] 11:00 in the [**Hospital Ward Name 121**] Building [**Location (un) **] [**Hospital1 **] [**First Name (Titles) 479**] [**Last Name (Titles) 7755**] Clinic Chest X-Ray [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology 30 minutes before your appointment Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2191-4-19**] 1:30 in the [**Last Name (un) 2577**] Building Cardiac Surgery Suite [**Location (un) 551**] Completed by:[**2191-3-31**]

[ "162.8", "511.81", "276.1", "V10.46", "747.0", "198.89", "458.29", "285.1", "272.4" ]

icd9cm

[ [ [] ] ]

[ "38.85", "40.3", "32.59", "33.24", "38.45", "39.61", "34.22" ]

icd9pcs

[ [ [] ] ]

9360, 9424

4753, 8165

439, 725

9518, 9518

3673, 4730

10341, 10998

3239, 3307

8249, 9337

9445, 9497

8191, 8226

9669, 10318

3322, 3654

270, 401

753, 2909

9533, 9645

2931, 3128

3144, 3223

23,234

115,398

15019

Discharge summary

report

Admission Date: [**2175-9-14**] Discharge Date: [**2175-9-20**] Date of Birth: [**2110-9-18**] Sex: F Service: Neurology HISTORY OF PRESENT ILLNESS: 65-year-old woman who presents with left leg weakness. The patient was found to have a stenosis of the brachiocephalic artery on an MRA/MRI. MRI of the entire spine was obtained by her PCP for suspicion of disc disease. The rationale for pursuing of an MRA is unknown. She saw Dr. [**Last Name (STitle) **] from vascular surgery who referred her to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5730**]. He performed an angiogram and confirmed the stenosis. On [**9-14**], a stent was placed but afterwards she developed flaccid left hemiparesis of arm and leg. She was taken back to angiography where she had another stent placed for "another blockage." The radiology report of the angio states that there was an apparent narrowing of the proximal common carotid artery. It was felt that the patient had developed a flap distal to the site in the common carotid artery. She received three further stents of the carotid. Afterwards, Dr. [**Last Name (STitle) 5730**] states that her left sided weakness resolved. After the second visit to the angio suite, the patient says she developed a drop in hematocrit, requiring three units of packed red blood cells. She does not know if she had a hematoma. Before discharge, the patient said she still had some weakness which significantly improved but she also developed left leg numbness while in the hospital which progressively worsened after she was discharged. She came to the Emergency Department because the numbness has worsened to the point where she felt the leg feels "dead". She is walking without support but she leans to the left and is not steady. PAST MEDICAL HISTORY: 1) Restless leg syndrome 2) Duodenal ulcer Medications: Coumadin-started after the stent Plavix Klonopin SOCIAL HISTORY: The patient lives with two sons. Independent in activities of daily living. No tobacco or ETOH. On physical examination, blood pressure 140/70, heart rate 70 and regular. The patient appeared comfortable. OP clear, right carotid bruit, no JVD, no thyromegaly. Cardiac examination was notable for a regular rate and rhythm. Chest was clear to auscultation, and abdomen was benign. No clubbing, cyanosis, or edema of the extremities. On neurological examination, Mental Status: The patient was awake, alert, and oriented times three. The patient stated the months of the year backwards and forwards. Language testing demonstrated normal naming of high and low frequency objects, good repetition. Normal fluency and comprehension. The patient could write a sentence to dictation. Memory: Registered and recalled [**3-19**] objects at one and five minutes. Calculations were normal. The patient could demonstrate how to strike a match, light a cigarette, puff it, throw it to the ground, and stamp it out. CN: Optic disks were normal. PERRLA, EOMI, VFFTC, V1-V3 intact to light touch and to pinprick. Face, tongue, palate, SCM move symmetrically. Hearing intact to finger rub bilaterally. Motor: Normal tone and bulk. No pronator drift. No asterixis. D B T WE WF FE FF IO IP H Q G AT [**Last Name (un) 938**] R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 3 4 5 5 4 4 Sensory: LT and PP severely reduced on the left leg compared to the right. Poor JPS of the left toe. There is no sensory level. Reflexes: B, T, BR, patella, ankle Plantar R 3 3 3 3 2 down L 3 1 2 2 2 down Coordination: [**Last Name (LF) 43945**], [**First Name3 (LF) **], FFM were normal. Romberg maneuver was negative. Gait: She does lean to the left. Labs: INR 1.4 ASSESSMENT AND PLAN: 65-year-old woman who developed left sided weakness and left common carotid artery stenosis found to have common carotid artery dissection requiring further stents. On examination she has UMN weakness in the left leg with concurrent sensory loss. Given the clinical setting, the most worrisome possibility is a stroke. The vascular distribution would be ACA territory (unusual compared to MCA). If imaging is negative, then the second possibility is lumbar disc disease, although the history is not consistent. RECOMMENDATIONS: 1) MRI with DWI, MRA of the brain. If stents are prohibitive, then proceed with CT and CTA (of neck as well) if renal function allows. 2) If imaging negative, then we should consider imaging of the L-spine. 3) Her Coumadin needs to be continued and brought up above 2.0 given the dissection. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 13-224 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2175-9-22**] T: [**2176-4-8**] 17:27 JOB#:

[ "305.1", "428.0", "427.89", "300.00", "285.9", "433.80", "533.90", "997.1", "997.02" ]

icd9cm

[ [ [] ] ]

[ "39.50", "88.41", "39.90" ]

icd9pcs

[ [ [] ] ]

177, 1819

2454, 4781

1842, 1951

1968, 2438

11,815

137,037

54414+54415+59603

Discharge summary

report+report+addendum

Admission Date: [**2103-1-22**] Discharge Date: [**2103-2-12**] Service: Cardiothoracic Intensive Care Unit ADDENDUM: This is an Addendum starting on [**2103-1-22**]. The patient was admitted to the Cardiothoracic Intensive Care Unit and aggressively hydrated. Significant Cardiothoracic Intensive Care Unit event; on hospital day four, a new pericardial rub, with a troponin of 0.1 to less than 0.20, and electrocardiogram changes were appreciated. There was a decreased lipase and amylase. Lactate was up from 0.4 to 0.8. Cardiology evaluation was as follows. They suspected demand ischemia in the setting of acute pancreatitis. Recommended aspirin for the time being. No heparin given. Acute pancreatitis. The patient with severe mitral regurgitation. Was also worked up, and it was suggested that after the patient recovered from her acute episode the patient would probably need ACE inhibitor and antidiuretics. On hospital day nine, the patient spiked a temperature after imipenem was discontinued and the dobutamine was off. The patient converted to Lopressor and enzymes were cycled. Lasix was begun on hospital day ten for gentle diuresis and an ACE inhibitor for afterload reduction. The patient had a spontaneous breathing fall on hospital day twelve. By hospital day fifteen, the patient the nasogastric tube was discontinued. The patient had a bedside swallowing evaluation and was prepared for transfer to the floor. On hospital day sixteen, the patient was started on full liquids. The patient had flash pulmonary edema post extubation but recovered. The patient spiked a white count to 19.2 and was followed until transfer to the floor on [**2-7**]. A Dobbhoff was placed at the same time. The patient was confused when she came to the floor, but her sensorium cleared over the next several days. The patient's tube feeds began at 10 cc per hour and were advanced to 60 cc per hour as the patient was able to tolerate. The patient was also taking oral intake; however, her calorie counts were around 300 per day. The patient also had repeated episodes of desaturations to the middle 80s during the evenings. The patient rapidly went back up after arousal. DISCHARGE STATUS: The patient to be discharged to an acute rehabilitation hospital. DISCHARGE INSTRUCTIONS/PLAN/FOLLOWUP: The patient to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one to two weeks. The plan is to continue to wean the patient off her tube feeds and revert back to oral intake. MEDICATIONS ON DISCHARGE: (The patient to be discharged on) 1. Lasix 20 mg by mouth once per day. 2. Albuterol as needed. 3. Amlodipine 5 mg by mouth twice per day. 4. Tylenol as needed. 5. Colace 100 mg by mouth twice per day as needed. 6. Lopressor 100 mg by mouth three times per day. 7. Captopril 100 mg by mouth three times per day. 8. Protonix 40 mg by mouth q.24h. 9. Aspirin 325 mg by mouth once per day. DISCHARGE DISPOSITION: As stated previously, the patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in clinic in one to two weeks. The patient was to call to set up this appointment. DISCHARGE DIAGNOSIS: Gallstone pancreatitis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], M.D. Dictated By:[**Name8 (MD) 8276**] MEDQUIST36 D: [**2103-2-12**] 15:02 T: [**2103-2-12**] 15:24 JOB#: [**Job Number 111381**] Admission Date: [**2103-1-23**] Discharge Date: [**2103-2-12**] Date of Birth: Sex: Service: GOLD SURGERY DISCHARGE DIAGNOSIS: Gallstone pancreatitis and choledocholithiasis. HISTORY OF PRESENT ILLNESS: This is an 80-year-old female with intermittent episodes of midabdominal cramping, pain, and discomfort radiating to the back in the setting of cholelithiasis based on an right upper quadrant ultrasound in [**2099**], who presented with 18 hours of midabdominal pain, severe, radiating to the deep back with 4 out of 5 rents criteria with gallstone pancreatitis and choledocholithiasis. PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia. PAST SURGICAL HISTORY: Status post appendectomy. Hysterectomy. SOCIAL HISTORY: No tobacco. Occasional ethanol use. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS ON ADMISSION: Aspirin 81 q.d., Zocor 80 q.d., Nifedipine 60 q.d. REVIEW OF SYSTEMS: No fevers, chills, or vomiting. No jaundice. No colored stools. No dark urine. The patient has had [**12-26**] loose bowel movements. PHYSICAL EXAMINATION: Vital signs: Temperature 96.2??????, heart rate 81, blood pressure 143/94, respirations 18, oxygen saturation 90% on room air. General: The patient was a pleasant, elderly female in no acute distress. HEENT: Scleral anicteric. Oropharynx clear. Chest: Clear to auscultation bilaterally. Cardiovascular: Machine rub/murmur. Abdomen: Severe midabdominal tenderness with guarding. No rebound, right greater than left. Extremities: Within normal limits. Rectal: Guaiac negative. No masses. LABORATORY DATA: White count 22.5, hematocrit 37.6, platelet count 252; CHEM7 139/4.2, 103/25, 22/1.1, 123. Electrocardiogram revealed lateral ST depressions. CT of the abdomen revealed severely calcified aorta but with patent vessels, edematous pancreatic head, cholelithiasis/choledocholithiasis. IMPRESSION: This was an 80-year-old female with gallstone pancreatitis and choledocholithiasis. HOSPITAL COURSE: The patient was admitted to the SICU for aggressive intravenous hydration, MRCP, and rule out for myocardial infarction. The patient's ERCP performed on the same day revealed a single nonbleeding periampular diverticula with a large opening found in the rim of the major papilla. Mini-regular stones ranging from size 4-7 mm causing partial obstruction causing partial obstruction were seen in the common bile duct. There was some poststricture dilatation. Sphincterotomy was performed at 12 o'clock positioning of the sphincterotome over it .................. guidewire, and multiple .................. successfully using a 2 mm balloon. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8275**] Dictated By:[**Name8 (MD) 8276**] MEDQUIST36 D: [**2103-2-12**] 14:47 T: [**2103-2-12**] 15:17 JOB#: [**Job Number 111382**] Name: [**Known lastname 18281**], [**Known firstname 2770**] Unit No: [**Numeric Identifier 18282**] Admission Date: [**2103-1-22**] Discharge Date: [**2103-2-15**] Date of Birth: [**2022-10-21**] Sex: F Service: FIRST ADDENDUM LEFT OFF ON [**Month (only) **]: The patient actually was not discharged on the 22nd due to a late evening event of her pulling her Dobbhoff tube. The decision was made then for the patient to try to increase her po intake. The patient was still not meeting daily caloric needs because of the po intake, therefore, the decision was made for the patient to receive a PICC line and to start parenteral nutrition. On the [**3-16**], the patient was not allowed to house access due to a white blood cell count of 20, however, the following day, once it was propelled upon Interventional Radiology that despite the high white blood cell count, all cultures of the patient's have been negative to date, as well as white blood cell count of 13. Interventional Radiology did place a PICC line and TPN was started on that date. Patient has been stable ever since with number of desaturation episodes. Patient will be discharged on the [**3-19**] to rehabilitation on TPN with a plan of eventually weaning her off of her parenteral nutrition and to transition her to po intake to meet her dietary needs. MEDICATIONS: Same as above. FOLLOW-UP: The patient is to follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 213**]. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-AAG Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2103-2-15**] 05:27 T: [**2103-2-15**] 18:29 JOB#: [**Job Number 18283**]

[ "518.82", "486", "398.91", "414.8", "401.9", "396.2", "263.9", "577.0", "574.91" ]

icd9cm

[ [ [] ] ]

[ "96.72", "99.15", "38.93", "51.85", "96.6", "96.04", "51.88" ]

icd9pcs

[ [ [] ] ]

2999, 3210

3660, 3709

2578, 2975

4372, 4424

5528, 8184

4211, 4252

4606, 5510

4444, 4583

3738, 4126

4149, 4187

4269, 4345

494

125,330

43464

Discharge summary

report

Admission Date: [**2168-2-20**] Discharge Date: [**2168-3-2**] Date of Birth: [**2109-12-22**] Sex: F Service: MEDICINE Allergies: Captopril / Vancomycin Attending:[**First Name3 (LF) 5037**] Chief Complaint: N/V, abdominal pain ,shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 58 yo woman s/p pancreas/kidney transplant ([**2159**]), CAD, hypercholesterolemia, HOCOM p/w chest and abd pain. Patient reports that 2 weeks ago she developed an upper respiratory infection with a cough, runny nose and shortness of breath. Cough was production with one episode of blood tinged sputum. She noted increasing shortness of breath 4 days ago. Two days ago she developed N/V (4 episodes of vomiting at home), as well as abd pain and intermittent sub sternal chest pain. The chest pain is poorly characterized, sometimes worse with eating and deep inspiration, non-radiating. She also notes that she has had dysuria x 1 week, and ? of urinary frequency. . In [**Name (NI) **], pt [**Name (NI) 20851**]. Labs notable for elevated [**Doctor First Name **] 190, elevated lip 374, bicarb 6, AG 16 (gap and non-gap acidosis), BUN/Cr 54/1.7 (baseline cr 1.0-1.1), K 5.5, WBC 10 (baseline 5), Hct elevated at 41.9 (baseline 28-32). Lactate nl. CXR fairly unchanged. Transplant surgery consulted in ED -> no current surgical issues. Renal fellow notified -> recommended IV bicarb and will see in AM. In [**Name (NI) **], pt given 2500cc NS, SL nitro x 1 (no relief of CP), lopressor 5mg IV x 1, morphine 2mg IV x 1, maalox 30mL x 1, kayexalate 15mg x 1. . On arrival to floor vitals were as follows: T 97.4, BP 106/54, HR 85, RR 28, O2 98% 4L NC. Admitting resident noted that patient was increasingly tachypneic. Her repeat labs again demonstrated a bicarb of 7. No bicarb had been given in the ED. An ABG on the floor was: 7.20/19/156. Given her increased respiratory rate and concern for her metabolic derangements, she was transferred to the unit for further monitoring. . At present, she feels that her shortness of breath is slightly improved. She is denying chest pain, abdominal pain, pain over renal or pancreatic graft or nausea. She denies diarrhea - has not moved her bowels in several days. No BRBPR. Past Medical History: - DM1 - s/p pancreas/kidney transplant in [**2159**] - CAD - cath [**5-21**] - LAD - distal 60% stenosis distally before the apex, LCx - 50% stenosis in one branch, RCA - dominant vessel with mild diffuse disease, PDA - 70% mid-vessel stenosis - ECHO [**11-22**] LVEF > 55%, PFO present - history of obstructive cardiomyopathy (LV outflow tract with a 41 mm Hg gradient at rest) - HTN - Hypercholesterolemia - SCCA vulva s/p vulvectomy - Anemia - Vit D deficiency - hx of spetic knee in [**10-22**] - asp grew strep viridans - chronic UTIs - hx of MRSA UTI, on supressive therapy Social History: Pt was a pediatrician in Russian, came to US many years ago. Lives alone in [**Location (un) **]; she has a male partner. She has never smoked and does not drink. Family History: non-contributory Physical Exam: Vitals on arrival to MICU T 95.5 HR 71 BP 123/54 RR 22 sat 100% ra Gen - NAD, chronically ill appearing HEENT - asymmetric pupils, dry MM CVS - RRR, nl S1, S2, no m/r/g Lungs - CTA b/l Abd - soft, NT/ND, no tenders over pancreatic or renal grafts Ext - warm, DP 2+ b/l, no LE edema b/l Neuro - aao x 3 Pertinent Results: Admission labs: [**2168-2-20**] 09:38PM K+-5.4* [**2168-2-20**] 08:20PM ALT(SGPT)-11 AST(SGOT)-15 AMYLASE-190* TOT BILI-0.2 [**2168-2-20**] 08:20PM LIPASE-374* [**2168-2-20**] 08:20PM WBC-10.4# RBC-4.61# HGB-14.1# HCT-41.9# MCV-91 MCH-30.6 MCHC-33.7 RDW-14.1 [**2168-2-20**] 08:20PM PLT COUNT-237 [**2168-2-20**] 08:20PM PT-12.3 PTT-34.1 INR(PT)-1.1 [**2168-2-20**] 07:13PM GLUCOSE-120* UREA N-54* CREAT-1.7* SODIUM-134 POTASSIUM-5.5* CHLORIDE-112* TOTAL CO2-6* ANION GAP-22* [**2168-2-20**] 07:13PM estGFR-Using this [**2168-2-20**] 07:13PM CK(CPK)-33 [**2168-2-20**] 07:13PM CK-MB-NotDone cTropnT-<0.01 . MICRO: [**2168-2-21**] 7:33 am URINE Site: CLEAN CATCH **FINAL REPORT [**2168-2-23**]** URINE CULTURE (Final [**2168-2-23**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Trimethoprim/Sulfa sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . Blood culture NGTD . Imaging: RUQ Ultrasound: IMPRESSION: 1. Normal gallbladder and no biliary ductal dilatation. 2. Small subcentimeter hepatic parenchymal calcification is of doubtful significance and may represent a calcified granuloma or other remote insult. . Renal Transplant US: IMPRESSION: Doppler flow demonstrated within the transplanted pancreas and kidneys, with mildly elevated resistive indices as described. No evidence of abnormal fluid collections adjacent to the transplanted organs. No evidence of hydronephrosis within the transplanted kidney. Transplanted pancreas appears of homogeneous echotexture. . Head CT: IMPRESSION: 1. No evidence of acute intracranial hemorrhage. 2. Diffuse sinus disease. . ECHO: Conclusions: The left atrium is normal in size. A left-to-right shunt across the interatrial septum is seen at rest. A secundum type atrial septal defect is present. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. 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. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Impression: secundum atrial septal defect; no resting outflow tract gradient is present at this time . CT Abd/Pelvis: CT OF ABDOMEN WITHOUT IV CONTRAST: The liver is diffusely hypodense consistent with fatty infiltration. The spleen contains areas of calcifications. This is of indeterminate significance. The adrenal glands are unremarkable. Both kidneys are atrophic. Loops of small and large bowel are unremarkable. Fatty replacement of the patient native pancreas is noted. The gallbladder has normal appearance with no stones. Extensive vascular calcification is noted within the aorta and its major branches. Shotty mesenteric and retroperitoneal lymph nodes are noted. No free air or fluid is seen within the abdomen. CT OF PELVIS WITHOUT IV CONTRAST: The transplanted kidney is visualized in left lower quadrant. Few small areas of low attenuation are visualized in the transplanted kidney likely representing simple cysts. Transplanted pancreas is visualized in the right lower quadrant. No fatty stranding is seen surrounding the transplanted pancreas to suggest pancreatitis. The urinary bladder, distal ureters, and pelvic loops of small and large bowel are unremarkable. Vascular calcification is noted. BONE WINDOWS: No concerning lytic or sclerotic lesions are seen. IMPRESSION: 1. No evidence of pancreatitis, pseudocysts, or stones is seen within the patient native pancreas or transplanted pancreas. 2. Status post kidney transplant with no evidence of stone or hydronephrosis. Multiple hypodense lesions within the transplanted kidney most likely represent simple cysts. . CXR: Heart size is normal. Small right pleural effusion vs. pleural thickening is without change. No focal areas of consolidation are present. IMPRESSION: No pneumonia. Persistent right pleural effusion vs. pleural thickening Brief Hospital Course: Elevated Pancreatic Enzymes: Patient had elevated pancreatic enzymes on admission. Native vs. tranplant pancreatitis was considered, though patient was asymptomatic. Patient was hydrated for volume depletion. Ultrasound was negative for any acute rejection. Moreover, her blood sugars were normal, indicating good exocrine function. There was no evidence of stones or hypertriglyceremia. She was not on new medications. Through the course of her admission, her enzymes fluctuated up and down. CT abd/pelvis was negative for pancreatitis. Given her anatomy, we thought she may be having reflux causing her enzymes to increase. She was made NPO. Transplant surgery thought her elevated enzymes were due to relux. However, her enzymes continued to fluctuate despite being entirely asymptomatic. These fluctuations were thought an exacerbation of her chronic process. She was to follow up closely in clinic to monitor her pancreas function. Patient agreed with this plan. . Acid/base disturbance: AG 15, Low bicarb (7). Delta delta was consistent with both gap and non-gap acidosis. Patient appeared to have a metabolic acidosis w/ respiratory compensation. The source of her acidosis was initially unclear; renal failure and infection were both consiered. Her lactate was normal. Patient did have a UTI. No new medications. After ruling out other causes, her acidosis was thought due to her pancreatic fistula draining into the GU tract and her inability to take her bicarb supplement PO. She was given IV bicarb with improvement in her acidosis. Her PO regimen was adjusted. Though her bicarb fluctuated during admission, once she was able to take PO we resumed her PO bicarb and stopped her IV repletion with good effect. . HOCM/Chest pain: Patient initially had CP. Her EKG was unremarkable and she ruled out for MI. Her pain resolved. However, she remained orthostatic with dizziness while standing. She was given IVF. However, after experiencing SBps in the 70s, she fell in the bathroom. Her neuro exam was unremarkable and her head CT was negatyive. She also had an episode of chest discomfort a few hours later. EKG showed TWIs inferiorly and anterolaterally. Her CEs became positive with Troponin in the 0.3-0.4. Her CP resolved with nitro/morphine. Repeat EKG showed persistent changes. She was given ASA and beta blocked and given fluids. Cardiology was consulted. They felt that her episode was related to her HOCM and hypotension, with subendocardial ischemia despite mild CAD on previous cath. We treated her supportively, and maintained her positive fluid status. ECHO did not show a gradient. She was also started on a low dose of Florinef at the behest of cardiology given her orthostasis. She improved symptomatically. Cardiology recommended an adenosine MIBI as an outpatient for risk stratification. . SOB/cough: Patient had mild SOB and cough. CXR showed possible vacular congestion. There was no evidence of pneumonia. She was diuresed which may have contributed to her worsened orthostasis and outflow obstruction (see above). However, her SOB improved and she was stable on room air. Her cough was thought viral tracheobronchitis. She was treated supportively. All culture data was negative. . ARF: Patient was thought in pre-renal azotemia due to her inability to take POs on admission and volume depletion. Her ARF improved with IVF and remained stable. . UTI: Patient was diagnosed with a UTI. She was initially put on Cipro, then Bactrim, then finally Cefpodoxime for a 10 day course given her history of immunosupression and transplant. . S/p kidney/pancreas transplant: Continued her IS meds and sensipar, which included Cyclosporine, cellcept, and prednisone. . CAD: See above. Continued her outpt metoprolol and lipitor. Also started on ASA. ECHO was performed (see above). ACEI was held given her orthostasis and renal dysfunction. . Hypercholesterolemia: continued outpt lipitor . DM: s/p pancreas transplant. Her sugars remained stable without insulin in house. . Code: FULL for this admission. Medications on Admission: Cellcept 250mg [**Hospital1 **] Prednisone 4mg daily CSA 100mg [**Hospital1 **] Sensipar 30mg [**Hospital1 **] (calcimimetic) NaHCO3 650mg QID Fosamax 70mg q wk Vit D 50 qwk Citracal D 2 tabs qam, 1 tab qpm Atenolol 12.5mg daily Lipitor 10mg daily Bactrim SS daily nitrofurantoin 100 mg qd (for supression of UTI) Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 4. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). Disp:*15 Tablet(s)* Refills:*2* 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Sodium Bicarbonate 650 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). Disp:*240 Tablet(s)* Refills:*2* 9. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Fludrocortisone 0.1 mg Tablet Sig: [**1-19**] Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Metabolic Acidosis Transplant Pancreatitis Urinary Tract Infection . Secondary Diagnoses: Tracheobronchitis Type 1 Diabetes Mellitus Coronary Artery Disease Anemia Discharge Condition: Good, hemodynamically stable Discharge Instructions: Please take all medications as prescribed. Please keep all follow up appointments. Please return to the hospital if you experience worsening cough, fevers, worsening abdominal pain, vomitting or diarrhea. Followup Instructions: Please present to [**Last Name (NamePattern1) 439**] on Wednesday [**3-9**] to have your labs drawn. . Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2168-3-10**] 10:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 4022**] Date/Time:[**2168-3-14**] 4:20 . Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2168-3-15**] 9:30 . Please call your PCP to schedule an appointment Provider: [**Name10 (NameIs) 9091**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule appointment [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]

[ "397.0", "584.9", "250.01", "996.81", "425.1", "599.0", "996.86", "276.2", "272.0", "424.0", "466.0", "276.50", "E878.0", "577.0", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14204, 14210

8709, 12792

324, 331

14437, 14468

3444, 3444

14723, 15587

3088, 3106

13157, 14181

14231, 14231

12818, 13134

14492, 14700

3121, 3425

14340, 14416

244, 286

359, 2287

5827, 8686

3460, 5818

14250, 14319

2309, 2892

2908, 3072

22,575

154,868

47919

Discharge summary

report

Admission Date: [**2142-7-14**] Discharge Date: [**2142-7-25**] Date of Birth: [**2095-5-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: ARF, MRSA UTI and bacteremia, GI Bleed Major Surgical or Invasive Procedure: EGD History of Present Illness: CC: GI Bleed, MRSA UTI/bacteremia, ARF HPI: 47 yo M with DM, HCV, remote EtOH and cirrhosis transferred from OSH with ARF, MRSA bacteremia, GI Bleed. He presented to [**Hospital6 **] on [**7-10**] after being seen by his PCP and sent to ED to evaluate lethargy and UTI and had ARF. He had been taking 1-3 tabs of Aleve everyday for shoulder pain. He denies taking any tylenol. On [**7-10**], urine grew MRSA and he was noted to have a MRSA bacteremia. Tagged white cell scan was also reportedly done and lit up in his shoulder which was thought to be d/t inflammation. On [**7-13**], he had a large amount of maroon colored stool with clots. He had an EGD with grade 1 varices but no active bleeding. Tagged RBC scan on [**7-14**] with no active bleeding source. Per OSH, he is hemodynamically stable (Vitals on transfer Afebrile, 169/76 HR 83 RR 28 100%/2L), although he was transfused 3 units pRBCs today in addition to 6 units of platelets and 2 units of FFP (2 units of pRBCs had been transfused the night prior). He has also been becoming progressively encephalopathic at the OSH with ammonia level > 100 and was so obtunded that he was unable to take his po lactulose on [**7-14**] (a.m. of transfer). He is followed in the [**Hospital 3585**] clinic and is in a COPILOT study comparing pegylated interferon to colchicine in patients with hepatitis C and advanced fibrosis and cirrhosis. ROS: Patient unable to provide history Past Medical History: NKDA . PMH: HCV cirrhosis with grade 1 esophageal varices, severe obesity, diabetes mellitus, insomnia, anxiety and depression, [**Doctor Last Name 9376**] disease, scrotal abscess . Meds: glipizide 5mg po bid, Klonopin, nadolol (unsure of dose), trazodone, Ursodiol 300 tid, lantus 50u qhs, Oxycodone 5 mg, Trazodone 50 mg q.h.s. p.r.n. . OSH meds: morphine prn oxycodone prn lactulose nexium folate thiamine Social History: remote EtOH abuse, remote ivdu. Three brothers. Family History: Non-contributory Physical Exam: .Afebrile HR 85 BP 176/71 RR 23 96% Gen: Lethargic, obtunded, answers yes to whether he has pain but unable to localize, not oriented HEENT: PERRL, icteric sclera, OP clear, MMM Neck: obese CV: S1, S2, RRR Pulm: CTA-ant Abd: Hypoactive bowel sounds, soft, obese, distended, nontender in all quadrants, no rebound or guarding, [**Doctor Last Name 515**] absent Ext: warm, 2+ LE edema GU: scrotal edema, nontender, no abnormal fluid collections Pertinent Results: Studies: [**7-11**] and [**7-12**] CXR: pulm vascular congestion . [**7-14**] Upper GI pan-endoscopy at [**Hospital3 2568**]. 1. Small nonbleeding esophageal varices. 2. Larger proximal stomach gastropathic folds and possible gastric varices,but no active bleeding at this time. 3. No evidence of ulcer disease. 4. Digital rectal exam confirms more bright red maroonish stool. . RUQ U/S 1. Thickened GB wall with echogenic material possibly reflecting sludge or nonshadowing stones. This was present on the prior exam of [**2141-9-22**]. There was no evidence of focal gallbladder tenderness during the exam. 2. Nodular heterogeneous appearing liver with splenomegaly . [**7-13**] Tagged WBC scan: 1. Splenomegaly. Cirrhosis. 2. No definite evidence of osteomyelitis involving the left shoulder. Mild asymmetric appearance of the left shoulder most likely reflects asymmetric degenerative change. 3. No evidence of vertebral osteomyelitis. . [**7-14**] Tagged RBC scan: prelim report - active active bleeding source identified. Labs pending Brief Hospital Course: 47 yo M with HepC cirrhosis, transferred from OSH w/ GI Bleed, MRSA UTI and bacteremia, ARF. # GI Bleed: peripheral ivs, q8hr Hct checks, blood transfusions as needed. Liver service to be following patient. Tagged RBC scan with no active bleed in outside hospital. His HCT was stable intially. On [**2142-7-24**], patient started having active upper and lower GI bleeding. FFP and Blood was given. emergent endoscopy was performed and initially it was not possible to terminate the procedure. Patient was intubated, FFP was given again and endoscopy was repeated. Bleeding esophageal varices were banded. Despite this intervention, patient continue bleeding actively. He received about 12 units of PRBCs. Remained hypotensive despite being on pressors and active transfusions. Lactate was checked and it was 9. Goals of care where discussed with family members at this point- see below. . # MRSA bacteremia - likely from MRSA UTI. White count rising but may be from second source of infection. patient was kept on Vancomycin dose by levels. . # Rising WBC count - on admission, he was started on Ceftazidime for ?SBP in OSH on [**7-14**]. U/s in house showed minimal ascitis. . # Cirrhosis - Patient was initially on octreotide, and midodrine but per liver recs it was discontinued. His encephalopathy improved with rifaximin and lactulose. . # ARF - By day 4 of admission, his creatinine increased to 5 and he was anuric. CVVH was started. Renal felt that it was consistent with heparorenal sd. . # Code: code status was discussed in multiple ocassions with family. Patient was made DNR/DNI. On [**2142-7-25**] after massive bleeding and not responding to multiple blood/FFP transfusions, it was decided to direct goals of care towards confort. Patient passed away at 12:05pm on [**2142-7-25**] Medications on Admission: nMeds: glipizide 5mg po bid, Klonopin, nadolol, trazodone, Ursodiol 300 tid, Colchicine 0.6 mg b.i.d., lantus 50u qhs, Oxycodone 5 mg, Trazodone 50 mg q.h.s. p.r.n., Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: 1. Hepatic failure 2. Renal failure 3. Gastrointestinal bleeding. Discharge Condition: n/a Discharge Instructions: n/a Followup Instructions: n/a [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2142-7-25**]

[ "571.2", "578.9", "250.00", "995.92", "599.0", "V09.0", "276.51", "572.4", "572.2", "518.81", "584.9", "070.70", "456.20", "303.91", "038.11", "286.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.95", "39.95", "96.6", "42.33", "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

5985, 5994

3938, 5740

361, 366

6103, 6108

2861, 3915

6160, 6330

2359, 2377

5957, 5962

6015, 6082

5766, 5934

6132, 6137

2392, 2842

283, 323

394, 1843

1865, 2277

2293, 2343

27,409

196,645

24549+57406

Discharge summary

report+addendum

Admission Date: [**2119-3-9**] Discharge Date: [**2119-3-14**] Date of Birth: [**2044-4-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2119-3-9**] Four Vessel Coronary Artery Bypass Grafting(LIMA to LAD, SVG to Diag, SVG to Ramus, SVG to PDA) History of Present Illness: This is a 74 year old male with complaints of chest pain, dyspnea and abnormal stress test. In [**2119-2-3**] he was referred for cardiac catheterization which revealed severe three vessel coronary artery disease. He underwent preoperative evaluation at that time and was cleared for surgery. He presented this admission for surgical revascularization. Past Medical History: Coronary Artery Disease Hypertension Elevated Cholesterol Peripheral Vascular Disease - prior left SFA stenting and left popliteal PTCA, prior left femoral artery endarterectomy Carotid Disease - prior left carotid stent Prior PPM Implantation Renal Artery Stenosis History of GI Bleed Anemia Benign Prostatic Hypertrophy GERD Gout Anxiety Cataract Surgery Social History: Married for 49 years with 5 children. Former smoker, quit in [**2102**], drinks 4-5 beers per day Patient is an avid golfer. Family History: Mother had stroke x2 '90s. Brother died from ruptured AA. Physical Exam: PREOP: Vitals: 138/60, 62, 16 General: WDWN male in NAD HEENT: Oropharynx benign, EOMI, teeth in poor repair Neck: Supple, no JVD Lungs: CTA bilaterally Heart: Regular rate and rhythm Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 1+ distally Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Pertinent Results: [**2119-3-13**] 05:00AM BLOOD WBC-10.9 RBC-3.11* Hgb-9.9* Hct-27.3* MCV-88 MCH-31.9 MCHC-36.4* RDW-14.4 Plt Ct-206 [**2119-3-11**] 05:19AM BLOOD WBC-17.6* RBC-2.96* Hgb-8.8* Hct-25.7* MCV-87 MCH-29.9 MCHC-34.4 RDW-14.7 Plt Ct-207 [**2119-3-10**] 03:10AM BLOOD WBC-12.5* RBC-2.59* Hgb-7.6* Hct-23.0* MCV-89 MCH-29.2 MCHC-32.9 RDW-14.3 Plt Ct-179 [**2119-3-13**] 05:00AM BLOOD Glucose-71 UreaN-39* Creat-1.3* Na-140 K-3.9 Cl-103 HCO3-27 AnGap-14 [**2119-3-11**] 05:19AM BLOOD Glucose-109* UreaN-36* Creat-1.4* Na-137 K-4.7 Cl-105 HCO3-25 AnGap-12 [**2119-3-10**] 03:10AM BLOOD Glucose-103 UreaN-22* Creat-1.3* Na-137 K-5.4* Cl-109* HCO3-22 AnGap-11 RADIOLOGY Final Report CHEST (PA & LAT) [**2119-3-13**] 4:26 PM CHEST (PA & LAT) Reason: r/o inf, eff [**Hospital 93**] MEDICAL CONDITION: 74 year old man with REASON FOR THIS EXAMINATION: r/o inf, eff REASON FOR EXAMINATION: Followup of pleural effusion. PA and lateral upright chest radiograph compared to [**2119-3-10**]. The interval decrease is still present moderate left pleural effusion. The left pleural effusion is small, grossly unchanged. The heart size is moderately enlarged, stable. The pacemaker leads terminate in right atrium and right ventricle, unchanged. The upper lungs are unremarkable. There is no evidence of failure. IMPRESSION: Bilateral left more than right pleural effusion, slightly decreased since [**2119-3-10**]. Moderate cardiomegaly, stable. No pneumothorax. No evidence of failure. DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: TUE [**2119-3-14**] 9:12 AM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 62026**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 62027**] (Complete) Done [**2119-3-9**] at 11:19:23 AM FINAL 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: [**2044-4-10**] Age (years): 74 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Coronary artery disease. Left ventricular function. Preoperative assessment. ICD-9 Codes: 440.0 Test Information Date/Time: [**2119-3-9**] at 11:19 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW2-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Aorta - Annulus: 2.0 cm <= 3.0 cm Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm Aorta - Ascending: 3.0 cm <= 3.4 cm Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness and cavity size. RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. 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. Conclusions PREBYPASS No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS Preserved biventricular systolic function. The study is otherwise unchanged from prebypass. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2119-3-9**] 11:29 Brief Hospital Course: Mr. [**Known lastname **] was admitted and underwent coronary artery bypass grafting surgery by Dr. [**Last Name (STitle) **]. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He was transfused with PRBCs for a postoperative anemia. EP interrogation of his pacemaker showed normally functioning dual chamber pacemaker. Plavix was resumed in addition to Aspirin for his carotid and peripheral stents. He made gradual improvements and eventually transferred to the SDU on postoperative day three. He tolerated beta blockade and remained v-paced. He continued to make clinical improvements with diuresis and made steady progress with physical therapy. He had some slight serous sternal drainage on POD#4 and was discharged to home on stable condition of POD#5. Medications on Admission: Plavix 75 qd - stopped, Aspirin 81 qd, Doxazosin 8 qd, Lipitor 40 qd, Carvedilol 12.5 [**Hospital1 **], Imdur 30 qd, Prilosec 20 qd, Lisinopril 10 qd, Alprazolam prn sleep Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed. Disp:*45 Tablet(s)* Refills:*0* 6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 vial* Refills:*2* 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*1 vial* Refills:*2* 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 6 days. Disp:*12 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary Artery Disease - s/p CABG Hypertension Elevated Cholesterol Peripheral Vascular Disease - prior left SFA stenting Carotid Disease - prior left carotid stent Prior PPM Implantation Renal Artery Stenosis Anemia Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [**Last Name (STitle) **] in [**4-8**] weeks, call for appt Dr. [**Last Name (STitle) **] or [**Doctor Last Name 7047**] in [**2-5**] weeks, call for appt Dr. [**Last Name (STitle) 17025**] in [**2-5**] weeks, call for appt Completed by:[**2119-3-14**] Name: [**Known lastname 11184**],[**Known firstname 4076**] Unit No: [**Numeric Identifier 11185**] Admission Date: [**2119-3-9**] Discharge Date: [**2119-3-14**] Date of Birth: [**2044-4-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 741**] Addendum: The pt. had sl. serrous sternal discharge and had gm+ cocci and gm- rods in sputum, so he was started on a 7 day course of Cipro. Discharge Disposition: Home With Service Facility: [**Hospital1 328**] VNA [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2119-3-14**]

[ "V15.82", "440.1", "443.9", "V17.1", "401.9", "530.81", "V45.01", "413.9", "414.01", "285.9", "272.0", "433.10" ]

icd9cm

[ [ [] ] ]

[ "39.61", "88.72", "36.15", "36.13", "99.04", "39.63" ]

icd9pcs

[ [ [] ] ]

10989, 11166

6791, 7730

331, 444

9838, 9845

1816, 2572

10181, 10966

1366, 1426

7952, 9498

2609, 2630

9597, 9817

7756, 7929

9869, 10158

1441, 1797

281, 293

2659, 6768

472, 826

848, 1207

1223, 1350

23,739

176,715

48558

Discharge summary

report

Admission Date: [**2130-6-12**] Discharge Date: [**2130-6-19**] Date of Birth: [**2058-12-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5893**] Chief Complaint: Primary ONC: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] . CC: fever Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname **] is a 71 yo M with hodgkins and non hodgkins lymphoma s/p chemoradiation, paroxysmal Afib with RVR who was admitted [**2130-6-12**] with fevers of unknown etiology, transferred to the ICU for Afib with RVR. On the day of transfer he converted from sinus to Afib with RVR with rate in 150's, blood pressure 100-110 systolic, asymptomatic other than palpitations. He was given diltiazem 20mg IV and shortly after converted to normal sinus rhythm with rate in 80's. Blood pressure remained stable in the low 100's systolic. Of note he had low oxygen saturation in the 90's on admission which is lower than his baseline, unknown etiology, he denies any dyspnea. He was also noted to have elevated LDH and lactate as well as swelling of his left leg greater than right for which he had CTA chest prior to transfer. . Of note, he was recently admitted from [**6-2**] -[**2130-6-9**] for his first cycle of ICE. His hospital course during that admission was complicated by volume overload and Afib with RVR for which he was admitted to the ICU twice. He was diuresed with lasix gtt and temporarily treated with IV diltiazem. His RVR at that time was felt to be triggered by acute volume overload. Following diuresis he was continued on his home dose of diltiazem ER. He was discharged on [**6-9**] and received a neulasta shot on [**2130-6-10**]. That evening he had a temperature to 100.2 for which he was advised to come to the ED for further evaluation. He is without localizing symptoms other than nasal congestion. He has been afebrile since admission, with unremarkable chest xray. He has been treated with cefepime and levofloxacin to cover for bacterial cause for fever in the setting of recent chemotherapy. . On arrival to the ICU he is resting comfortably, HR in normal sinus rhythm in the 80's. Past Medical History: PAST MEDICAL HISTORY: 1. Hodgkin's Lymphoma (diagnosed [**2121**], relapsed [**2126**] treated with AVBD c/b Afib w/RVR, bleomycin lung toxicity, PCP [**Name Initial (PRE) 1064**]) and Non-Hodgkin's lymphoma (diagnosed [**2127**], treated w/rituxan in [**2128**]). 2. Bleomycin toxicity 3. h/o PCP [**Name Initial (PRE) 1064**] 4. Paroxysmal A-Fib: Noted in clinic on day of his first dose of neupogen, [**2127-3-11**], has been recurrant in setting of pulmonary edema, chemotherapy, fever. 5. Hypertension 6. Hypercholesterolemia 7. Nephrolithiasis 8. Retinal detachment [**6-/2129**] 9. Peripheral neuropathy Social History: Mr. and Mrs. [**Known lastname **] remain in a temporary apartment as their house is being repaired due to flooding. They have 2 children and several grandchildren. He is a retired telecommunications engineer. He denies tobacco or alcohol use. Family History: Non-contributory Physical Exam: per ICU admit: VITAL SIGNS: T99.1 BP 134/63 HR 88 RR 22 94% on NC GEN: A&O x3, resting comfortably in NAD HEENT: NC AT, PERRL. Oropharynx is moist without erythema, lesions or thrush. NECK: Supple LUNGS: basilar crackles bilaterally, no wheezing HEART: RRR, 2/6 systolic murmur audible throughout the precordium ABDOMEN: Soft, nontender, and nondistended, normal bowel sounds and without hepatosplenomegaly or other masses appreciated. EXTREMITIES: With trace ankle edema. Pertinent Results: Labs on Transfer to ICU: [**6-15**] ABG: 7.45/36/52/26 lactate 3.2 Na 146 Creat 1.2 LDH 717 WBC 23.1 8%bands, HCT 23 PLT 79 INR 1.4 [**2130-6-12**] Blood Cultures: NGTD . Imaging: [**2130-6-14**] CTA Chest - preliminary read - No PE . [**2130-6-13**] CXR - Borderline interstitial edema which cleared from [**6-4**] to [**6-12**] has recurred. Mild azygous distention suggests volume overload. There are no lung findings to suggest pneumonia. Heart size is normal and there is no pleural effusion. Streaky opacities at the left base are probably atelectasis. . [**2130-5-24**] ECHO: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is 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. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . Micro: [**2130-6-12**] Blood - pending Brief Hospital Course: Mr. [**Known lastname **] is a 68 year old gentleman with relapsed Hodgkin's disease admitted with fever, transferred to the ICU for Afib with RVR. ICU course by problem: . #Afib with RVR - Asymptomatic with HR in 150's. Converted back to sinus with rate in the 80's prior to transfer to the ICU after getting 20mg IV diltiazem on the floor. No hypotension in response to IV dilt. He has been prone to paroxysms of atrial fibrillation in the setting of chemotherapy, volume overload in the past. BMT team concerned for possible pulmonary process such as PE as cause for acute afib given elevated lactate, LDH and hypoxia, however prelim report of CTA negative. We spoke with Dr. [**Last Name (STitle) 73**] to help with rate control. He recommended we increase dilt to 180 ER daily. He also recommended that we diurese and improve his hematocrit. We did both. We made these intervention and he remained HD stable. Had very short runs of AFib to the low 110s but this was not hemodynamically significant. Dr. [**Last Name (STitle) 73**] recommends an outpatient pulm appointment to discuss whether BB would be harmful to lungs. If not, this may be recommended. . #Hypoxia - new asymptomatic hypoxia of unclear etiology with [**Name (NI) 85993**] of 52 on ABG on ICU admit in the setting of Afib with RVR. BMT team concerned for pulmonary embolism given elevated lactate, new hypoxia and concern for L > R le swelling. Preliminary report of CTA negative for PE. He was diuresed in the ICU and his sx improved. . # Fever - patient is s/p ICE on [**2130-6-2**], last granulocyte count on [**6-9**] was 30, has been given neulasta in the meantime with WBC count up to 23. No localizing symptoms or signs to indicate pneumonia or UTI. CXR and CTA unremarkable. Has been treated with cefepime for febrile neutropenia by the BMT service. Further abx therapy per BMT . #Anemia - possibly due to recent chemotherapy with HCT down to 23 from 26 on admission. No evidence of blood loss at this time however will monitor closely. We gave 2u in ICU per d/w Dr. [**Last Name (STitle) 73**]. Medications on Admission: Medications on Discharge [**2130-6-9**]: 1. Allopurinol 100 mg PO DAILY 2. Cyanocobalamin 50 mcg PO DAILY 3. Omeprazole 20 mg DAILY 4. Bactrim DS 160-800 mg one po 3X Week MWF. 5. Glucosamine 1500 Complex 500-400 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Levofloxacin 750 mg Tablet PO Q24H 7. Diltiazem 120 mg Sustained Release DAILY 8. Albuterol 90 mcg/Actuation Aerosol Q6 prn 9. Multivitamin PO DAILY 10. Lovastatin 20 mg PO once a day 11. Filgrastim 480 mcg/1.6 mL Solution Sig: One (1) Injection once a day: to be given in outpatient clinic. . Medications on Transfer: Diltiazem Extended-Release 120 mg PO DAILY 150 mEq Sodium Bicarbonate/ 1000 mL D5W Continuous at 75 ml/hr for 300 ml Levofloxacin 750 mg PO Q24H Acetylcysteine 20% 600 mg PO BID x 4 doses Lovastatin 20 mg Oral daily Allopurinol 100 mg PO DAILY Pantoprazole 40 mg PO Q24H Albuterol MDI 2 PUFF IH Q4H:PRN CefePIME 2 g IV Q12H Clotrimazole 1 TROC PO QID Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (MO,WE,FR) Cyanocobalamin 100 mcg PO DAILY . ALLERGIES: No known drug allergies. History of bleomycin toxicity. Discharge Disposition: Home Discharge Diagnosis: Paroxysmal Atrial fibrillation with rapid ventricular response Neutropenic fever Hypoxia secondary to volume overload Discharge Condition: Stable Followup Instructions: Pt is to follow up with oncology services and primary care physician within two weeks of discharge. . Pt instructed to notify physician or return to hospital if experiencing fever, shortness of breath, chest pain, loss of consciousness, or heart palpations.

[ "285.22", "201.91", "780.6", "288.00", "427.31", "799.02", "356.9", "V13.01", "272.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

8479, 8485

5239, 7338

406, 412

8646, 8654

3718, 5216

8677, 8937

3191, 3209

8506, 8625

7364, 7923

3224, 3699

276, 368

440, 2278

7948, 8456

2322, 2913

2929, 3175

20,561

155,651

7472

Discharge summary

report

Admission Date: [**2125-11-27**] Discharge Date: [**2125-12-5**] Service: MICU CHIEF COMPLAINT: Hypotension, altered mental status and respiratory distress. HISTORY OF PRESENT ILLNESS: This 76 year-old white female with coronary artery disease, hypotension, atrial fibrillation, status post abdominal aortic aneurysm with recent repair of thoracoabdominal aneurysm with a long postop course complicated by aspiration pneumonia and ARDS transferred for altered mental status and respiratory distress and hypertension. The patient underwent repair of thoracoabdominal aneurysm with the implantation of SMA and left renal arteries and spent two weeks in the Surgical Intensive Care Unit for aspiration pneumonia and ARDS. She was extubated on [**11-4**] and required reintubation on [**11-6**]. The patient underwent trach feeding tube placement and was discharged to [**Hospital **] Rehab Facility on [**11-13**]. On [**11-18**] the patient had positive sputum culture for MRSA and was begun on Vancomycin and Ceftriaxone course antibiotics. The patient also began on Fluconazole for [**Female First Name (un) **] urinary tract infection. On admission the patient was found with altered mental status and respiratory distress and found to have a blood pressure of 80/50, heart rate 85. Prior to this patient was alert and responded to voice by following eyes, but on admission she was unresponsive. Arterial blood gases on SIMV 650 by 12, FIO2 of 60%, peak of 7.5/7.44/51/136/34. The patient was given intravenous fluid bolus and was transported to [**Hospital1 18**] where her heart rate was 100 and blood pressure was 60/40. The patient was started on a Dopamine drip in the Emergency Department. Dopamine was weaned off with intravenous fluid boluses. In the Emergency Department the patient was alert and followed eyes to voice, but also unresponsive. A triple lumen was placed after two unsuccessful attempts at subclavian. PAST MEDICAL HISTORY: Coronary artery disease, hypertension, atrial fibrillation, status post abdominal aortic aneurysm repair in [**2123**], hyperthyroidism, thoracoabdominal aneurysm repair [**2125-10-8**]. ALLERGIES: Sulfonamide. MEDICATIONS ON TRANSFER: Coumadin 1 mg q day, Amiodarone 200 mg q..d, Lopresor 12.5 mg q day, Methimazole 10 mg q day, Ativan 2 mg q.h.s, Prevacid 30 mg q.d., Nystatin, Ceftriaxone 1 gram q 24, Vancomycin 1 gram q 36, fluconazole 100 mg q.d., Aldactone 550 mg q.d., Lasix 50 mg q.d., Albuterol nebulizers q 6 hours, Atrovent nebulizers q 6 hours and Haldol .5 mg q.h.s. PHYSICAL EXAMINATION: The patient's temperature was 101. Heart rate 83. Blood pressure 100/60. Respiratory rate 12. O2 sat 97%. This is a frail, elderly appearing white female in no acute distress. Pupils are equal, round and reactive to light. Mucous membranes are moist. Grade 2 out of 6 harsh systolic murmur heard best at the apex. Regular rate and rhythm. Normal S1 and S2. Decreased breath sounds. Lungs clear to auscultation. Loud abdominal bruit. Abdomen soft, nontender, nondistended. No masses. Positive bowel sounds. Extremities are cool with no edema. The patient is alert and following intermittent commands. There is a sacral decubitus ulcer, 5 x 3 cm in greatest diameter. Also a stage .................... superficial .................... LABORATORY: The patient's white count was 27.5, hematocrit 34.8, platelets 286. Chem 7 146, 4.6, ................, ................... AST .................., ALT 260. Alkaline phosphatase 169, total bilirubin 0.6. CK 19, lipase 29. Urinalysis showed trace protein, otherwise unremarkable. Chest x-ray, showed a large tortuous aorta, resolving bilateral alveolar infiltrates, improving right upper lobe pneumonia. Head CT was negative for acute bleed. No evidence or signs of disease. Electrocardiogram was normal sinus rhythm at 83 and left atrial enlargement and left ventricular hypertrophy. There were [**Street Address(2) 27354**] depressions in V4 and 5. These were compared to [**2125-10-13**] electrocardiogram. Echo showed 2+ moderate left ventricular hypertrophy, normal left ventricular systolic function, trace mitral regurgitation. HOSPITAL COURSE: This 76 year-old female with coronary artery disease status post abdominal aortic aneurysm repair, atrial fibrillation with recent thoracoabdominal aneurysm repair with a very complicated postop course transferred from a vent weaning facility for fever, hypotension, altered mental status and recent sputum culture positive for MRSA presented with fever, increased white count, believed to be septic shock. 1. Cardiovascular: The patient was given fluid boluses and subsequent to the Emergency Department course was weaned off blood pressure medication. Over the course of the hospitalization she had several episodes of hypotension believed to be due to hypovolemia. The patient responded well to fluid boluses. The patient had episodes of hypotension secondary to sedative medications in particular Ativan and morphine. These episodes were also responsive to fluid boluses. 2. Pulmonary: The patient's vent setting initially was SIMV 550/10, 40% FIO2 with a PEEP of 5. During the course of the day the patient was eventually changed over to pressor support 10 and 5, FIO2 of 40% with a PEEP of 5, which she tolerated well. Several spontaneous weaning trials were attempted; however, the patient failed these secondary to agitation, tachypnea, and mucous plugging. Subsequently the patient's SIMV was stable with pressor support. The patient developed a MRSA positive pneumonia while at rehab. During the course of this hospitalization she completed her Vancomycin course. Subsequent sputum cultures grew out Stenotrophomonas maltophilia and Providencia stuartii. Infectious Disease was consulted and believed these to be low virulence organisms, not likely to be the cause of the patient's original septic shock presentation. The patient was started on admission on Ceftazidime 2 grams q 24. This was subsequently discontinued on [**12-4**]. The patient was also started on Flagyl 250 mg q 8, which was discontinued on [**12-2**]. 3. Infectious disease: The patient's presentation was most consistent with septic shock. The most likely source was believed to be the MRSA positive pneumonia; however, subsequent workup did not reveal another source of infection. The patient's urine was unremarkable. Foley catheter was subsequently changed during this hospitalization. Nasogastric tube was subsequently discontinued. The patient had multiple blood cultures, which showed no growth to date. The patient's peak white count was on admission at 27.5, and subsequently the white count trended downward. Infectious Disease was consulted. The issue of a graft infection was discussed with infectious disease, however, they felt that the likelihood of graft infection was low given that the graft was placed in [**Month (only) 216**] of this year with no subsequent infection. Additionally, infectious disease believed that sinusitis was unlikely given that on admission head CT showed no evidence of sinus disease. 4. Neurological: The patient had head CT which showed no signs of intracranial bleed. The patient's mental status was believed to be at her baseline. She would respond to voice; however, it did not appear that she recognized family members. This was believed to be baseline. 5. Renal: On admission BUN and creatinine were elevated at 82 and 1.3. Subsequently over the course of the hospitalization the BUN and creatinine trended downward on [**12-4**], BUN was 29, creatinine 0.9. 6. Hematology: The patient was recently admitted on Coumadin secondary to extensive deep venous thrombosis involving the brachiocephalic vein, axillary vein and left subclavian vein. This was originally discovered on hospital admission during [**Month (only) 216**] for which the patient had a thoracoabdominal aneurysm repair. This was believed to be secondary to multiple central line catheters in place for prolonged course. During that hospitalization a chest and abdominal CT was obtained, which showed no evidence of malignancy. 7. FEN: The patient received multiple fluid boluses over the course of the hospitalization. During her hospitalization the patient became mildly hypernatremic at 152, subsequently water boluses returned sodium to normal levels. 8. Intravenous access: Upon admission the patient had a left groin triple lumen placed. This was subsequently discontinued. The patient also initially had a left PICC line placed, however, this subsequently failed and the patient had a right PICC line placed. CODE STATUS: The patient is a full code. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSES: Septic shock. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3851**] Dictated By:[**Name8 (MD) 4575**] MEDQUIST36 D: [**2125-12-5**] 07:17 T: [**2125-12-5**] 07:44 JOB#: [**Job Number 27355**]

[ "707.0", "427.31", "414.01", "112.2", "401.9", "785.59", "507.0", "518.82", "276.0" ]

icd9cm

[ [ [] ] ]

[ "43.11", "96.72", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

8808, 9081

4215, 8727

2589, 4197

109, 171

200, 1957

2220, 2566

1980, 2194

8752, 8787

17,791

122,466

47920

Discharge summary

report

Admission Date: [**2189-4-22**] Discharge Date: [**2189-4-26**] Date of Birth: [**2117-4-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: back pain, chest pain Major Surgical or Invasive Procedure: None History of Present Illness: 72 y/o M with PMH of CABG and Cx stenting presented to his PCP c/o approx. 12 hours of chest pain radiating to back and shoulders bilaterally, associated with some sweating, and alleviated by NTG, intermittantly. Had some TWI (new) in inf. leads per PCP, [**Name10 (NameIs) **] ASA and NTG SL and sent to ED for ROMI. . In the ED, noted to have ? inf TWI, given morphine and NTG with some relief of pain. 1st set of cardiac enzymes negative. CTA showed penetrating aortic ulcer in the most proximal descending aorta, localized periaortic hematoma but no signs of rupture or dissection. . Surgery was consulted, and decided that surgery was not indicated at this point. Recommended strict BP control. HR was already beta blocked as outpatient (50's), so started nipride gtt in the ED, admitted to the CCU for close monitoring. Goal SBP approx. 120 or lower. Past Medical History: 1. CABG, three vessel, [**2173**] 2. Cath [**3-31**] (1. Two vessel coronary artery disease. 2. Patent LIMA-LAD. 3. SVG not engaged as they are known to be occluded. 4. RCA not engaged as known to be occluded.) 3. HTN 4. HCL 5. nephro and urolithiasis 6. GERD 7. ulcerative disease 8. Prostate CA - s/p brachytherapy Social History: Quit smoking 30 years ago. Prior to that he smoked 4 cigarettes a day for 10-15 years. No history of alcohol abuse. Family History: Heart disease on Father's side of the family. No history of sudden cardiac death. Physical Exam: Blood pressure was 126/77 mm Hg while seated. Pulse was 83 beats/min and regular, respiratory rate was 12 breaths/min. Generally the patient was well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. . There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with JVP of 6 cm. The carotid waveform was normal. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. The respirations were not labored and there were no use of accessory muscles. The lungs were clear to ascultation bilaterally with normal breath sounds and no adventitial sounds or rubs. . Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. There were no rubs, clicks or gallops. There was a 2/6 systolic murmer at the apex. . The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had no pallor, cyanosis, clubbing or edema. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue showed 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: [**2189-4-22**] 03:45PM PT-13.4* PTT-27.5 INR(PT)-1.2* [**2189-4-22**] 03:45PM PLT COUNT-204 [**2189-4-22**] 03:45PM WBC-5.3 RBC-3.71* HGB-11.1* HCT-31.8* MCV-86 MCH-30.0 MCHC-35.1* RDW-16.8* [**2189-4-22**] 03:45PM CK-MB-NotDone [**2189-4-22**] 03:45PM cTropnT-<0.01 [**2189-4-22**] 03:45PM CK(CPK)-57 [**2189-4-22**] 03:45PM GLUCOSE-103 UREA N-18 CREAT-1.3* SODIUM-139 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-32 ANION GAP-13 [**2189-4-22**] 10:23PM HCT-29.1* [**2189-4-22**] 10:23PM CK-MB-NotDone cTropnT-<0.01 [**2189-4-22**] 10:23PM CK(CPK)-44 . IMAGING/STUDIES: [**2189-4-23**] CTA CHEST: 1. Penetrating aortic ulcer in the most proximal descending aorta as detailed above. There is a very localized periaortic hematoma but no signs currently of rupture or dissection. These however remain impending possible complications. 2. No thoracic aneurysm. 3. Cardiomegaly with evidence of prior CABG as above. 4. Emphysema. . [**2189-4-23**] CROSSMATCH: Mr. [**Known lastname 101110**] has a new diagnosis of an antibody against the Fya antigen. The Fya antigen is a member of the [**Doctor Last Name 5239**] antigen blood group. Anti-Fya is a clinically significant antibody and capable of causing hemolytic transfusion reactions. As such, in the future, red cell transfusions for this patient should be limited to Fya antigen negative products. Approximately 33% of ABO compatible blood will be Fya negative. A wallet card and letter stating the above will be sent to the patient. Brief Hospital Course: Mr. [**Known lastname 101110**] is a 72 year old male with significant coronary history who presented to his PCP complaining of CP radiating to his back and shoulder. He was sent to the ED for evaluation and found to have a 1.3 centimeter aortic ulceration with intramural hematoma concerning for possible progression to thoracic aneurysm. He was admitted to the CCU for IV blood pressure managment and close monitoring. . 1. AORTIC ULCERATION W/ MURAL HEMATOMA: Surgery was consulted but felt that the ulcer was not an indication for immediate surgery. The patient was hypertensive with a systolic BP of 200 on admission. Tight blood pressure control was first obtained with a nitroprusside drip, and the patient was subsequently transitioned to a labetalol drip, then oral medications. He tolerated all medications well and was instructed on how important it was to continue taking his medications at home. The patient was instructed to call the Cardiology Clinic for an appointment in the next 2 weeks and he will need close monitoring for the ulcer and his blood pressure. . 2. HTN: The patient has a history of HTN and it was unclear how compliant he is with home medications. Tight blood pressure was obtained as above and he was instructed to continue his medication regimen as an outpatient. . 3. UTI: The patient was found to have a urinary tract infection on routine UA. He was treated with antibiotics for a 5 day course. . 4. CASHD: The patient has known CASHD and has undergone both 3-vessel CABG and cardiac catheterization in the past. Given his history, myocardial ischemia as a source of his chest pain was a consideration. However, the patient ruled out for MI and all EKG's remained stable. He was continued on aspirin, statin and beta-blocker. . 5. GERD: The patient has a history of GERD. He was continued on a PPI as an inpatient. Medications on Admission: ASPIRIN 81MG--Take one by mouth every day for prevention Citalopram 10 mg--1 tablet(s) by mouth once a day anxiety, depression DOXAZOSIN 8 mg--1 tablet(s) by mouth at bedtime for bp, and improve urine flow HYDROCHLOROTHIAZIDE 25 mg--1 by mouth once a day bp Hydromorphone 2 mg--2 tablet(s) by mouth three times a day as needed for pain Leuprolide (4 Month) 30 mg--inject q4months ? prostate ca METOPROLOL SUCCINATE 100 mg--1 tablet(s) by mouth once a day bp SIMVASTATIN 40 mg--1 tablet(s) by mouth once a day chol Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 7. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: aortic ulceration hypertension urinary tract infection Discharge Condition: Stable. Afebrile. Normotensive. Tolerating PO. Discharge Instructions: You were admitted to the hospital for an ulcer in your aorta, a large blood vessel that branches from your heart. You were admitted in order to obtain tight control of your blood pressure. Please return to the emergency room or call your doctor if you experience any of the following symptoms: fever > 101.4, chest pain that radiates to your back, shortness of breath, dizziness, weakness, intractable nausea or vomiting or any other concerning symptoms. . Please take all medications as prescribed. It is very important for you to take all of you heart and blood pressure medications. . Please call the cardiology department at [**Hospital1 18**] to schedule an appointment in the next 2 weeks. ([**Telephone/Fax (1) 2037**]. . You should avoid lifting anything that weighs more than 10 lbs. Followup Instructions: Please call the cardiology department at [**Hospital1 18**] to schedule an appointment in the next 2 weeks. ([**Telephone/Fax (1) 2037**]. . You have an appointment with your primary care physician to [**Name9 (PRE) 702**]. Please remind Dr. [**Last Name (STitle) **] to recheck your kidney function at your next appointment. Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB) Date/Time:[**2189-5-6**] 1:30

[ "V10.46", "530.81", "441.2", "599.0", "401.9", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

8539, 8545

4902, 6757

337, 344

8644, 8693

3381, 4879

9534, 10005

1720, 1804

7321, 8516

8566, 8623

6783, 7298

8717, 9511

1819, 3362

276, 299

372, 1230

1252, 1570

1586, 1704

50,434

163,782

4632

Discharge summary

report

Admission Date: [**2194-1-15**] Discharge Date: [**2194-1-21**] Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 633**] Chief Complaint: Dyspnea, hypoxia. Major Surgical or Invasive Procedure: None. History of Present Illness: [**Age over 90 **] y/o F with HIV, CKD, anemia, critical aortic stenosis, peripheral neuropathy, and G6PD deficiency who is being admitted to the [**Hospital Unit Name 153**] for dyspnea and hypoxia. She was at a scheduled outpatient CT scan, where she appeared short of breath and complained of dyspnea, which was significantly worsened when the patient lied flat on the CT scanner table. She has had steadily worsening dyspnea over the last 2-3 weeks, which has occasionally been accompanied by a productive cough. She was referred to the ED, where her triage SpO2 was reported as 50% and her RR was in the 40s. She was initially unresponsive, but her oxygen saturation and her mental status improved with a non-rebreather and nebulizer treatments. She had a chest x-ray that was reportedly concerning for pneumonia. She was given vancomycin, pip/tazo, azithromycin, and furosemide 80 mg IV. ID was consulted, and recommended obtaining urine legionella, bacterial/fungal blood cultures, sputum gram stain & culture, influenza swab, and PCP [**Name Initial (PRE) **]. . On arrival to the [**Hospital Unit Name 153**], the patient reports that her dyspnea is significantly improved since this afternoon. She reports that her dyspnea had been worsening over the past 2-3 weeks, and she has also had an occasional wheeze for the past one week. She has also had worsening bilateral ankle edema over that same period of time. She denies coughing, hemoptysis, chest pain or pressure, fevers, chills, sweats, abdominal pain, nausea, vomiting, or changes in bowel or bladder habits. She also reports she had a similar episode last [**Month (only) 116**], for which she was admitted to [**Hospital1 18**]. Discharge summary indicates that she was treated with diuresis and levofloxacin, for CAP. During that same admission, she had a CT scan showing right hilar and precarinal lymphadenopathy, with narrowing of the bronchus intermedius by adjacent lymph nodes. Past Medical History: -HIV (CD4 247, VL nondetectable in [**11/2193**]) on HAART -Critical aortic stenosis ([**Location (un) 109**] < 0.8 cm^2) -CKD (baseline creatinine 1.3-1.4) -Anemia -Leukopenia -Peripheral neuropathy -restless leg syndrome -CAD -tinea versicolor -G6PD deficiency -s/p TAH Social History: Lives with daughter in [**Name (NI) 2624**]. No pets. Retired. Used to work at [**Hospital1 18**]. Her daughter [**Name (NI) **] is also very involved. Pt lives with her daughter. She walks with a cane outside and with a walker in the house. She smoked for 4 years, 3 cigarettes a day when she was younger. She drinks ETOH occasionally in social situations but does not use any drugs. She is widowed for 10 years, and she contracted HIV from a man she dated 10 years ago. She has a visiting nurse who comes by 1 time a week and a care giver who comes by for 2 hours multiple days per week. Family History: Noncontributory; mother lived until 100. Physical Exam: Upon admission: GEN: pleasant elderly woman in NAD, awake, alert, interactive, appropriate HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy. + JVD to ear lobe at 30 degrees. no carotid bruits RESP: Mild bibasilar crackles. Good air movement throughout, with mild expiratory wheeze diffusely CV: 5/6 systolic crescendo murmur heard throughout the precordium. RRR, S1 and S2 wnl, no r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: Symmetric 3+ edema bilateral lower extremities to the ankles-shins. No clubbing or cyanosis. Symmetric 2+ radial/DP/PT pulses bilaterally SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength upper extremities, [**4-22**] srength bilateral hips/knees, 5/5 strength plantarflexion/dorsiflexion bilatearlly. No sensory deficits to light touch appreciated. 2+DTR's-patellar and biceps Pertinent Results: . Micro: [**2194-1-16**] Influenza A/B by DFA: DIRECT INFLUENZA A ANTIGEN TEST (Final [**2194-1-17**]): Negative for Influenza A DIRECT INFLUENZA B ANTIGEN TEST (Final [**2194-1-17**]): Negative for Influenza B . [**2194-1-15**] urine legionella negative [**2194-1-15**] blood cultures negative [**2194-1-15**] urine culture negative . Imaging: [**2194-1-15**] CT chest without contrast: 1. New pulmonary edema and small left pleural effusion. 2. Severely limited assessment of persistent left lower lobe fissural nodule due to inadvertent expiratory phase of respiration and respiratory motion. This nodule could be reassessed in [**2194-5-18**] as originally recommended. 3. Tracheomalacia, with over 70% narrowing of tracheal lumen on inadvertent expiratory CT acquisition. 4. Probable pulmonary arterial hypertension. . [**2194-1-15**] CXR: The cardiomediastional shilouette and hila are normal. Compared to the prior exam, there is new mild cardiomegaly and small mild new pulmonary edema. Trace left effusion. No pneumothorax. . [**2194-1-16**] TTE: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Diastolic function could not be assessed. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild to moderate ([**1-19**]+) aortic regurgitation is seen. [Due to acoustic shadowing, the severity of aortic regurgitation may be significantly UNDERestimated.] The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-19**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Biventricular hypertrophy with preserved global and regional biventricular systolic function. Critical calcific aortic stenosis with mild to moderate regurgitation. At least mild mitral regurgitation. Severe pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2193-5-2**], the degree of pulmonary hypertension has increased. The degrees of aortic and mitral regurgitation have probably increased also. The other findings are similar. . [**2194-1-16**] CXR: Previous heterogeneous pulmonary opacification is largely cleared, consistent with resolving edema. Small residual in the right lower lobe should be followed to exclude pneumonia. Borderline cardiomegaly stable. Pleural effusion, minimal on the left, if any. No pneumothorax. [**2194-1-21**] 06:30AM BLOOD WBC-2.9* RBC-3.34* Hgb-11.4* Hct-34.6* MCV-103* MCH-34.0* MCHC-32.9 RDW-13.5 Plt Ct-262 [**2194-1-20**] 07:55AM BLOOD WBC-3.2* RBC-3.47* Hgb-11.7* Hct-36.2 MCV-104* MCH-33.7* MCHC-32.2 RDW-13.6 Plt Ct-267 [**2194-1-18**] 07:05AM BLOOD WBC-3.0* RBC-3.28* Hgb-11.2* Hct-33.8* MCV-103* MCH-34.2* MCHC-33.1 RDW-13.7 Plt Ct-232 [**2194-1-17**] 04:54AM BLOOD WBC-3.2* RBC-3.11* Hgb-10.5* Hct-32.4* MCV-104* MCH-33.7* MCHC-32.3 RDW-13.6 Plt Ct-221 [**2194-1-16**] 04:29AM BLOOD WBC-3.6* RBC-3.01* Hgb-10.2* Hct-32.5* MCV-108* MCH-33.8* MCHC-31.3 RDW-13.7 Plt Ct-207 [**2194-1-15**] 02:18PM BLOOD WBC-4.6 RBC-3.44* Hgb-12.4 Hct-36.3 MCV-106* MCH-36.1* MCHC-34.2 RDW-14.0 Plt Ct-231 [**2194-1-15**] 02:18PM BLOOD Neuts-64 Bands-0 Lymphs-24 Monos-3 Eos-4 Baso-0 Atyps-5* Metas-0 Myelos-0 [**2194-1-15**] 02:18PM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL [**2194-1-21**] 06:30AM BLOOD Plt Ct-262 [**2194-1-20**] 07:55AM BLOOD Plt Ct-267 [**2194-1-18**] 07:05AM BLOOD Plt Ct-232 [**2194-1-16**] 04:29AM BLOOD WBC-3.6* Lymph-15* Abs [**Last Name (un) **]-540 CD3%-83 Abs CD3-448* CD4%-30 Abs CD4-162* CD8%-38 Abs CD8-208 CD4/CD8-0.8* [**2194-1-21**] 06:30AM BLOOD Glucose-85 UreaN-18 Creat-1.3* Na-143 K-3.5 Cl-105 HCO3-32 AnGap-10 [**2194-1-20**] 07:55AM BLOOD Glucose-90 UreaN-18 Creat-1.1 Na-144 K-4.0 Cl-106 HCO3-28 AnGap-14 [**2194-1-19**] 07:05AM BLOOD Glucose-81 UreaN-19 Creat-1.1 Na-142 K-3.2* Cl-103 HCO3-32 AnGap-10 [**2194-1-18**] 07:05AM BLOOD Glucose-88 UreaN-19 Creat-1.1 Na-142 K-3.0* Cl-102 HCO3-35* AnGap-8 [**2194-1-17**] 04:54AM BLOOD Glucose-88 UreaN-17 Creat-1.2* Na-142 K-3.7 Cl-104 HCO3-32 AnGap-10 [**2194-1-16**] 08:46PM BLOOD Na-140 K-3.8 Cl-102 [**2194-1-16**] 03:36PM BLOOD Glucose-101* UreaN-18 Creat-1.3* Na-138 K-3.4 Cl-101 HCO3-30 AnGap-10 [**2194-1-16**] 04:29AM BLOOD Glucose-72 UreaN-19 Creat-1.2* Na-145 K-3.4 Cl-105 HCO3-32 AnGap-11 [**2194-1-15**] 02:18PM BLOOD Glucose-165* UreaN-22* Creat-1.3* Na-142 K-4.5 Cl-103 HCO3-27 AnGap-17 [**2194-1-15**] 02:18PM BLOOD proBNP-2611* [**2194-1-21**] 06:30AM BLOOD Mg-2.2 [**2194-1-19**] 07:05AM BLOOD Mg-2.3 [**2194-1-18**] 07:05AM BLOOD VitB12-748 Folate-18.1 [**2194-1-16**] 04:08PM BLOOD Type-ART pO2-148* pCO2-54* pH-7.41 calTCO2-35* Base XS-8 [**2194-1-16**] 10:08AM BLOOD Type-ART pO2-49* pCO2-50* pH-7.44 calTCO2-35* Base XS-7 [**2194-1-16**] 04:08PM BLOOD Lactate-1.0 Brief Hospital Course: [**Age over 90 **] yo female with history of HIV, CKD, anemia, G6PD deficiency, and critical AS presenting with dyspnea, hypoxia, and somnolenc, found to have a CHF exacerbation and severe pulmonary hypertension. . # Dyspnea/hypoxia/acute diastolic heart failure: She was found to have an acute diastolic CHF exacerbation given new report of orthopnea, hypervolemia on exam, an elevated BNP, a CXR suggestive of fluid overload, and improvement with diuresis. She was given an increased dose of furosemide 80mg PO BID goal of 500cc-1L negative daily. Initially antibiotics were started for CAP coverage, but she remained afebrile without sputum or a leukocytosis throughout so these were stopped after three days given imporvement with diuresis. Urine legionella was negative. Influenza DFA was negative. PCP was thought to be less likely as she improved quickly with diuresis and takes atovaquone daily for prophylaxis. Her oxygen requirement was weaned throughout admission from NRB to 6L NC to 3L NC to eventually 2L (baseline) at the time of discharge. Pt's weight 151 lbs on discharge. Sent home on lasix 80mg qam and 60mg qpm. Discharged on 60mg qpm rather than 80mg as pt with slight creatinine bump on day of discharge and reporting thirst/dry mouth. PT will have BMP checked [**1-23**] and results sent to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Pt discharged with VNA and urged to check daily weights, follow low sodium diet, and 2L fluid restriction for now. . # CAD/Critical AS: [**Location (un) 109**] < 0.8 cm^2, with likely subsequent CHF as above. ECG was without ischemic ST changes. Volume depletion during diuresis was avoided as she is highly pre-load dependent with critical AS. She was continued on her home aspirin, beta blocker, and [**Last Name (un) **], and recommended to follow up with her PCP/cardiologist for reevaluation of her beta blocker choice in light of her diagnosis of heart failure. . # Altered mental status: Likely altered on arrival to ED [**2-19**] hypercapnia, although no blood gas performed to evaluate this. Serum bicarbonate was only mildly elevated on arrival. Mental status quickly cleared and patient remained awake, alert and fully oriented. . # HIV: Prior labs in [**11/2193**] noted a CD4 247 and VL nondetectable however repeat CD4 was 162. She was maintained on her outpatient HAART regimen and atovaquone for PCP prophylaxis and instructed to follow up with her outpatient ID providers. . # Chronic kidney disease: Her creatinine was within her known baseline at admission and throughout diuresis. She was maintained on her home [**Last Name (un) **]. . #anemia-unspecified, macrocytic, at her baseline. b12, folate WNL. . #leukopenia-appears stable, likely due to HIV, no neutropenia . DVT PPx:hep SC . CODE: DNR, but NOT DNI, ok to try brief intubation for resp failure. . PT evaluated by physical therapy. She will recommended for home with VNA and PT Medications on Admission: -ALBUTEROL SULFATE HFA 2 puffs INH Q4 PRN -AMLODIPINE 10 mg PO daily -ATOVAQUONE 750 mg/5 mL Suspension 10 ml PO daily -CANDESARTAN 32 mg PO daily -CLOTRIMAZOLE-BETAMETHASONE [LOTRISONE] 1%-0.05% Lotion - apply to affected areas twice a day -FUROSEMIDE 80 mg PO QAM, 40 mg PO QPM -LABETALOL 300 mg PO BID -LAMIVUDINE 150 mg PO daily -NEVIRAPINE 200 mg PO BID -NITROGLYCERIN 0.4 mg SL PRN -POTASSIUM CHLORIDE 40 mEq PO QAM, 20 mEq PO QPM -TENOFOVIR 300 mg PO BID -ACETAMINOPHEN 500 mg 1-2 tabs PO TID PRN -ASPIRIN 81 mg PO daily -CALCIUM CARBONATE 500 mg (1,250 mg) PO TID -ERGOCALCIFEROL 800 unit PO daily -MVI with iron-mineral [CENTRUM] Dosage uncertain Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebullizer Inhalation Q6H (every 6 hours) as needed for dyspnea, wheeze. 2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. atovaquone 750 mg/5 mL Suspension Sig: Two (2) dose PO DAILY (Daily). 4. candesartan 16 mg Tablet Sig: Two (2) Tablet PO Daily (). 5. clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 6. betamethasone dipropionate 0.05 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 7. labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 12. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1) Tablet PO QTUTHUR (TU,TH). 14. furosemide 40 mg Tablet Sig: Two (2) Tablet PO see below (80mg QAM, 60mg Qpm): 2 tablets in the morning. 1 tablet in the evening with a 20mg tablet. 15. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day: In the morning. 17. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day: In the evening. 18. furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)): please take this medication with your 40mg medication. Total PM dose 60mg. Disp:*30 Tablet(s)* Refills:*0* 19. Outpatient Lab Work basic metabolic panel. Please fax results to Name: [**Last Name (LF) **], [**First Name3 (LF) **] Pager: [**Numeric Identifier 19648**] Office Phone: ([**Telephone/Fax (1) 12388**] Office Location: W/[**Hospital1 **] 319 Department: Cardiology Organization: [**Hospital1 18**] Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Primary diagnosis: acute on chronic diastolic CHF exacerbation, critical AS Secondary diagnosis: HIV, CKD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Chest pain free. Oxygen requirement at discharge: 2L Weight at discharge: 151 lbs Discharge Instructions: It was a pleasure taking care of you during your stay here at [**Hospital1 18**]. You were admitted for trouble breathing due to heart failure. You were treated with increased doses of diuretics to help remove fluid from your lungs and your legs and your symptoms improved with good effect. You should follow a low salt and fluid restricted diet. You were evaluated by physical therapy who felt that you would benefit from home nursing services and physical therapy at home. The following changes were made to your medication regimen: 1.The dose of your Lamivudine was changed. You have been given a new prescription for this. 2.Your lasix is now 80mg (2 tablets of 40mg) in the morning and 60mg (one 40mg tablet with a 20mg tablet) in the afternoon. . Please notify [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] if you notice any increased difficulty breathing, increased lower extremity edema, or weight gain, as this may indicate that you need more Lasix. Please follow a low sodium diet and adhere to a 2 liter per day fluid restriction. . Please have the VNA check your kidney function labs in 2 days. These results should be sent to your cardiologist and PCP. . Please take all of your medications as prescribed and follow up with the appointments below. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [**2194-2-10**] at 3:00 PM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: INFECTIOUS DISEASE When: TUESDAY [**2194-3-4**] at 1:30 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 16976**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2194-3-19**] at 10:30 AM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2194-5-21**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "042", "285.9", "428.0", "424.1", "V49.86", "356.9", "428.33", "585.9", "282.2", "416.8" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15399, 15462

9527, 11496

232, 239

15612, 15612

4134, 9504

17153, 18434

3141, 3183

13184, 15376

15483, 15483

12504, 13161

15845, 17130

3198, 3200

15811, 15821

175, 194

267, 2222

15580, 15591

15502, 15559

3214, 4115

15627, 15773

2244, 2518

2534, 3125

23,161

115,895

17796

Discharge summary

report

Admission Date: [**2138-8-2**] Discharge Date: [**2138-8-3**] Date of Birth: [**2055-3-1**] Sex: M Service: MEDICINE Allergies: Phenylephrine Attending:[**First Name3 (LF) 1711**] Chief Complaint: Altered mental status, hypotension, respiratory distress Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 49411**] is a 83 yo Russian-speaking male with a history of three vessel CAD, sCHF, AF, AS, DM, CKD and a history of aspiration events, recently discharged from the [**Hospital1 18**] CCU service who re-presents from his rehab facility to the ED today. Around 10AM on the day of admission, the patient was noted to acutely desaturate and his rehab and become lethargic. Initial ABG demonstrated 7.34/50/54. His supplemental oxygen was increased and he was eventually placed on NIPPV. His PO2 increased to 93 with this but he remained somnolent. He was also noted to become hypotensive with SBPs in the 60s, shortly prior to his transfer to the ED. He was given 250cc NS bolus x 2 for this and for poor urine output. He was also noted to have tremulous extremities. . In the ED, the patient was found to be hypoxic, with sats in the 70s on 100% FiO2, as well as hypotensive to the 60s systolic. A chest x-ray was concerning for CHF. The patient was intubated for progressive respiratory distress. A femoral line was placed and he was started on dopamine and Levophed for blood pressure support after receiving 3L NS. His serum K was noted to be elevated and he was treated with Ca, insulin, glucose and bicarb. He was also emperically treated with ciprofloxacin and Flagyl. . The patient's most recent admission was for evaluation of hypotension in the setting of receiving SL NTG despite his known AS. His hospital course was complicated by hematuria, a UTI, and a new diagnosis of frequent aspiration. Just prior to that [**Hospital1 18**] admission, he had been hospitalized at [**Hospital3 **] medical center for an NSTEMI complicated by cardiogenic shock. During that hospitilization, PCI for the patient's known CAD was attempted but could not be performed. While on the [**Hospital1 18**] CCU service, the patient's [**Hospital3 **] cath films were obtained and reviewed by both interventional cardiology and cardiac surgery; he was not felt to be a candidate for revascularization. . On arrival to the CCU, the patient is somnolent and unresponsive to painful stimuli. ROS is unable to be obtained. . Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: 3. OTHER PAST MEDICAL HISTORY: . MR AS, severe CHF, systolic and diastolic dysfunction, Recurrent MI with cardiogenic shock [**2133-8-7**]. Multiple PCI procedures PAD with IC Right foot plantar ulcer CRI. Bronchiectasis/emphysema/recurrent bronchitis Diabetic neuropathy, possible early diabetic nephropathy Chronic recurrent left ear infection Social History: Lives at home with wife. -Tobacco history: Denies. -ETOH: Rare social EtOH. -Illicit drugs: Family History: Noncontributory. SOCIAL HISTORY . No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: GENERAL: Critically ill adult male, intubated, sedated. Diffuse, intermittent muscle twitching. [**Month/Day/Year 4459**]: NCAT. Sclera anicteric. PERRL but sluggish to respond. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. NECK: Supple; neck veins difficult to assess. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No R/R/G. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Mechanical breath sounds. Decreased breath sounds at bases bilaterally. Few rhonchi; no frank wheezing. ABDOMEN: Distended, tympanitic abdomen with decreased bowel sounds. No HSM. No abdominial bruits. EXTREMITIES: No C/C/E. No femoral bruits. SKIN: Mild stasis dermatitis changes. No other ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ Left: Carotid 2+ Femoral 2+ DP 2+ Pertinent Results: [**2138-8-2**] 11:43PM GLUCOSE-199* UREA N-58* CREAT-3.6* SODIUM-130* POTASSIUM-6.1* CHLORIDE-98 TOTAL CO2-21* ANION GAP-17 [**2138-8-2**] 11:43PM ALT(SGPT)-122* AST(SGOT)-108* LD(LDH)-394* CK(CPK)-51 ALK PHOS-218* TOT BILI-0.6 [**2138-8-2**] 11:43PM WBC-15.7*# RBC-3.63* HGB-10.7* HCT-34.4* MCV-95 MCH-29.5 MCHC-31.1 RDW-15.3 [**2138-8-2**] 04:50PM WBC-8.8 RBC-3.08* HGB-9.3* HCT-28.9* MCV-94 MCH-30.1 MCHC-32.1 RDW-15.4 [**2138-8-2**] 10:26PM LACTATE-2.1* K+-6.2* [**2138-8-2**] 04:50PM cTropnT-0.11* [**2138-8-2**] 04:50PM CK-MB-NotDone proBNP-[**Numeric Identifier 49412**]* EKG: Sinus bradycardia at 59. NA; first degree AV delay. LBBB. Compared to prior tracing from [**2138-7-27**], QRS duration is wider and QRS axis has shifted to the right. . 2D-ECHOCARDIOGRAM: ([**2138-7-18**]) The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. LV systolic function appears depressed (ejection fraction 30 percent) secondary to akinesis of the posterior wall and anterior septum, and hypokinesis of the rest of the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . CXR ([**2138-8-2**]): 1. Moderate congestive heart failure with small bilateral pleural effusions. 2. Bibasilar opacities may reflect atelectasis, but infection is not excluded. . CT C/A/P ([**2138-8-2**]) (PFI): Pulmonary edema, bilateral plueral effusions. Fluid in trachea and bronchi concerning for aspiration. Gallbladder severely enlarged with stone in neck may relate to cholecystitis. US should be considered for further evaluation. . CT Head ([**2138-8-2**]) (PFI): No acute intracranial pathology; chronic small vessel ischemic changes; fluid in the nasopharynx likely due to intubation. . PFTs ([**4-14**]): Mild obstructive ventilatory defect. The reduced FVC may be due to gas trapping but a coexisting restrictive defect cannot be excluded. Suggest lung volume measurements if clinically [**Month/Year (2) 9304**]. Compared to the prior study of [**2137-12-27**] the FVC has increased by 0.35 L (+16%). . Brief Hospital Course: 83 yoM with multiple medical problems including extensive CAD, AS, sCHF, AF, DM and CKD presents from rehab with lethargy, hypoxic respiratory failure and hypotension. Pt was brought to the CCU intubated and on pressors. Some ECG changes were noted on admission, likely due to pt's significant acidemia. Pt was significantly fluid overloaded by CXR. Exact precipitant was unclear but pt was given cautious diuresis. Pt was simultaneously hypotensive, on dopamine and levophed. Hypoxic respiratory failure/respiratory acidosis/question aspiration persisted and vent settings had to be maximized. Pt's muscle fasciculations continued in CCU, likely related to his uremia or hyperkalemia. Despite aggressive medical management, pt's condition continued to deteriorate rapidly in the CCU. A family meeting was called where goals of care were discussed and patient made DNR/DNI. Pt was found unresponsive, without electrical activity on cardiac monitor and with no pupillary reflex. Pt expired at 4:19 am on [**2138-8-3**] w/ pt's wife present at the bedside. Medical Examiner declined the case and autopsy declined by the family. Medications on Admission: 1. Fluticasone-Salmeterol 250-50 [**Hospital1 **] 2. Allopurinol 150 mg daily 3. Spironolactone 12.5 mg daily 4. Gabapentin 600 mg [**Hospital1 **] 5. Lisinopril 5 mg daily 6. Simvastatin 80 mg daily 7. Aspirin 81 mg daily 8. Pantoprazole 40 mg daily 9. Ferrous Sulfate 325 daily 10. Amiodarone 200 mg daily 11. Metoprolol Tartrate 25 mg [**Hospital1 **] 12. Furosemide 40 mg daily 13. Lantus 50 units qHS 14. Insulin Lispro sliding scale 15. Simethicone 80 mg four times daily PRN 16. Polyethylene Glycol [**Hospital1 **] PRN constipation 17. Senna 8.6 mg 1-2 tabs [**Hospital1 **] PRN 18. Bactrim DS [**Hospital1 **] through [**2138-8-3**] for UTI . ALLERGIES: Phenylephrine Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: congestive heart failure acute renal failure respiratory failure acidosis Discharge Condition: expired Discharge Instructions: patient expired Followup Instructions: expired

[ "424.1", "403.90", "492.8", "427.31", "785.51", "584.9", "410.72", "428.43", "428.0", "357.2", "250.70", "250.40", "276.1", "599.0", "250.60", "585.9", "425.4", "507.0", "041.4", "276.7", "518.81", "574.00", "443.81", "V12.04", "276.4" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8556, 8565

6671, 7799

328, 335

8683, 8693

4138, 6648

8757, 8768

3087, 3236

8527, 8533

8586, 8662

7825, 8504

8717, 8734

3251, 4119

2575, 2613

232, 290

363, 2495

2644, 2961

2517, 2555

2977, 3071

32,134

102,304

34716

Discharge summary

report

Admission Date: [**2188-5-20**] Discharge Date: [**2188-5-25**] Date of Birth: [**2129-7-6**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 371**] Chief Complaint: 58y Male presenting via transfer from OSH. Involved in low speed scooter accident with loss of consciousness, intubated at OSH. Major Surgical or Invasive Procedure: none History of Present Illness: Patient in scooter accident, GCS 14 at scene, repetitive verbal response, intubated at [**Hospital **] transfered to [**Hospital1 18**]. CT of head, c-spine, face, torso performed. No evidence of intracranial bleed, c-spine injury, or intrabdominal injury. Facial CT demonstrated nasal bone fracture and chronic R maxillary sinus fracture. CT torso: Left ribs [**2-28**] fractured. Social History: ETOH abuse, horse trainer Physical Exam: GEN: Intubated and sedated HEENT: PERRL, abrasions on left face, 3cm lac on left forehead RESP: Bilateral breath sounds, clear lung fields, CV: Regular rate rhythum, no murmurs, gallops, rubs ABD: Soft, non-distended GU: no blood at meatus, good rectal tone, no blood on DRE EXT: no gross deformities, no edema/clubbing/cyanosis SKIN: 3-4cm lac left forehead, abrasion left cheek, Pertinent Results: [**2188-5-20**] 10:24PM 7.28/129/50 [**2188-5-20**] 05:28PM ALT(SGPT)-102* AST(SGOT)-141* LD(LDH)-273* ALK PHOS-100 AMYLASE-99 TOT BILI-1.1 [**2188-5-20**] 05:28PM WBC-8.8 RBC-3.59* HGB-12.4* HCT-35.3* MCV-98 MCH-34.5* MCHC-35.1* RDW-13.2 [**2188-5-20**] 05:28PM PT-15.0* PTT-30.1 INR(PT)-1.3* [**2188-5-20**] 05:28PM GLUCOSE-82 LACTATE-1.4 NA+-146 K+-4.1 CL--109 TCO2-24 CT chest-Multiple left-sided rib fractures extending from rib 4 to rib 10 are noted. The fractures are anterior superiorly and aligned obliquely in more lateral and posterior regions inferiorly. There is no pneumothorax CT face-1. Bilateral nasal alar lucencies could represent nondisplaced fractures of unknown chronicity. Correlation with physical exam is recommended. 2. Right zygomatic arch and lateral maxillary sinus wall deformity could reflect healed, old fractures. Brief Hospital Course: Pt admitted to T-SICU, intubated. CTLS spine cleared, CT showed left rib fractures, [**2-28**], nasal bone fractures, old R maxillary sinus fracture. Pt. weaned from vent and extubated on HD 2 (7/2/08/). Pain control post-extubation was managed via placement of a thoracic epidural. Ativan given per CIWA scale. Pt transfered out of T-SICU on HD 3 ([**2188-5-22**]). Epidural was displaced during transfer, pt opted not to have cathter replaced, oral pain meds started, oxycodone SR 10mg and neurontin 200mg TID. Physical therapy evaluated for safety and need for rehabilitation, recommendation home without rehab. Discharged to home with follow-up in trauma clinic on [**2188-6-3**] Medications on Admission: none Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*20 Capsule(s)* Refills:*0* 2. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day. Disp:*30 Tablet Sustained Release 12 hr(s)* Refills:*0* 3. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO three times a day. Disp:*45 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Left rib fractures, #[**2-28**], nasal bone fracture, R maxillary sinus fracture Discharge Condition: Good, hemodynamically stable, pain controlled, tolerating regular diet. Discharge Instructions: Return to emergency department if intolerable pain, chest pain, shortness of breath, fever >101.4. Followup Instructions: f/u in trauma clinic on [**2188-6-3**] call [**Telephone/Fax (1) 79580**] for appointment Completed by:[**2188-5-27**]

[ "289.59", "807.07", "338.11", "E818.0", "780.39", "571.5", "518.0", "E849.5", "802.0", "801.06" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

3376, 3382

2199, 2886

439, 446

3507, 3581

1316, 2176

3729, 3849

2941, 3353

3403, 3486

2912, 2918

3606, 3706

915, 1297

272, 401

474, 857

873, 900

29,418

190,253

32043

Discharge summary

report

Admission Date: [**2135-9-21**] Discharge Date: [**2135-9-30**] Date of Birth: [**2061-11-1**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: Barrett's Esophagus Major Surgical or Invasive Procedure: Esophagoscopy, Esophagectomy, Transhiatal, Feeding jejunostomy History of Present Illness: Mrs. [**Known lastname 34578**] is a 73 year-old female who present with fatique and satiety related to iron deficiency anemia. An investigational EGD done at an OSH found an asymptomatic 2cm lesion at the junction of the esophagus and stomach consistent with Barrett's Esophagus. She is being admitted for a Transhiatal Esophagectomy with feeding J-tube placement. Past Medical History: Hypothyroidism Anemia Thyroidectomy [**2110**] Appendectomy Right Breast lumpectomy [**2129**] Social History: Lives with husband. [**Name (NI) 75042**]: quit [**2104**] ETOH rarely Family History: Non-contributory Physical Exam: General: 73 year-old female in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple Card: regular rate & rhythm, normal S1,S2, no murmur/gallop or rub Resp: decreased breath sounds GI: bowel sounds positive, abdomen soft non-tender/non-distended Extr; warm no edema Wound: mid abdominal clean dry intact with staples. J-tube site clean Esophageal incision clean, dry, intact with steri-strips Neuro: non-focal Pertinent Results: [**2135-9-27**] 07:35AM BLOOD WBC-8.2 RBC-3.24* Hgb-9.7* Hct-29.5* MCV-91 MCH-29.7 MCHC-32.7 RDW-17.3* Plt Ct-203 [**2135-9-29**] 07:20AM BLOOD PT-12.6 INR(PT)-1.1 [**2135-9-27**] 07:49PM BLOOD Glucose-142* UreaN-17 Creat-0.6 Na-137 K-4.3 Cl-101 HCO3-28 AnGap-12 CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2135-9-23**] CONCLUSION: 1. Left segmental and right subsegmental upper lobe pulmonary emboli. 2. Status post esophagectomy with gastric pull through; drain in the superior mediastinum and an NG tube insitu. 3. Bibasal effusions with atelectasis at the lung bases. 2-mm pulmonary nodules in the left lung may be followed up with a chest CT in three months to assess stability. Brief Hospital Course: Mrs. [**Known lastname 34578**] is a 73 year-old female who present with fatique and satiety related to iron deficiency anemia. An investigational EGD done at an OSH found an asymptomatic 2cm lesion at the junction of the esophagus and stomach consistent with Barrett's Esophagus. Mrs. [**Known lastname 34578**] was admitted on [**2135-9-21**] and taken to the operating room for an EGD, Esophagectomy Transhiatal, pyloroplasty, and Feeding Jejunostomy with placement of an epidural pain pump. She tolerated these procedures well and there were no complications. . On POD 1, [**2135-9-22**], Mrs. [**Known lastname 34578**] was extubated in the SICU without complication. She was placed on a high flow oxygen face tent. . On POD 2, [**2135-9-23**], Mrs. [**Known lastname 34578**] continued to have low O2 saturation and was monitored closely while kept on a high flow face tent. She was mildly diuresed with furosemide with good urine output and no electrolyte abnormalities. She was consulted by Nutrition on this day to determine her feed goal of 50cc/hr Probalance for 1440 cals/65g protein. She was placed on a heparing drip which was titrated to a PTT of 60 - 80. She remained in the SICU for oxygen saturation monitoring and made steady progress on advancing her tube feeds. . On POD6 Mrs. [**Known lastname 34578**] was transferred out of the SICU to the floor without complication. Her tube feeds were steadily advanced to her goal rate of 50cc/hr. She was started on Lovenox 80 mg [**Hospital1 **]. She was evaluated by PT and cleared to go home. . On POD 7 her heparin drip was stopped and she passed her grape juice PO test showing no extravasation to the JP drain. The JP drain was pulled without complication. . On POD8 Mrs. [**Known lastname 34578**] was given a full liquid diet which she tolerated well. She was up and out of bed multiple times without assistance. . Mrs. [**Known lastname 34578**] was discharged on POD9. At the time of discharge she was afebrile, tolerating a full liquid diet, ambulating without assistance, and at her goal tube feed rate of 50cc/hr of Probalance. Her pain was well controlled with PO medication and she was without complaints. Medications on Admission: Levothyroxine 112mcg alternating with 100mcg Tamoxifen 10 mg once daily Simvastatin once daily Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. Disp:*450 ML(s)* Refills:*0* 2. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO QOD. 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO QOD: alternate with 112 mcg. 4. Warfarin 1 mg Tablet Sig: take as directed Tablet PO once a day: take as directed. Disp:*150 Tablet(s)* Refills:*2* 5. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): until INR 2.0 or higher. Disp:*8 * Refills:*2* 6. Lopressor 50 mg Tablet Sig: 0.5 Tablet PO three times a day: crush give via J-tube. Disp:*30 Tablet(s)* Refills:*2* 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: Barrett's Esophagus with 2cm mass at junction of stomach & esophagus Hypothyroidism Anemia Thyroidectomy [**2110**] Right Breast Cancer s/p lumpectomy Discharge Condition: Good Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office if experience: -Fever > 101 or chills -Increased sputum production, cough or shortness of breath -Chest pain -Incision develops drainage Steri-strips remove in 10 days or sooner if starts to come off Abdominal staples please remove on [**10-5**] th J-tube: monitor site for redness. Should tube fall out cover site with clean dressing and have tube replaced immediately to prevent closure of site. Bring tube with you. Flush tube with 50cc of water every eight hours and before and after usage. Lovenox continue twice daily until INR reaches 2.0 or higher. Coumadin daily: dosage according to your PCP Coumadin take 4 mg Fri, Sat & Sun then Monday have blood drawn and call PCP for further dosing. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] on [**10-20**] at 10:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]. Barium Swallow on [**10-20**] at 8:30 on the [**Hospital Ward Name 516**] Radiology Department [**Location (un) **]. Nothing to eat or drink after Midnight [**10-20**] Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 75043**] [**Telephone/Fax (1) 75044**]

[ "518.0", "244.9", "280.9", "211.1", "415.11", "V10.3", "E878.6", "530.85" ]

icd9cm

[ [ [] ] ]

[ "44.66", "42.42", "46.39", "96.6", "44.29" ]

icd9pcs

[ [ [] ] ]

5405, 5466

2228, 4426

341, 406

5660, 5667

1516, 2205

6458, 6921

1027, 1045

4571, 5382

5487, 5639

4452, 4548

5691, 6435

1060, 1497

282, 303

434, 803

825, 922

938, 1011

9,763

178,829

30578

Discharge summary

report

Admission Date: [**2187-2-27**] Discharge Date: [**2187-3-29**] Date of Birth: [**2117-6-18**] Sex: M Service: SURGERY Allergies: Bactrim Ds Attending:[**First Name3 (LF) 695**] Chief Complaint: Fever, vomiting, stomach pain, productive cough Major Surgical or Invasive Procedure: [**2187-3-1**]: Tube cholangiogram History of Present Illness: Pt is a 69M who underwent right hepatic lobectomy, cholecystectomy and small bowel resection [**2186-5-22**] for a primary metastatic GI Stromal Tumor; his course was complicated by a bile leak, pneumonia, and bacteremia. Drainage was complicated by perforation of the diaphragm and subsequent bilio-pleural fistula. [**Month/Day/Year **] had remained in place to hepatic collection. Stent was removed and then he underwent scheduled hepaticojejunostomy with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Last Name (NamePattern1) 19843**] on [**2-12**]. He was discharged to home on [**2-24**] and states he felt okay on Sunday and then by [**Month/Year (2) 766**] was noting some epigastric pain. He had a fever in the afternoon to 101 and was advised by Dr [**Last Name (STitle) 37914**] office to start Augmentin and PO Vanco. He has since developed nausea, vomiting x 3 (green vomit) and a cough productive of white sputum. His last BM was 2 days ago which was loose, no blood noted. Last meal was AM of [**2-26**]. He reports having hiccups. Denies chest pain or difficulty with breathing. Past Medical History: GIST Hypertension Hypercholesterolemia Benign esophageal growth h/o prostate CA s/p resection in [**2179**] s/p hepaticojejunostomy with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Last Name (NamePattern1) 19843**] [**2187-2-12**] Social History: Denies tobacco, retired, married Family History: Non-contributory Physical Exam: VS: 97.1, 60, 111/58, 16, 99% RA pain [**3-12**] Gen: Appears pale, thin and frail. Hiccuping HEENT: no scleral icterus, no LAD, mucous membranes and lips appear dry Lungs: CTA bilaterally Card: Regular rate and rhythm Abd: Soft, slightly distended, slightly tender epigastrum. PTC [**Month/Year (2) 19843**] capped, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Last Name (NamePattern1) 19843**] with clear brown fluid, JP [**Last Name (NamePattern1) 19843**] with cloudy brown fluid, hypoactive bowel sounds. Extr: No edema, 2+ pedal pulses Pertinent Results: On Admission: [**2187-2-27**] WBC-29.7* RBC-3.51* Hgb-10.9* Hct-31.8* MCV-91 MCH-31.0 MCHC-34.2 RDW-14.0 Plt Ct-404 PT-15.1* PTT-27.9 INR(PT)-1.3* Glucose-143* UreaN-17 Creat-1.2 Na-135 K-3.9 Cl-95* HCO3-31 AnGap-13 ALT-20 AST-16 AlkPhos-171* Amylase-52 TotBili-0.9 Albumin-3.1* Calcium-9.0 Phos-3.4 Mg-1.8 Labs [**2187-3-29**]: [**2187-3-29**] 4:40AM WBC-12.2* RBC-3.41* Hgb-10.0* Hct-30.0* MCV-88 MCH-29.4 MCHC-33.4 RDW-16.3* Plt Ct-364 [**2187-3-29**] 12:13PM WBC-35.7*# RBC-2.98* Hgb-8.5* Hct-28.3* MCV-95# MCH-28.7 MCHC-30.1* RDW-14.7 Plt Ct-355 [**2187-3-29**] 04:40AM Glucose-117* UreaN-45* Creat-1.1 Na-141 K-3.9 Cl-105 HCO3-30 AnGap-10 [**2187-3-29**] 12:13PM Glucose-78 UreaN-51* Creat-1.6* Na-146* K-4.4 Cl-114* HCO3-18* AnGap-18 [**2187-3-29**] 04:40AM ALT-50* AST-29 AlkPhos-201* TotBili-0.7 [**2187-3-29**] 12:13PM CK(CPK)-47 [**2187-3-29**] 04:40AM Albumin-2.6* Calcium-8.4 Phos-3.6 Mg-2.4 Brief Hospital Course: Patient admitted and evaluated with CT of Abdomen and pelvis, Findings: -New/enlarging anterior perihepatic fluid collection with multiple locules of air, concerning for spread of perihepatic infection, despite multiple drainage catheters in place nearby. -Small right and trace left pleural effusions. -Unchanged mesenteric and retroperitoneal lymphadenopathy. Cultures from [**Month/Day/Year 19843**] fluid yielded Enterococcus, Yeast (not C albicans) Pseudomonas and he was initially started on fluconazole for the yeast in addition to the Vanco and Zosyn started on admission. Cholangiogram was performed on [**2187-3-1**] showing a persistent bile leak from the free edge of the residual liver (as previously), and small amount of contrast seen tracking along the insertion tract of the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] tube. Due to poor nutritional status and decreased calorie counts the patient had a PICC line placed and started TPN. The initial PICC line had to be removed due to swelling in the arm with the finding by ultrasound of Thrombus within the right basilic vein with no flow detected and nonocclusive thrombus seen in the right IJ. This was treated with warm packs and elevation with good relief of swelling. A new PICC line was placed and TPN continued. On [**3-8**] the drains were [**Last Name (un) 7162**] studied with individual cholangiograms. -Initial spot fluoroscopic image demonstrates [**Location (un) 1661**]-[**Location (un) 1662**] [**Last Name (LF) 19843**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] catheter, biliary T-tube and biliary stent present in the right upper quadrant: T Tube cholangio demonstrated an approximately 2 cm long stricture of the common duct. One end of the stent previously placed by ERCP is located within the stricture; however, the stent does not fully traverse the stricture. There is no evidence of leak of contrast outside of the bile duct. The [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Last Name (NamePattern1) 19843**], which demonstrates a proximal sidehole to be located outside of the liver with associated leakage of contrast outside the liver. No communication with the biliary tree is seen. Leakage of contrast is also noted at the anastomosis with jejunum. There is no intraluminal opacification of jejunum. The [**Location (un) 1661**]-[**Location (un) 1662**] [**Location (un) 19843**] demonstrates extravasation out of the [**Location (un) 1661**]-[**Location (un) 1662**] [**Location (un) 19843**] into a perihepatic collection along the inferolateral liver edge. There is no intraluminal opacification of bowel. On [**2187-3-9**] he underwent ERCP which showed a single stricture of benign appearance in the mid CBD. There was no post-obstructive dilation. A leak with extravasation of contrast was noted at the site of the stricture in the CBD. There was successful placement of a 5cm by 10Fr double pig tail biliary stent across the stricture and the leak. In addition on the same day he underwent paracentesis by Ultrasound-guidance for diagnostic and therapeutic paracentesis, with drainage of 1 liter of clear dark yellow fluid. Cultures did not yield any growth of organisms. He continued to spike fevers on a daily basis. Chest xray was done on [**3-11**] showing increased opacity at the right lung base. [**Month (only) 116**] be due to a combination of right lower lobe atelectasis, pleural effusion, or subpulmonic fluid. Underlying infiltrate cannot be entirely excluded. He then underwent a thoracentesis on [**3-12**] under CT guidance with removal of 500 cc fluid. No [**Month/Year (2) 19843**] was left in place. On [**3-16**] he underwent CT of abdomen showing: 1. Increased amount of air in subdiaphragmatic perihepatic air-fluid collection when compared to the prior examination. New small-to- moderate degree of pneumoperitoneum. Increased ascites. If there has been no history of recent manipulation to account for these findings, anastamotic dehiscence cannot be excluded. 2. Stable small right loculated pleural effusion. 3. Stable spiculated left upper lobe nodules. He spiked a fever on the evening of [**3-16**] and was taken back to the OR on [**3-17**] with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. PROCEDURE PERFORMED: Exploratory laparotomy, abdominal washout, drainage of intra-abdominal abscess. Postoperative diagnosis was Retroperitoneal sepsis. During the procedure it was noted initially that there was about 30 cc of thick pus. This was aspirated and sent for microbiologic study, which grew out yeast (presumptively not C albicans) and Enterobacter. The small bowel and colon were reported as plastered to the anterior abdominal wall. These were taken down with great care. No enterotomies of the bowel noted. The liver was then pulled off the anterior abdominal wall and the large retroperitoneal space seen on CT scan filled with air and pus was found. About 40-50 cc of yellow bile stained material was aspirated. During the irrigation, the T-tube became dislodged and was found in the intraperitoneal space. The T-tube was removed in its entirety. The JP [**Last Name (NamePattern1) 19843**] was pulled from the vicinity of the IVC and then a new [**Doctor Last Name 406**] was attached running through the original tract. He was transferred from the PACU to the SICU, where he stayed for several days until deemed stable for transfer back to [**Hospital Ward Name 121**] 10. ID was consulted, who recommended the initiation of Gentamycin and the discontinuation of Cefepime due to resistance. Caspofungin, Linezolid and PO Vanco were continued. Patient had been maintained nutritionally on TPN, and on [**3-26**] an attempt was made to pass a nasoduodenal tube for enteral feeding. Despite 2 attempts on two separate days, the tube was unable to be passed through the pyloris, and the tube was subsequently removed. His appetite remained poor with minimal intake, supplements offered daily. Cultures taken from the drains on [**3-27**] continued to grow Enterobacter and yeast-non-albicans. CT of the abdomen was obtained on [**3-27**] showing: 1. Decreased amount of air in the subdiaphragmatic perihepatic air-fluid collection when compared to the prior examination. Marked decrease in intraperitoneal free air. 2. Unchanged amount of ascites as well as mild mesenteric stranding and mesenteric lymph nodes consistent with given history of peritonitis. 3. Small right loculated pleural effusion. On the morning of [**2187-3-29**], the patient was noted to have increased crackles throughout all lung fields. He received 40 mg IV lasix. He was transferred from bed to chair around 9:30 AM and it was noted that his O2 sat dropped to high 80's. He was placed on O2 via NC at 4L and a chest xray was obtained. The chest xray was read as Extensive bibasilar atelectasis with possible additional small left pleural effusion. No evidence of fluid overload. The patient was having tachypnea, labored breathing and O2 sats were difficult to maintain and he was placed on a non-rebreather and transferred to the Trauma ICU (bed availability) He was intubated immediately after arrival to the ICU, a BAL was performed and an additional chest xray suggested aspiration or pneumonia. Serial lactates were performed with rising levels, the final Lactate was 16. Later in the afternoon the patient was coded and subsequently died. Medications on Admission: Metoprolol 25mg daily, Iron 325 mg TID, atorvastatin 10 mg daily, imatinab 400 mg daily, tylenol PRN, Oxycodone PRN, Colace 100 mg hs, lactobacillus 2 caps daily, Augmentin 875 mg [**Hospital1 **], Vanco 250 mg PO TID, Ursodiol 300 TID Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: To be determined Discharge Condition: Death [**2187-3-29**] Discharge Instructions: None Followup Instructions: None [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2187-3-30**]

[ "707.05", "E878.2", "998.6", "276.52", "E849.7", "112.89", "E849.8", "576.2", "511.9", "995.91", "707.03", "V10.09", "038.9", "272.0", "999.31", "996.74", "996.59", "E870.5", "E879.8", "197.7", "401.9", "997.4", "518.0", "567.81", "451.84", "998.59" ]

icd9cm

[ [ [] ] ]

[ "97.05", "00.14", "96.04", "99.60", "96.08", "54.91", "51.10", "38.93", "33.24", "93.59", "96.71", "97.49", "99.04", "54.25", "87.54", "38.91" ]

icd9pcs

[ [ [] ] ]

11202, 11211

3412, 10886

318, 354

11271, 11294

2481, 2481

11347, 11509

1857, 1875

11173, 11179

11232, 11250

10912, 11150

11318, 11324

1890, 2462

230, 280

382, 1507

2495, 3389

1529, 1790

1806, 1841

56,527

101,342

12249

Discharge summary

report

Admission Date: [**2151-5-21**] Discharge Date: [**2151-6-5**] Date of Birth: [**2079-7-18**] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[**Name (NI) 9308**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 71 year old man with recent hospitalization [**Date range (1) 28125**] for heart failure, during which he was diuresed and discharged home. He is a poor historian. He reports that he has been taking his Lasix, but for the past day or so has been having shortness of breath and discomfort in his xiphoid/epigastric region. It is "mild" in intensity and does not radiate. He denies nausea, vomiting, and abdominal pain. His shortness of breath limits his ability to walk. He saw his primary care RN three days ago and was instructed to increase his Lasix dose by 80mg daily x 3 days. . In the ED, triage vitals were T97.4F, BP 101/56, HR 95, Sat 94%RA. He was given 325mg aspirin. CXR showed no acute process and improvement from prior with better aeration, although he still has decreased lung volumes. He was noted to have bibasilar rales and expiratory wheezes, and given increased creatinine (1.7) . Review of the Atrius records indicates that his [**Location (un) 2274**] caregivers were quite concerned about him at home given his medication noncompliance and recommended that he stay in the hospital until completely diuresed or go to short term rehab. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough. Denied palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. All other review of systems are negative. Past Medical History: - Coronary artery disease s/p stent (LCx, [**2145**]) - CHF (EF 30-35%) - Aortic stenosis (1.2cm2) - CVA on warfarin - BPH - Prostate CA - Hyperlipidemia - Hypertension - Thalassemia trait, G6PD Social History: Lives alone in [**Location (un) 686**]. He is able to cook for himself. Able to walk [**12-12**] blocks without dypnea. Poor compliance with diet. Uses bubble packs for his medications. Doesn't know the names of any of his medications. Has assistance of his son and daughter. [**Name (NI) **] [**Name (NI) 5586**] is his HCP [**Telephone/Fax (1) 38272**]. EtOH: none Tobacco: former 20 pack year smoker, quit 20 years ago. Illicits - none Family History: Mother deceased from MI at age 37. Father deceased with CVA and lung cancer. Maternal aunts with DM. Brother deceased from esophageal cancer. Physical Exam: ADMISSION PHYSICAL EXAM VS - BP 102/65, HR 87, RR 18, Sat 100%2L Gen: No acute distress HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Neck: Supple. JVP unappreciable. CV: RR, normal S1, S2. + 1-2/6 systolic ejection murmur. No S3 or S4. Chest: Rales [**12-13**] bilaterally. Occasional wheezes at apices. Abd: Soft, NTND. No HSM. Tender in epigastric region worse with deep palpation. Ext: No clubbing or cyanosis. 1+ pitting edema to the knee bilaterally. Pertinent Results: Admission labs: [**2151-5-21**] 02:15PM BLOOD WBC-8.6 RBC-3.91* Hgb-9.1* Hct-29.5* MCV-75* MCH-23.2* MCHC-30.7* RDW-20.3* Plt Ct-203 [**2151-5-21**] 02:15PM BLOOD Neuts-77.6* Lymphs-12.1* Monos-7.2 Eos-2.7 Baso-0.3 [**2151-5-21**] 02:15PM BLOOD PT-17.5* PTT-29.5 INR(PT)-1.6* [**2151-5-21**] 02:15PM BLOOD Glucose-99 UreaN-51* Creat-1.7* Na-134 K-4.3 Cl-94* HCO3-31 AnGap-13 [**2151-5-22**] 07:40AM BLOOD CK(CPK)-943* [**2151-5-22**] 01:45AM BLOOD CK(CPK)-1097* [**2151-5-22**] 07:40AM BLOOD CK-MB-5 cTropnT-0.04* [**2151-5-22**] 01:45AM BLOOD CK-MB-6 cTropnT-0.04* [**2151-5-21**] 02:15PM BLOOD cTropnT-0.05* [**2151-5-22**] 07:40AM BLOOD Calcium-8.1* Phos-5.6*# Mg-1.9 . CHEST X-RAY PA and lateral [**2151-5-21**]: Similar to the prior exam, lung volumes are diminished with marked elevation of the right hemidiaphragm again noted and stable. There is improved aeration with no focal consolidation or superimposed edema noted. Mild aortic tortuosity is again noted with calcified plaque at the arch. The cardiac silhouette size is stable and likely top normal accounting for patient and technical factors. No effusion or pneumothorax is noted. The osseous structures are unremarkable. IMPRESSION: Stable chest x-ray examination with no definite acute pulmonary process. . CT Scan of CHEST on [**2151-5-29**]: 1. Mild atelectasis at the right base. 2. Opacification noted in prior study is due to vessels tortuosity. No concerning lung lesion or lymphadenopathy is noted. 3. Small amount of ascites. . RENAL Ultrasound on [**2151-5-26**]: The study is slightly limited by difficulties with positioning. The right kidney measures 10.4 cm. The left kidney measures 9.8 cm. No stones or hydronephrosis are identified. The bladder is decompressed with a Foley catheter noted. IMPRESSION: No evidence of hydronephrosis. Brief Hospital Course: ASSESSMENT/PLAN: 71 yo M with history of CHF (EF 30-35%) and recent admission for CHF now admitted with dizziness, chest pain, and shortness of breath. . #) Shortness of Breath: Likely multifactorial. His initial presentation was consistent with acute on chronic systolic heart failure. The patient was diruesed with IV Lasix, but subsequently became dehydrated and developed hypotension and acute on chronic renal failure. He was transfered to the CCU for further management. In the CCU: his diuretics were held to allow renal recovery. Despite diuresis and appearing near-euvolemic on exam, he remained dyspneic. Pulmonology was consulted for further investigation. ABGs demonstrated hypercarbic respiratory acidosis, likely due to his obstructive airway disease. Patient improved by using BIPAP from 10pm-7am, and treating for COPD exacerbation with azithromycin and prednisone taper. He has an appoitment to follow up with his outpatient cardiologist. . #) Acute on chronic renal failure: The patient developed acute on chronic renal failure in the setting of overdiuresis. He was treated with initially IV fluids and then with holding of Lasix. Upon recovery of renal function, Lasix was resumed at 80mg po daily. . #) Hypotension: On [**2151-5-25**], the patient's blood pressure was noted to be 82/doppler. This responded quickly, with a fluid bolus, with systolic blood pressure subsequently 110. The patient was transferred to the CCU for further management. On admission to the CCU, his blood pressure was normotensive and remained such throughout the rest of his admission. . #) Chest pain: The patient had chest pain prior to admission, which recurred on [**2151-5-25**], in the setting of hypotension to 82. He ruled out for MI. . #) History of CVA: The patient was subtherapeutic on admission. Warfarin was started at 10 mg daily. Subsequently, the patient became supratherapeutic and warfarin was held. Warfarin continued to be held in the setting of hematuria and rectal bleeding. . #) Rectal bleeding: Patient had intermittent boughts of BRBPR. According to Atrius records, he has known hemorroids. H/H have been stable. Patient will follow up with his PMD for this issue. . #) Hematuria: Patient's foley was frequently irrigated and eventually switched to a 3 way foley. He has known prostate CA. H/H stable throughout admission and there were no signs of urinary tract obstruction. Patient will follow up with his PMD and his PMD will refer to urology as needed. . Confirmed full code . Dispo: to rehab Medications on Admission: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 6. Colchicine 0.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for back pain. 8. Bicalutamide 50 mg Tablet Sig: One (1) Tablet PO once a day: to complete 21 day course as directed. 9. Zoladex 10.8 mg Implant Sig: One (1) implant Subcutaneous as directed: per your oncologist. 10. Viagra 50 mg Tablet Sig: One (1) Tablet PO as needed as needed for erectile dysfunction. 11. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 12. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 15. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO HS (at bedtime). 16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 17. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 18. Bipap at night 19. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 11. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO at bedtime. Discharge Disposition: Extended Care Facility: [**Location (un) 86**] Center for Rehab & Sub-Acute Care - [**Location (un) 2312**] Discharge Diagnosis: Primary: 1. Acute on chronic systolic heart failure . Secondary: 1. Aortic stenosis 2. Back pain 3. Benign prostatic hypertrophy 4. History of stroke Discharge Condition: Mental Status: Alert and oriented to person and place. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came to the hospital with shortness of breath. This was thought to be due to congestive heart failure and chronic obstructive pulmonary disease. You were treated with Lasix with improvement in your symptoms. You were also treated with antibiotics, steroids, and used CPAP at night to help with your breathing. . Continue to take all of the medications that you were on prior to admission, with the following changes: 1. Change Lasix (furosamide) from 80mg twice a day to 80mg once a day 2. Please stop taking Calcium Acetate 3. Please stop taking Ipratropium bromide. 4. Please stop taking coumadin (warfarin). . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Use CPAP every night to help with your breathing. Followup Instructions: 10:30AM on Friday, [**6-18**] Name: [**Last Name (LF) 38274**],[**First Name3 (LF) **] X. Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 19604**] Phone: [**Telephone/Fax (1) 3530**] Fax: [**Telephone/Fax (1) 6808**] . 11:50AM on FRIDAY, [**6-11**] Name: [**Name (NI) **], [**Name (NI) **] Location: [**Hospital1 641**] Address: [**Street Address(2) **], [**Location **] MA Phone: [**Telephone/Fax (1) 38275**] Fax: [**Telephone/Fax (1) 38276**]

[ "424.1", "V58.61", "272.4", "599.71", "276.2", "584.9", "276.7", "416.8", "402.91", "455.8", "491.21", "V12.54", "327.23", "278.01", "428.23", "428.0", "185" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10483, 10593

5036, 7569

280, 287

10787, 10787

3193, 3193

11771, 12276

2560, 2703

9305, 10460

10614, 10766

7595, 9282

10990, 11748

2718, 3174

1494, 1869

221, 242

315, 1475

3209, 5013

10802, 10966

1891, 2087

2103, 2544

4,995

148,410

21442

Discharge summary

report

Admission Date: [**2115-12-11**] Discharge Date: [**2115-12-20**] Date of Birth: [**2036-4-21**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1283**] Chief Complaint: 79 year old white female with 2 year history of shortness of breath. Major Surgical or Invasive Procedure: AVR with 21mm CE valve [**2115-12-11**] Past Medical History: CHF Aortic stenosis Right upper lobe bullae Anxiety Diverticulosis L carotid disease Peripheral vascular disease Obesity s/p TAH/BSO s/p cataract surgery s/p foot surgery Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2115-12-16**] 05:40AM 14.0* 4.41 12.0 36.9 84 27.3 32.6 15.3 240 BASIC COAGULATION PT PTT Plt Ct INR(PT) [**2115-12-17**] 06:05AM 13.41 24.0 1.1 1 NOTE NEW NORMAL RANGE AS OF 12A OF [**2115-9-10**] Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2115-12-17**] 06:05AM 107* 43* 0.8 137 5.1 96 36* 10 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2115-12-16**] 05:40AM 8.9 3.9 2.8* [**2115-12-19**] 06:25AM BLOOD WBC-13.4* RBC-4.19* Hgb-11.3* Hct-35.4* MCV-85 MCH-26.9* MCHC-31.8 RDW-15.3 Plt Ct-310 [**2115-12-19**] 06:25AM BLOOD Plt Ct-310 [**2115-12-19**] 06:25AM BLOOD PT-14.0* PTT-25.3 INR(PT)-1.2 [**2115-12-19**] 06:25AM BLOOD UreaN-36* Creat-1.0 K-5.2* [**2115-12-20**] 06:15AM BLOOD WBC-14.0* RBC-4.23 Hgb-11.2* Hct-35.0* MCV-83 MCH-26.6* MCHC-32.2 RDW-15.3 Plt Ct-329 [**2115-12-20**] 06:15AM BLOOD Plt Ct-329 [**2115-12-20**] 06:15AM BLOOD PT-14.0* PTT-24.7 INR(PT)-1.2 [**2115-12-20**] 06:15AM BLOOD Glucose-100 UreaN-35* Creat-0.9 Na-142 K-4.1 Cl-94* HCO3-43* AnGap-9 Brief Hospital Course: Mrs. [**Known lastname 56625**] was admitted to BIDMCon [**2115-12-11**] and taken to the operating room with Dr. [**Last Name (STitle) **] for an AVR with a 21mm CE pericardial tissue valve. She tolerated the procedure well and was transferred to the ICU in stable condition. Postoperatively she remained intubated on mechanical ventilation due to CO2 retention, and was extubated on the evening of POD#2. She continued to have elevated CO2 with a normal pH, which was thought to be her baseline. She was noted to have a prolonged PR interval of about .33. She was transferred from the ICU to the regular floor on POD#2. She developed fib on POD#4, was started on amiodarone on POD#5. She converted into SR, but continued to have a very prolonged PR interval. An EP consult was obtained and the team was concerned that she was having heart block with the atrial fibrillation. She was taken to the electrophysiology lab for a study on POD#7 where it was determined that she had some AV nodal disease with a LBBB, but she was at very low risk for progression to CHB and it was decided that there was no indication for a permanent pacer. She was also cardioverted into sinus rhythm. The EP service recommended lo dose beta blocker and anticoagulation and no amiodarone therapy. She was started on 12.5mg of Lopressor [**Hospital1 **] and tolerated it well. Her PR interval remains 2.5-.3. On the morning of discharge, she developed periods of slower heart rates into the 60s. EP service evaluated her rhythm and determined that it was due to blocked premature atrial contractions and recommended continuing her lopressor and continue with plan for discharge to rehab with a monitored bed. She has continued to require oxygen thru out her hospital stay, 4L nasal cannula to maintain a Sp O2 of 96%. Her CXR shows a large right upper lobe bullae, small bilateral pleural effusions. The RUL bullae is consistent with her preoperative CXR, and Dr. [**Last Name (STitle) **] has requested Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 56626**]/Thoracic surgery to consult regarding management of her bullous disease. She is being anticoagulated with Coumadin to achieve an INR of 2.0-2.5 for the atrial fibrillation. Medications on Admission: Digoxin 0.25 mg PO daily HCTZ/Triam. 37.5/25 PO daily Detrol 4 mg PO daily Premarin 0.625 mg PO daily Candesartan 16 mg PO daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed. 7. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. Premarin 0.625 mg Tablet Sig: One (1) Tablet PO once a day. 9. Furosemide 10 mg/mL Solution Sig: 40 mg IV Injection [**Hospital1 **] (2 times a day): wean to PO lasix when fluid status decreases. 10. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold HR<60. 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 13. Warfarin Sodium 1 mg Tablet Sig: Five (5) Tablet PO once [**12-20**]: titrate for INR 2.0-2.5. 14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Critical aortic stenosis Congestive heart failure Peripheral vascular disease Obesity s/p AVR atrial fibrillation RUL bullous disease first degree AV block anxiety Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 56627**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks. Please consult Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 56628**] upon arrival to rehab re:RUL bullous disease Completed by:[**2115-12-20**]

[ "278.00", "428.0", "427.31", "997.1", "426.11", "443.9", "562.10", "424.1" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.26", "99.61", "35.21" ]

icd9pcs

[ [ [] ] ]

5365, 5445

1751, 4001

349, 391

5653, 5660

604, 1728

5903, 6217

4180, 5342

5466, 5632

4027, 4157

5684, 5880

241, 311

413, 585

53,798

168,212

35019

Discharge summary

report

Admission Date: [**2101-8-7**] Discharge Date: [**2101-8-12**] Date of Birth: [**2053-8-29**] Sex: F Service: OTOLARYNGOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 12657**] Chief Complaint: Transfer from OSH, laryngeal fracture Major Surgical or Invasive Procedure: 1. Tracheostomy. 2. Open repair of cricoid fracture. 3. Laryngoscopy. History of Present Illness: 47F w/ h/o anxiety who slipped in her hotel room and struck her anterior neck and chin on a chair. She had severe pain in her neck and went to an OSH ED to be evaluated. She was having no respiratory difficulties, but was hoarse. CT scan showed cricoid fracture. She was transferred to [**Hospital1 18**] in stable condition. The patient was quite hoarse on arrival, though able to speak louder than a whisper with effort. She complained of significant anterior neck pain over the midline and on either side of larynx/trachea, but could not pinpoint a specific location. She had no bleeding from her mouth or nose. She had a normal voice prior to the fall and has had no prior head and neck surgeries. Past Medical History: anxiety, mood disorder Social History: n/c Family History: n/c Physical Exam: 98.4 97.2 66 110/40 18 99%TC NAD Breathing comfortably Trach site intact No edema or erythema Pertinent Results: [**2101-8-7**] On admission WBC-8.7 RBC-4.10* Hgb-13.6 Hct-38.5 MCV-94 MCH-33.3* MCHC-35.4* RDW-13.7 Plt Ct-379 Neuts-84.2* Lymphs-12.9* Monos-2.4 Eos-0.1 Baso-0.3 Neuts-89.1* Lymphs-9.5* Monos-0.7* Eos-0.6 Baso-0.1 PT-12.5 PTT-24.3 INR(PT)-1.1 PT-11.9 PTT-24.6 INR(PT)-1.0 Glucose-123* UreaN-11 Creat-0.7 Na-139 K-3.4 Cl-104 HCO3-26 AnGap-12 Glucose-151* UreaN-13 Creat-0.8 Na-134 K-8.7* Cl-101 HCO3-27 AnGap-15 Calcium-9.1 Phos-2.9 Mg-1.9 HCG-<5 Brief Hospital Course: 47F s/p blunt trauma to neck and cricoid fracture was transferred to [**Hospital1 18**] from OSH. Patient was taken to OR and had tracheostomy, open repair of cricoid fracture, laryngoscopy. Patient tolerated procedure well and recovered on the floor without events. she was on centrally monitored oxygen monitoring and did not desat during her hospital stay. Psychiatry was consulted to manage meds due to her NPO status. Her anxiety was controled with IV ativan. On POD3 she passed her swallow eval and was started on diet as per speech and swallow and re-started on her home meds. Psych meds were started as per psychiatry recommendation. On POD4 her trach was downsized at bedside and was tolerated well. Patient is being discharged with VNA for trach care: afebrile, tolerating regular diet without nausea/vomiting, pain well controlled on oral medication, voiding, and ambulating well. Patient will follow-up in [**6-9**] days with Dr. [**Last Name (STitle) 1837**]. ‎ Medications on Admission: abilify 20 QD, lamictal 200 QD, klonopin 2 QHS/PRN, prozac 20 4x/month, HCTZ 25 QD Discharge Medications: 1. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Clonazepam 1 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 7 days: do not drink, drive, or operate heavy machinery while taking percocet. Disp:*40 Tablet(s)* Refills:*0* 6. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 10 days. Disp:*40 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Cricoid fracture Discharge Condition: stable Discharge Instructions: Seek immediate medical attention for fever >101.5, chills, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. OK to shower but do not soak incision until follow up appointment, at least. No strenuous exercise or heavy lifting until follow up appointment, at least. Do not drive or drink alcohol while taking narcotic pain medications. Narcotic pain medications may cause constipation, if this occurs take an over the counter stool softener. Resume all home medications. Call your surgeon to make follow up appointment. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 1837**] in [**12-1**] weeks. Please call his office to set up an appointment [**Telephone/Fax (1) 8120**]. Completed by:[**2101-8-12**]

[ "807.5", "296.80", "478.31", "300.00", "E917.7" ]

icd9cm

[ [ [] ] ]

[ "31.1", "31.64", "31.42" ]

icd9pcs

[ [ [] ] ]

3591, 3640

1861, 2852

360, 432

3701, 3710

1384, 1838

4356, 4536

1248, 1253

2986, 3568

3661, 3680

2878, 2963

3734, 4333

1268, 1365

282, 322

460, 1164

1186, 1211

1227, 1232

24,547

129,957

21609

Discharge summary

report

Admission Date: [**2165-8-7**] Discharge Date: [**2165-8-23**] Service: CSURG Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1505**] Chief Complaint: presented to PCP with increasing [**Name Initial (PRE) **]/o chest pain, referred to ED, admitted for cardiac catheterization Major Surgical or Invasive Procedure: CABG X 3 (LIMA > LAD, SVG>OM, SVG>PDA) History of Present Illness: 87 y/o male presented to PCP w/CP (had recent positive ETT), referred to ED, admitted for cath with revealed 95% left main occlusion and 3vCAD, IABP placed in Cath Lab. Past Medical History: arthritis s/p total knee replacement s/p total hip replacement Social History: remote smoker, quit 45 years ago denies ETOH retired Family History: N/A Physical Exam: elderly male in NAD L sided facial droop CV: RRR, +SEM Lungs: CTA bilat. extrem: venous stasis changes Pertinent Results: [**2165-8-6**] 09:20PM PT-13.3 PTT-29.4 INR(PT)-1.1 [**2165-8-6**] 09:20PM BLOOD WBC-7.5 RBC-3.90* Hgb-13.7* Hct-38.0* MCV-98 MCH-35.2* MCHC-36.1* RDW-13.2 Plt Ct-219 [**2165-8-6**] 09:20PM BLOOD PT-13.3 PTT-29.4 INR(PT)-1.1 [**2165-8-23**] 05:35AM BLOOD PT-16.0* INR(PT)-1.6 [**2165-8-22**] 05:55AM BLOOD PT-15.5* INR(PT)-1.5 [**2165-8-6**] 09:20PM BLOOD Glucose-107* UreaN-16 Creat-0.7 Na-142 K-4.0 Cl-107 HCO3-26 AnGap-13 [**2165-8-23**] 05:35AM BLOOD Glucose-92 UreaN-34* Creat-0.9 Na-147* K-4.0 Cl-110* HCO3-28 AnGap-13 Brief Hospital Course: IABP in cath lab due to LM disease to OR on [**8-8**], CABG X 3 post-op to CSRU on neosynephrine extubated, IABP removed, transfused on POD #1Progressed well from hemodynamic standpoint. Placed on ceftriaxone prophylactically for possible aspiration, pt. remained intermittantly confused, agitated at times. Treated with haldol, but became too somnolent, so it was stopped. Swallow eval: failed initially, had tube feeds, but as mental status cleared, he did well with nectar thick and pureed foods (still at risk for aspiration with thin liquids). Had recurrent post-op AFIB, with controlled ventricular rate, placed on amiodarone, and coumadin. Has now been in NSR for the past few days. Medications on Admission: glucosamine ASA MVI Toprol XL 100 QD Detrol 4mg QD Imdur 120mg QD Lasix 20mg QD KCl 10 mEq QD Vit E Lipitor 20mg QD Discharge Medications: 1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QD (once a day). Capsule, Delayed Release(E.C.)(s) 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 5. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO QD (once a day). 6. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once a day). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (once a day). 8. Lipitor 20 mg PO QD Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: CAD post-op delirium aspiration of thin liquids post-op AFib Discharge Condition: good Discharge Instructions: no lifting > 10# OR DRIVING FOR 1 MONTH no creams, lotions or ointments to incisions No water or thin liquids due to aspiration risk Followup Instructions: with Dr. [**Last Name (STitle) **] in 3 weeks or upon discharge from rehab with Dr. [**First Name (STitle) 6930**] in [**12-18**] weeks with Dr. [**Last Name (STitle) **] in [**12-18**] weeks Completed by:[**2165-8-23**]

[ "411.1", "428.0", "V43.64", "293.0", "V43.65", "414.01", "272.0", "530.81", "427.31", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.23", "96.6", "88.53", "37.61", "36.15", "88.56", "36.12" ]

icd9pcs

[ [ [] ] ]

3004, 3078

1456, 2151

350, 390

3183, 3189

903, 1433

3370, 3593

760, 765

2317, 2981

3099, 3162

2177, 2294

3213, 3347

780, 884

185, 312

418, 588

610, 674

690, 744

55,515

195,984

35413+58002

Discharge summary

report+addendum

Admission Date: [**2140-3-1**] Discharge Date: [**2140-3-5**] Date of Birth: [**2083-2-20**] Sex: M Service: CARDIOTHORACIC Allergies: Meperidine / Lipitor Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2140-3-1**] - Mitral valve repair with a quadrangular resection of the posterior leaflet and an annuloplasty ring repair with a 30-mm [**Company 1543**] 3-D ring. History of Present Illness: Mr. [**Name14 (STitle) 80719**] is a very nice 56-year-old gentleman with a history of mitral valve prolapse, which has been followed by serial echocardiograms. He had been relatively asymptomatic until [**2139-11-9**] when he began to experience dyspnea on exertion. He was admitted to an outside hospital on [**2139-11-28**], for chest pain where a work up showed normal coronaries and severe mitral regurgitation. He was treated with diuretics at that time, which seemed to not significantly improve his symptom of dyspnea on exertion. Due to severity of his mitral regurgitation, he is now referred for mitral valve surgery. Review of his cardiac catheterization from [**Hospital **] Hospital on [**2139-12-1**], shows his ejection fraction to be 70% with severe mitral regurgitation, a very dilated left atrium, and no significant coronary artery disease. His PA pressure was 30/13 mmHg. His echocardiogram from [**2139-11-26**] showed an ejection fraction of 65-70%. He had left atrial enlargement, mitral valve prolapse with severe mitral regurgitation, normal pulmonary pressures, and a normal left ventricular size. An echo from [**2139-2-12**], showed bileaflet mitral valve prolapse with severe MR. The regurgitant fraction was calculated to be 71%. Past Medical History: mitral valve prolapse, dyslipidemia, hypertension, right bundle branch block, migraines, anxiety, gastroesophageal reflux disease, nephrolithiasis, and benign prostatic hypertrophy. Surgical history is notable for inguinal hernia repairs bilaterally three times and left shoulder surgery. Social History: Currently, he is employed as a superintendent at a waste treatment center. He never has smoked. He uses alcohol very rarely and he lives with his wife currently in [**Name (NI) 1727**]. His last dental exam was a week ago. Family History: Family history is notable for a father who had had several cerebrovascular accidents as well as a myocardial infarction and ultimately passed away at the age of 56. His family history is also pretty significant for atrial fibrillation in his parents and a mother who passed away at the age of 34 of colon cancer. Physical Exam: His pulse is 64 and regular. Respirations are 14. His blood pressure on his right is 124/80 and on his left is 118/80. He is 5 feet 8 inches tall and weighs 170 pounds. In general, he is a well-developed and well-nourished gentleman in no acute distress. His skin is warm and dry without clubbing, cyanosis, or edema. His HEENT exam shows him to be normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Sclerae are anicteric. Oropharynx is benign. His teeth are in good repair. His neck is supple with full range of motion and no JVD. Lungs are clear to auscultation bilaterally. Heart shows a regular rate and rhythm with normal S1 and S2. There is a late 4/6 systolic murmur, which is best heard at the left sternal border and tracking to the apex. His abdomen is soft, nondistended, and nontender with normal active bowel sounds. There is no hepatosplenomegaly. Extremities are warm and well perfused without edema. There are no significant varicosities on standing. He does have some mild spider varicosities of his distal lower extremities. Pulses are 2+ throughout. Neurologically, he is alert and oriented x3. There are no focal deficits. His gait is steady and his strength is [**4-12**]. I do not appreciate a carotid bruit bilaterally. Pertinent Results: [**2140-3-1**] ECHO PRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are myxomatous. Moderate to severe (3+) mitral regurgitation is seen. There is no pericardial effusion. POST CPB: Preserved [**Hospital1 **]-ventricular systolic function. Annuloplasty ring in mitral position. Well seated and stable. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **] across mitral valve < 5 mm hg. LVOT peak [**Last Name (Titles) **] = 18 mm HG. Transient LVOR [**Last Name (Titles) **] generated with low CBP < 85 mm HG. Trated with volume and after-load augmentation and heart rate control < 90 beats/min. No other change in valve structure and function [**2140-3-2**] CTA No evidence of intracranial hemorrhage or infarction. [**2140-3-3**] Carotid 1. 0% stenosis in the left and right internal carotid arteries. [**2140-3-4**] 05:35AM BLOOD WBC-9.6 RBC-3.29* Hgb-10.1* Hct-29.0* MCV-88 MCH-30.7 MCHC-34.8 RDW-14.3 Plt Ct-128* [**2140-3-5**] 07:15AM BLOOD PT-21.6* INR(PT)-2.1* [**2140-3-4**] 05:35AM BLOOD Glucose-77 UreaN-20 Creat-0.8 Na-142 K-4.0 Cl-109* HCO3-27 AnGap-10 [**2140-3-2**] 05:29PM BLOOD ALT-18 AST-46* LD(LDH)-345* AlkPhos-56 Amylase-48 TotBili-0.7 [**Known lastname 80720**],[**Known firstname **] [**Medical Record Number 80721**] M 57 [**2083-2-20**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2140-3-3**] 3:53 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2140-3-3**] 3:53 PM CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 80722**] Reason: ? ptx after CT removal [**Hospital 93**] MEDICAL CONDITION: 57 year old man with s/p MV repair REASON FOR THIS EXAMINATION: ? ptx after CT removal Provisional Findings Impression: [**First Name9 (NamePattern2) 80723**] [**Doctor First Name **] [**2140-3-3**] 5:20 PM PFI: No pneumothorax. Worse bibasilar atelectasis, new small left pleural effusion and mild volume overload. Final Report PORTABLE AP CHEST INDICATION: ? Pneumothorax after chest tube removal. FINDINGS: Comparison is made with prior radiograph from [**2-23**] and 24, [**2139**]. There has been prior mitral valve replacement. Multiple lines and support devices have been removed. There is worsening bibasilar atelectasis and a new left pleural effusion. There is mild early volume overload. There is no pneumothorax. The bones are unremarkable. IMPRESSION: No pneumothorax. Mild volume overload, worsening bibasilar atelectasis, and new small left pleural effusion. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) 19115**] [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: [**Doctor First Name **] [**2140-3-3**] 6:10 PM Brief Hospital Course: Mr. [**Name14 (STitle) 80719**] was admitted for elective repair of his mitral valve on [**2140-3-1**]. He was taken to the operating room where he underwent a mitral valve repair with a 30mm ring. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. He later awoke neurologically intact and was extubated. He had a transient episode of word finding and confusion for which a neuroloy consult was obtained. A CT scan and carotid ultrasound were negative. His symptoms promptly resolved without reoccurence. On postoperative day two, he was transferred to the step down uniit for further recovery. The physical therapy service was consulted for asistance with his postoperative strength and mobility. He was gently diuresed towards his preoperative weight. He continued to make steady progress and was dishcarged home on postoperative day 4 ins stable condition. He will be anticoagulated with coumadin for 3 months and it will be followed by Dr. [**Last Name (STitle) 80724**]. Medications on Admission: Aspirin 325 mg daily, Diovan 80 mg once daily, Claritin as needed, Nexium 40 mg daily, Flomax 0.4 mg daily, Multivitamin, Lasix 20 mg daily, Potassium Chloride 10 mEq daily, and Amoxicillin dental prophylaxis. Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 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. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 8. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day for 3 months: Take as directed by Dr. [**Last Name (STitle) 80724**] for INR goal of [**1-11**].5. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Your Home Care Discharge Diagnosis: mitral valve prolapse, dyslipidemia, hypertension, right bundle branch block, migraines, anxiety, gastroesophageal reflux disease, nephrolithiasis, and benign prostatic hypertrophy. 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. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) 80724**] in 2 weeks. Please follow-up with Dr. [**Last Name (STitle) 80725**] in [**1-12**] weeks. [**Telephone/Fax (1) 80726**] Call all providers for appointments. Completed by:[**2140-3-5**] Name: [**Known lastname 12962**],[**Known firstname 499**] Unit No: [**Numeric Identifier 12963**] Admission Date: [**2140-3-1**] Discharge Date: [**2140-3-5**] Date of Birth: [**2083-2-20**] Sex: M Service: CARDIOTHORACIC Allergies: Meperidine / Lipitor Attending:[**First Name3 (LF) 741**] Addendum: Mr. [**Known lastname **] is a 56-year-old male with worsening symptoms of shortness of breath and heart failure who underwent evaluation which showed severe mitral regurgitation with posterior leaflet prolapse and anterior leaflet prolapse as well with a myxomatous mitral valve presenting for mitral valve repair. It should be further noted that Mr [**Known lastname **] suffered systolic heart failure preoperatively. [**Known lastname 12962**],[**Known firstname 499**] [**Medical Record Number 12964**] M 57 [**2083-2-20**] Cardiology Report ECG Study Date of [**2140-2-23**] 11:18:18 AM Sinus bradycardia. Right bundle-branch block pattern - consider left ventricular hypertrophy. No previous tracing available for comparison. Read by: [**Last Name (LF) **],[**First Name3 (LF) 1332**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 53 176 138 416/403 26 61 24 Discharge Disposition: Home With Service Facility: Your Home Care [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2140-4-14**]

[ "428.0", "458.29", "530.81", "600.00", "272.4", "428.20", "427.31", "401.9", "426.4", "424.0", "435.9" ]

icd9cm

[ [ [] ] ]

[ "35.12", "39.61" ]

icd9pcs

[ [ [] ] ]

12212, 12380

7031, 8069

305, 472

9813, 9822

3991, 4408

10620, 12189

2347, 2663

8330, 9519

5817, 5852

9608, 9792

8095, 8307

9846, 10597

2679, 3972

246, 267

5884, 7008

500, 1773

1795, 2087

2103, 2331

4418, 5777

74,632

101,095

36514

Discharge summary

report

Admission Date: [**2190-10-13**] Discharge Date: [**2190-10-19**] Date of Birth: [**2104-7-26**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 3298**] Chief Complaint: L knee pain Major Surgical or Invasive Procedure: [**2190-10-13**]: s/p left total knee replacement revision - rotating hinge History of Present Illness: (Per Orthopedic Admission Note) Mr. [**Known lastname **] previously had a total knee replacement performed in [**2174**] by Dr. [**Last Name (STitle) 26181**]. This was revised due to loosening in [**2184**] by Dr. [**Last Name (STitle) 82679**]. He required an allograft prosthetic reconstruction. At that point in time, the allograft fractured following a fall. In addition, the [**Doctor Last Name 3549**] taper between the tibial component and the tibial stem has become disengaged and has been disengaged for several years. Mr. [**Known lastname **] presents with chronic pain and requires a revision. As pt presented for elective surgery other review of systems unremarkable and feeling well. Past Medical History: aortic stenosis coronary artery disease hypertension hyperlipidemia benign prostatic hyperplasia s/p resection of left acoustic neuroma s/p left tibial rodding s/p bilateral total knee replacements revision of left knee bilateral cataract surgery bilateral carpal tunnel release tonsillectomy/adenoidectomy excision of left upper extremity lipoma Social History: retired lives with wife tobacco: quit 40 yrs ago EtOH: 1 drink per month Family History: brother with MI, RHD father suffered MI Physical Exam: On Admission: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength * SILT, NVI distally * Toes warm On Discharge: VS: T 99.2, BP 102/56, P 71, RR 18, O2 95% on RA HEENT:OP clear w/o lesions CV: RRR, 3/6 systolic murmur Pulm: Clear to ausculatation bilaterally GI: Soft, NT, ND, Bowel sounds + Extrem: Left leg in immobilizer, dressing C/D/I Neuro: Alert and oriented to person, place, year (intermittently month) appropriate and pleasant with fluent speech Pertinent Results: ==================== LABORATORY RESULTS ==================== On Admission (from ICU) WBC-7.0# RBC-2.83*# Hgb-8.9*# Hct-25.2*# MCV-89 RDW-14.9 Plt Ct-104* PT-13.1 PTT-26.6 INR(PT)-1.1 Glucose-140* UreaN-16 Creat-0.9 Na-142 K-4.0 Cl-109* HCO3-24 On Discharge: WBC-4.7 RBC-3.34* Hgb-10.2* Hct-30.1* MCV-90 RDW-14.2 Plt Ct-183 Glucose-100 UreaN-25* Creat-0.8 Na-140 K-3.7 Cl-108 HCO3-27 Other Important Trends: [**2190-10-14**] 05:43AM CK(CPK)-1137* CK-MB-14* MB Indx-1.2 cTropnT-0.07* [**2190-10-14**] 09:26PM CK(CPK)-1576* CK-MB-34* MB Indx-2.2 cTropnT-0.55* [**2190-10-15**] 03:14AM CK(CPK)-1250* CK-MB-28* MB Indx-2.2 cTropnT-0.72* [**2190-10-15**] 11:23AM CK(CPK)-853* CK-MB-17* MB Indx-2.0 cTropnT-0.76* [**2190-10-15**] 06:58PM CK(CPK)-599* CK-MB-10 MB Indx-1.7 cTropnT-0.86* ============= MICROBIOLOGY ============= Joint Fluid [**2190-10-13**]: GRAM STAIN (Final [**2190-10-13**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2190-10-16**]): NO GROWTH. ACID FAST SMEAR (Final [**2190-10-14**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Blood Cultures [**2190-10-14**] and [**2190-10-15**]: No growth to date Urine Culture [**2190-10-14**]: No growth ============== OTHER STUDIES ============== Knee Radiograph [**2190-10-13**]: IMPRESSION: Intact left total knee revision. No complications. ECG [**2190-10-14**]: Rapid regular tachycardia, rate 110. There is complete right bundle-branch block. Atrial activity is not visible on the current tracing. There is marked ST segment depression in leads V2-V6. Compared to the previous tracing of [**2188-3-25**] the complete left bundle-branch block and the ST segment depressions are new and consisetnt with acute ischemia. ECG [**2190-10-15**]: Sinus tachycardia. The P-R interval is prolonged. Left axis deviation. Right bundle-branch block with left anterior fascicular block. Compared to the previous tracing of [**2190-10-14**] the rate is slower and ST segment depression is no longer present. TTE [**2190-10-15**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with distal inferior hypokinesis. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and (top normal) transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**11-29**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2188-3-24**], a aortic bioprosthesis is now seen. In addition very focal distal inferior hypokinesis is now seen. Head CT [**2190-10-15**]: Impression: 1. Bilateral periventricular hypodensities likely representing chronic ischemic changes. There is a right caudate infarct of undeterminate age. If anacute infarct is suspected, MRI is recommended for further evaluation. 2. Dense opacification of the left maxillary sinus with calcification may represent fungal infection. Unilateral Upper Extremity Ultrasound [**2190-10-16**]: IMPRESSION: No evidence of right upper extremity DVT. Studies Pending at Discharge: Blood Cultures from [**10-14**] and [**10-15**] remained negative at discharge but will be held for a full week each. Brief Hospital Course: This is an 86 yo M with CAD s/p CABG, BPH admitted following left total knee arthroplasty revision which was complicated by significant intra-operative and post-operative blood loss and hypotension. He was initially admitted to the Medical Intensive Care Unit and his hospital course was notable for acute blood loss anemia requiring 12 units pack red blood cells in total as well as cardiac biomarker elevation related to increased demand from anemia, hypotension, and tachycardia. #Revision of left knee arthroplasty/Intra- and Post-Operative Acute Blood Loss Anemia/Hypotension: Patient suffered 1.2L blood loss in the OR and had intraoperative hypotension. He was admitted to the Medical Intensive Care Unit where he was transfused to a hematocrit of >30 which required 12 units in total including in the OR. Following hemodynamic stabilization the patient was transferred to the medical floor where betablockers and diuretics were restarted. He was also started on prophylactic anticoagulation with no signs of active bleeding. #CAD s/p CABG/NSTEMI: Following surgery the patient developed an elevation in his cardiac biomarkers with elevation in TnT but without elevation in CK-MB index. It was felt this was reflective of potential fixed obstruction with increased cardiac demand from hypotension, anemia, tachycardia, and withholding of home beta-blockers. Cardiology was consulted who felt there was no further intervention required. An echocardiogram was obtained which showed only a focal distal inferior hypokinesis which was not felt to represent an acute coronary syndrome as detailed above. EF was preserved. Patient was continued on aspirin, betablocker, and statin when hemodynamically stable. #Chronic diastolic heart failure: Initially beta-blockade and diuretics were held, but these were restarted when the patient became hemodynamically stable and when the patient became mildly volume overloaded following stablization of bleeding. He was restarted on home diuretic therapy with furosemide 40 mg a day with good improvement. #Encephalopathy: Patient developed encephalopathy post-operatively felt to be due to a combination of hypotension, anesthesia, and narcotics for pain control. He failed a speech evaluation in this setting and was made NPO. His encephalopathy cleared prior to discharge and he was cleared by speech and swallow for a ground solid and nectar-thickened liquid diet. #Benign Prostatic Hypertrophy: Terazosin was held in setting of hypotension but restarted prior to discharge. Pt voided after removal of foley catheter without incident. #CODE: FULL #Disposition: Patient was discharged to rehab with Orthopedics and cardiology follow-up. Transitional Issues: -Pt was previously on no limitation of diet and will need further speech and swallow evaluation to be advanced back to full liquid diet without limitations. -Pt will continue physical therapy and knee kept in immobilizer until cleared by orthopedics. Medications on Admission: Metoprolol 25 mg twice a day, simvastatin 40 mg once a day, terazosin 5 mg once a day, aspirin 81 mg once a day, - Held for OR potassium 20 mg once a day, furosemide 40 mg once a day, Zantac 150 mg twice a day. Discharge Medications: 1. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous once a day for 4 weeks. 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 7. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. terazosin 1 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 14. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Primary Diagnoses: failed L total knee replacement Post-operative bleeding complicated by acute blood loss anemia Type 2 (demand) non-ST elevation myocardial infarction Secondary Diagnoses: Aortic stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after your left total knee replacement revision. You had a significant amount of blood loss during surgery and required blood transfusions in the Intensive Care Unit. You were noted to have stress on your heart, but did not have a true heart attack. You also had a CT scan of your head which did not show any bleeding, but did show evidence of a possible old stroke. Therefore, it is important that you follow up with your primary care physician and cardiologist once you are discharged from rehab to see if you require any modifications to current medication regimen or if you require any additional testing. You also had a speech and swallowing evaluation prior to discharge to rehab which showed some difficulties with swallowing, likely due to weakness. You were put on thickened liquids and ground foods in order to help prevent aspiration of food into your lungs, which can cause respiratory problems. Please make sure to make follow up appointments with Orthopedics and cardiology. Your rehab will help make a follow up appointment with your PCP after discharge. In addition: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Stitches will be removed at your first f/u appt. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in 2 weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). [**Male First Name (un) **] STOCKINGS x 6 WEEKS. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed at your follow up appt in two (2) weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. Two crutches or walker at all times for 6 weeks. Mobilize. FULL EXTENSION AT ALL TIMES. NO ROM. KNEE IMMOBILIZER. No strenuous exercise or heavy lifting until follow up appointment. Followup Instructions: Department: ORTHOPEDICS When: THURSDAY [**2190-10-28**] at 1 PM With: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) 7327**],[**First Name3 (LF) **] R. Specialty: INTERNAL MEDICINE Address: [**Location (un) 7330**], [**Location (un) **],[**Numeric Identifier 7331**] Phone: [**Telephone/Fax (1) 7328**] **Please discuss with the staff at the facility the need for a follow up appointment with your PCP when you are ready for discharge.** Name: [**Last Name (LF) **], [**First Name3 (LF) **] Specialty: CARDIOLOGY Location: THE HEART CENTER OF [**Hospital1 **] Address: [**First Name8 (NamePattern2) **] [**Location (un) **], [**Numeric Identifier 7398**] Phone: [**Telephone/Fax (1) 6256**] Appointment: WEDNESDAY [**11-17**] AT 10AM

[ "458.29", "428.0", "348.31", "V43.3", "V43.65", "411.89", "996.43", "401.9", "272.4", "600.00", "V45.81", "428.32", "414.00", "996.44", "285.1", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "00.82", "00.81" ]

icd9pcs

[ [ [] ] ]

10924, 11069

6391, 9085

319, 397

11320, 11320

2512, 2757

15415, 16378

1609, 1650

9621, 10901

11090, 11260

9386, 9598

11503, 14594

1665, 1665

11281, 11299

3667, 3667

3700, 6234

6248, 6368

2771, 3631

9106, 9360

268, 281

14606, 15392

425, 1132

1679, 2134

11335, 11479

1154, 1502

1518, 1593

23,549

117,467

2788

Discharge summary

report

Admission Date: [**2168-10-20**] Discharge Date: [**2168-10-28**] Date of Birth: [**2094-3-23**] Sex: F Service: MEDICINE Allergies: Lorazepam / Morphine / Penicillins / Zosyn Attending:[**First Name3 (LF) 134**] Chief Complaint: "Tachy-brady syndrome" Major Surgical or Invasive Procedure: -flutter ablation -right subclavian central line with temporary pacer placement -dual chamber pacer placement History of Present Illness: HPI: Ms. [**Known lastname 1263**] is a 75 y/o female with PMH significant for COPD/asthma, systolic CHF (EF<20%), HTN, Afib, CRI (baseline Cr 1.1), and seizure d/o, with recent [**Hospital1 18**] admission from [**2168-8-17**] to [**2168-9-22**], who presents from rehab with Afib/Aflutter that was difficult to rate control. She was initially admitted to [**Hospital Unit Name 153**] [**8-17**] for resp distress thought [**2-10**] COPD failure and CHF, and eventually transferred to CCU for tailored CHF therapy. Major issues during this extended hospitalization included rate control of a fib s/p failed cardioversion, amiodarone (increased LFTs) and procainamide trials without effect, failed rate control as dilt caused hypotension, as well as placement of a trach after development of pneumonia, contained bowel perforation, maroon-colored stools and GI bleed, and management of volume overload. She was subsequently discharged to [**Hospital **] hospital. Discharged on Dig 0.25 mcg qd as only nodal blocking [**Doctor Last Name 360**]. . She now returns from NESH after noted to have HR in 140s (flutter), given extra dose of 12.5 mg PO Lopressor, and subsequently having a [**3-11**] second pause at rehab. . In ED, was noted to have ABG with hypoxia/hypercarbia, CXR consistent with mild CHF though improved from prior with elevated BUN/Cr and seeming dry on exam. Also with leukocytosis, left shift, bandemia; lactate wnl. Troponin T elevated at 0.17 from first set. In ED, NGT and PIV placed, received 500cc NS, Levaquin 500mg, Vanc 1gm, Tylenol 650mg. Evaluated by Cards fellow, felt to be likely infected with early ARF. Cards fellow recommended decreasing digoxin to 0.125, checking dig level, considering cautious hydration, normalizing electrolytes, avoiding lopressor with consideration of pindolol as an alternative, holding anticoagulation, and consulting EP for possible AVN ablation +PPM. Past Medical History: PMH: Afib/Aflutter CHF (Echo [**2168-8-18**]: LV EF < 20%. Global hypokinesis. 3+ MR, 2+ TR HTN COPD/asthma ?renal insufficiency (bl Cr 1.1), but 0.5 at OSH remote hx of seizure h/o GI Bleed . Social History: . SH: lives at [**Hospital1 700**]; daughter is HCP former [**Name2 (NI) 1818**], no EtOH/drug use Family History: noncontributory; no known hx of heart/lung dz Physical Exam: PE Vitals: HR 99 BP 111/40(57) Vent: TV 500 RR 18 (set at 15bpm) Sat 100% on 70% FiO2 PEEP 8 Gen: elderly frail caucasian woman lying in bed sleeping in no acute distress, breathing easily via trach, easily arousable HEENT: PERRL, EOMI, dry MM (mouth breather) Neck: trach site clean with no erythema Chest: anterior exam CTA bilaterally, no rales appreciated CVS: decreased heart sounds, irreg irreg, no m/g/r appreciated Abd: obese, soft, nt, nd, guiaic negative per ED Extrem: thin with decreased muscle mass, no edema, R forearm with ecchymosis, mildly tender to palpation Neuro: somnolent but arousable, communicating by writing on pad, moving all extremities with no apparent deficits Pertinent Results: [**2168-10-20**] 04:46PM CK(CPK)-19* [**2168-10-20**] 04:46PM CK-MB-NotDone cTropnT-0.17* [**2168-10-20**] 04:46PM PTT-66.2* [**2168-10-20**] 01:08PM TYPE-ART PO2-236* PCO2-64* PH-7.34* TOTAL CO2-36* BASE XS-6 [**2168-10-20**] 12:12PM URINE HOURS-RANDOM UREA N-427 CREAT-78 SODIUM-25 [**2168-10-20**] 09:04AM CK(CPK)-18* [**2168-10-20**] 09:04AM CK-MB-NotDone cTropnT-0.21* [**2168-10-20**] 07:25AM WBC-17.7* RBC-3.71* HGB-11.6* HCT-34.7* MCV-94 MCH-31.3 MCHC-33.5 RDW-15.9* [**2168-10-20**] 07:25AM PT-13.1 PTT-24.3 INR(PT)-1.1 [**2168-10-20**] 01:10AM GLUCOSE-97 UREA N-71* CREAT-0.8 SODIUM-136 POTASSIUM-5.1 CHLORIDE-94* TOTAL CO2-34* ANION GAP-13 [**2168-10-20**] 01:10AM CK-MB-4 cTropnT-0.17* [**2168-10-20**] 01:10AM DIGOXIN-1.4 [**2168-10-20**] 01:10AM WBC-20.0*# RBC-3.79* HGB-11.8* HCT-35.4* MCV-94 MCH-31.2 MCHC-33.4 RDW-15.9* [**2168-10-20**] 01:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2168-10-20**] 01:10AM URINE RBC-[**11-27**]* WBC-[**3-12**] BACTERIA-FEW YEAST-NONE EPI-0-2 TRANS EPI-0-2 [**2168-10-20**] 01:06AM LACTATE-1.6 . Admit CXR: The heart is upper limits of normal in size and the mediastinal contours appear unchanged. There is interval improvement in pulmonary vascular congestion with probable mild persistent congestive heart failure. A focal opacity is seen at the right base, possibly representing atelectasis. There is a small right pleural effusion. No pneumothorax. . Admit EKG: aflutter at 150bpm, nl axis, QRS wnl, no q waves, scooped out ST vs ST depressions in V1-6, II, III, aVF, STE in avL, avR . Echo [**2168-8-18**]: LV EF < 20%. Global hypokinesis. mild LVH. mild LAE. TR gradient 25-36%. severe RV free wall hypokinesis Valves: 3+ MR, 2+ TR, No AR. . Brief Hospital Course: A/P: 74 y/o female with CHF (EF <20%), h/o afib/flutter s/p failed cardioversion, COPD, HTN, renal insufficiency, h/o GIB, now presenting with atrial flutter/tachycardia to 150s and bradycardia with pauses of as long as [**3-11**] secs. Unsuccessful ablation therapy. Now s/p permanent dual chamber pacer placement. . 1. Tachy-brady syndrome: The pt has past history of atrial flutter/fib. The pt may have gone into aflutter this time secondary to infection vs. hypoxia vs. prerenal failure. On admission the pt's digoxin level was decreased to 0.125 per EP and she was maintained on this level throughout her admission. On [**2168-10-21**] EP evaluated the pt for flutter ablation. EP evaluated the pt for atrial ablation which was performed. However, on [**10-23**] the pt had recurrent episodes of tachy/brady with HRs as hisg as the 150s and as low as the 30s. The pt was asx during periods of tachy, lightheaded/pre-syncopal during brady, That evening a temporary pacer was placed after gaining consent from the pt's HCP. The following day a permanent dual chamber pacemaker was placed. EP has followed the pacer since placement. The pt's HR has been well-controlled since placement and the pacer was adequate upon EP interrogation. 2. CV #? Ischemia: On admission the pt experienced ST depressions in inferior leads and V2-V6. However, these changes were felt to be [**2-10**] to dig effectc. The pt's troponin was initially slightly elevated. However, the pt's cardiac enzymes contined to cycle down. #Pump: The pt has a h/o of significant CHF (EF 20% by echo). Throughout admission, the pt remained euvolemic-to-hypovolemic on exam. She was diuresed gently as needed. She was started and maintained on lisinopril and hydralazine. #Rhythm: as above. . 3. Leukocytosis/fever: Following permanent pacer placement, the pt spiked a temp to 103 and had elevated WBCs. Pan cxs were sent and her right SC cordis was removed. The pt demonstrated no evidence of pna on exam or cxr. Blood cxs were all negative, therefore infected pacer lines were felt to be unlikely. The pt was initially treated with keflex. However, her Ucx grew out enterococcus. It was also postulated that given her longterm NG, the pt possibly has sinusitis. The pt was started on a 7 day course of augmentin for UTI and possible sinusitis. After the pt's initial spike, her temp has trended down and on the day of d/c was 98 off all antipyretics. . 4. Resp Failure s/p trach: The pt has been at [**Hospital1 **] long term for ventilator maintenance and possible weaning. She was a h/o COPD. During her stay, potential vent weaning was deferred until til discharge. She was continued on albuterol-ipratropium nebs. She was given supplemental oxygen as required. . 5. ARF/CRI: Upon presentation the pt had an elevated BUN and Cr. She was pre-renal by FENA (0.21%). Her renal function resolved shortly after admission. 6. Foot pain--The pt had focal 1st to 2nd MTP joint pain. This was ? [**2-10**] to plantar nerve inflammation vs. musculoskeletal contractures vs. fx. PT has followed and has recommended longterm rehab and evaluation to clarify the etiology. 7. PPX: The pt was maintained on SQ Heparin, PPI and bowel regimen. . 8. FEN: The pt was maintained on TFs+hydration started via NGT. 9. FULL CODE 10. Communication--Son [**Name (NI) **] 11. [**Name (NI) 13694**] pt is to be d/c'd back to [**Hospital1 **] for further vent management. Medications on Admission: Allergies: Lorazepam/MSO4 . Meds on Admission: Digoxin 0.25mg qod, 0.125mg qod Lopressor 12.5 mg po bid Alprazolam 0.125mg prn Colchicine 0.6mg qd Nexium 20mg qd Flovent 2 puffs [**Hospital1 **] Lasix 60mg qd Hydral 25mg q8h RISS Discharge Medications: 1. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for Reconstitution Sig: Five Hundred (500) mg PO Q8H (every 8 hours) for 7 days. Disp:*21 doses* Refills:*0* 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. 4. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 5. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 6. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-10**] Puffs Inhalation Q6H (every 6 hours) as needed. 8. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 11. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 14. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO BID (2 times a day). 15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day): Give while on bedrest or not mobile. 18. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed. 19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Tachy/brady syndrome s/p pacemaker placement Sinusitis Discharge Condition: Stable. Requires chronic ventilator, functioning tracheostomy in place. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 L per day Followup Instructions: Please keep the following appointments: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2168-11-1**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 4022**] Date/Time:[**2168-11-28**] 2:00

[ "401.9", "427.31", "584.9", "473.9", "V46.11", "585.9", "424.0", "425.4", "397.0", "428.22", "719.47", "599.0", "V44.0", "493.20", "780.39", "427.81", "518.83", "428.0", "427.32" ]

icd9cm

[ [ [] ] ]

[ "37.78", "37.34", "37.72", "96.72", "37.83" ]

icd9pcs

[ [ [] ] ]

10807, 10879

5296, 8721

328, 439

10978, 11053

3512, 5273

11234, 11541

2733, 2780

9002, 10784

10900, 10957

8747, 8780

11077, 11211

2795, 3493

265, 290

467, 2381

8794, 8979

2403, 2599

2616, 2717

17,767

171,865

50127+50128+59226

Discharge summary

report+report+addendum

Admission Date: [**2115-4-26**] Discharge Date: Date of Birth: [**2069-2-27**] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 46 year-old female with a long stay in the MICU. On [**4-26**] she was admitted for lightheadedness, pancreatitis flare. The etiology of her pancreatitis is ethanol use. On [**5-7**] she ended up being transferred to the MICU in respiratory distress. She was intubated and the question at the time was congestive heart failure versus infection/ARDS. She ruled out for myocardial infarction. She has a PA cath, bronch, antibiotics and steroids at the time. The bronch showed erythematous airways and the rheumatology team saw her and stated this picture was not necessarily consistent with her history of lupus for which she has nephritis, vasculitis and cerebritis. On [**5-14**] she began to have a deteriorization of her mental status. Her head MRI was negative. Her EEG showed encephalopathy. Her creatinine at that time was beginning to rise and by [**5-22**] her creatinine had gone from 1.8 to 3.6. _____________________ were seen. She was given bicarb. She also at that time was reintubated for respiratory failure and acidosis. On [**5-24**] she was extubated, but then became striderous. On [**5-25**] she was reintubated. ENT saw her and they found bilateral vocal cord paralysis. She had a trach placed and at the same time aggressive diuresis was in progress. On [**5-26**] psych saw her for her mental status changes and asked that benzos be avoided. An NG tube was placed as a bridge to a PEG tube. She was called out to the floor with her creatinine still rising and the question at that time was AIN versus ATN. She had a short period where she had urine eosinophils, but otherwise no other clear causes of AIN. The renal team has been following her. On [**5-27**] she was called out to the floor and this discharge up date is on [**5-31**]. PAST MEDICAL HISTORY: Lupus with nephritis, vasculitis, cerebritis, alcohol hep C, cirrhosis, PUD, hypertension, pancreatitis, liver mass with negative biopsy, splenectomy, status post motor vehicle accident, multiple transient ischemic attack, gout, C-diff and question congestive heart failure. ALLERGIES: None. MEDICATIONS: By NG tube, Prednisone 5 q day, Thiamine 100 q.d., Lopressor 100 b.i.d., heparin subQ, folate one q day, Renagel three t.i.d., Hydralazine 20 q.i.d., Lasix with 120 IV b.i.d., and then change. Albuterol two puffs q 2 to 6 hours prn. Atrovent MDI two puffs q 6 hours, Tylenol, Epogen 3000 sub units q Monday, Wednesday, Friday. Protonix 40 q.d., Lactulose 50 and to 30 as needed, Nystatin b.i.d., Norvasc 10 q.d., Reglan 5 q.i.d., Bicitra 30 b.i.d., _________ tube feeds, Sentinel patch, morphine one to two IV q 4 hours, Haldol 1 mg po IV q 4 hours prn. PHYSICAL EXAMINATION: She was laying in bed in no apparent distress complaining of thirst. Her extraocular muscles are intact. Question proptosis. Pupils are equal, round and reactive to light. Mucous membranes are moist. Poor dentition. Trach in place. Heart regular rate and rhythm. No murmurs, rubs or gallops. Lungs expiratory wheezes, question upper airway. Abdomen obese, nontender, nondistended. Soft bowel sounds. Extremities 2+ left lower extremity edema, right lower extremity edema, 2+ upper extremity edema, left greater then right. Neurological alert and oriented times three. LABORATORY: On admission to the floor, white count 18, hematocrit 24.8. She was transfused 2 units. Platelets 307, sodium 143, potassium 3.6, chloride 103, bicarb 23, BUN 89, creatinine 4.1, which was just increased from 3.8, which again was 1.8 a week ago, glucose 111, PTT 30.2, INR 1.2, urinalysis trace protein, 13 white cells, few yeast, ALT 22 plus 181, T bili 0.6, albumin 2.3, calcium, mag, phosphate .3, 2.3, 7.5. HOSPITAL COURSE: Pulmonary, we kept her trach in place. We weaned her O2. She is currently on 35% cool nebulizer sating 93 to 95%. We continued her Albuterol Atrovent and Prednisone. Renal, her creatinine has continued to rise. We continued aggressive diuresis. She did not respond to 160 IV b.i.d. of Lasix. She was put on a Lasix drip at 10 an hour for 24 hours and she responded well to this Lasix drip and the Lasix drip was discontinued on [**2115-5-29**], because she at noon had already put out 2 liters and since then her Is and Os have been consistently negative even off diuretics. She was also placed in Diuril with a Lasix drip, which was recently discontinued. Her renal picture is confusing, but the possible etiologies are AIN, although there is no clear cause to her AIN. In this situation, the picture is not classic for a lupus nephritis exacerbation. ATN status post protracted MICU stay is probably the most likely etiology of her renal failure especially, because she is self diuresing at this time off diuretics. She might be in the diuresis phase of ATN. Other less likely possibilities include Hydralazine, hepatorenal syndrome, but these are not high on our differential. Question of a biopsy was brought up, but it was deemed that it would not be very useful, because we would probably see changes of lupus and would not know whether they are chronic or acute. There was also a thought that maybe her fungal urinary tract infection, which has been treated with Diflucan for may have caused AIN, but this is also less likely on our list. Her creatinine has stabilized around 4 for three days and we will continue to follow it. ID, she is no longer on antibiotics. CV, she is on Lopressor 100 b.i.d., Hydralazine and Norvasc 10 q.d. She has had poor blood pressure control and we will increase her Lopressor to 100 t.i.d. and she is on Hydralazine 60 q.i.d. Psych, we have avoided benzos for her, otherwise she has been with no psych issues. Heme, we transfused her and her crit has been stable since. We continued Epogen three times a week. She still has a central line. On [**5-27**] it was day sixteen. GI, she is on tube feeds. Her NG tube fell out and at one point it was replaced and placement was confirmed by chest x-ray. Tube feeds were restarted. Surgery has seen her with question of whether she needs a PEG or not and they have stated that they are uneasy about placing a PEG in a woman with such ascites, because of the possibility of infecting her acidic fluid/creating a leak of ascites through her PEG site and the speech and swallow team saw her on [**5-28**] and they saw no progress in her ability to swallow since three days prior, but we will reconsult them on Monday to see if they have new input. We may consider an ultrasound also to see the extent of acidic fluid now that she has been diuresed to see if there is less ascites and if surgery would be more comfortable placing a PEG at this time. FEN, she was on Nepro tube feeds. DISPOSITION: She is full code and she has been screened for rehab when her medical issues are clear. Medications on discharge and her diagnoses on discharge will be updated when she does leave. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22604**], M.D. [**MD Number(1) 22605**] Dictated By:[**Name8 (MD) 6340**] MEDQUIST36 D: [**2115-5-31**] 09:43 T: [**2115-5-31**] 11:18 JOB#: [**Job Number 102909**] Admission Date: [**2115-4-26**] Discharge Date: [**2115-6-28**] Date of Birth: [**2069-2-27**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old female with an extensive past medical history who initially presented to [**Hospital6 256**] Emergency Department on [**2115-4-25**], with complaints of chest pain, palpitations, light-headedness, and a clinical picture which subsequently had a prolonged and complicated hospital course including three transfers to the MICU. PAST MEDICAL HISTORY: SLE with nephritis, vasculitis, and cerebritis. Hepatitis C. Peptic ulcer disease. Hypertension. Gout. Transient ischemic attacks. Urinary tract infections. Liver mass which was benign on biopsy. motor vehicle accident. Alcohol abuse. Status post L5, S1 and S2 diskectomy. History of C-diff colitis. Pancreatitis. Congestive heart failure. Chronic renal insufficiency with a baseline creatinine of 1.4-1.9. History of spontaneous bacterial peritonitis. SOCIAL HISTORY: Positive for tobacco with a 30 pack-year history. Alcohol use is significant for the patient describing drinking six brandies per day for a month. MEDICATIONS ON ADMISSION: Prednisone 5 mg p.o. q.d., Prilosec, Lasix 40 mg p.o. q.d., Zoloft, Norvasc, Serax. HOSPITAL COURSE: 1. Pulmonary: The patient was intubated and admitted to the MICU on [**5-7**] for respiratory distress thought to be secondary to multilobar aspiration pneumonitis which had become pneumonia or possibly ARDS. A Swan-Ganz catheter was placed which was not consistent with congestive heart failure. The patient was slow to wean from the ventilator but was eventually extubated. The patient was reintubated on [**5-21**] for a metabolic acidosis secondary to acute renal failure with poor ventilations and fatigue. The patient was subsequently extubated on [**5-24**]. On [**5-25**], the patient was noted to be having stridor and was reintubated. ENT was called to evaluate the patient, and they found that she had bilateral vocal cord paralysis, and a tracheostomy was placed on [**5-25**]. The patient was subsequently followed by ENT who advised getting smaller and smaller tracheostomy tubes with the intent for the patient to learn to breath around the tube and through her upper airway. The patient was admitted for the third time to the MICU after an acute episode of desaturation, hypotension, and chest pain which occurred on hemodialysis. At this point, she had oxygen saturations in the 70s on a trach-mask. Systolic blood pressures were in the 80s, but there were no electrocardiogram changes. All of these symptoms resolved after deep suctioning and fluid repletion. The patient however continued to experience shortness of breath and was transferred to the MICU. The patient spent two days on the ventilator with pressure support. On [**6-23**] the patient was placed on a trial of trach-masks which she continued to tolerate quite well through the rest of her admission; however, she occasionally needed to be placed back on pressure support over night due to fatigue and/or anxiety. 2. Renal: The patient has a history of chronic renal insufficiency with a baseline creatinine of 1.4-1.9 prior to admission. During this admission, she developed an acute on chronic renal insufficiency from [**5-13**] to [**5-17**] with a creatinine rising to 3.3. Renal consult was called who suspected this change was due to ATN related to contrast or possibly AIN secondary to Ceftazidime, Hydralazine, or possibly Zantac. The Renal dysfunction has not resolved during the admission. The patient continues to require hemodialysis three days a week. She had a Port-A-Cath placed on [**6-26**] for dialysis access. 3. Neurological: The patient was initially placed on Benzodiazepines for her history of alcohol abuse, as well as Haldol which was given p.r.n. She subsequently had a prolonged evaluation for mental status changes including a negative head CT and negative lumbar puncture. MRI of the head showed an old infarct but no evidence of SLE cerebritis. She was seen by Psychiatry who recommended avoiding Benzodiazepines and Morphine if possible. This was done through the rest of the admission, and the patient's mental status slowly returned to [**Location 213**]. 4. Infectious disease: The patient was initially placed on Levaquin for a urinary tract infection, then on Levaquin and Flagyl for broader coverage. Subsequently the patient was placed on Flagyl, Ceftriaxone, and Vancomycin for a question of aspiration pneumonia. The pneumonia did improve on the multiple antibiotics. The patient's subsequently developed an elevated white count which led to blood cultures being drawn. One culture was positive for Vancomycin resistant enterococcus drawn through a triple lumen catheter. This was determined to be a contaminant, and the patient was not treated with any further antibiotics. 5. Fluids, electrolytes, and nutrition: The patient was found to be an increased risk for aspiration by a swallow study on [**6-20**] which showed a very dysfunctional swallow. At this point, the patient was started on total parenteral nutrition awaiting enteral access. The patient was reevaluated at the bedside on [**6-26**], and the swallow was determined to continue to be dysfunctional. Gastroenterology Services was contact[**Name (NI) **] regarding getting a PEG tube placed, but this was determined not to be possible due to her level of ascites (ascites would cause the PEG opening to not heal properly). Therefore, a nasopostpyeloric tube was placed by Interventional Radiology, and tube feeds were instituted per Nutrition Service recommendations. 6. Speech: Early evaluation by ENT showed the patient to have vocal cords paralyzed bilaterally; however, by the few days prior to discharge, the patient was tried on a Passe-Muir valve, and the patient was able to phonate. 7. Rheumatology: The patient was continued on a low-dose of Solu-Medrol while she was unable to take p.o. medications for her SLE. 8. Cardiovascular: The patient has a history of difficult to control hypertension. Her blood pressure was controlled with Hydralazine, as well as intermittently with Lopressor during her hospital course. These medications will be changed to p.o. medications now that the patient has enteral access. PHYSICAL EXAMINATION ON DISCHARGE: Vitals signs: T-max of 98.7??????, current 97??????, pulse 105-116, respirations 15-28, blood pressure 103-176/59-111, oxygen saturation between 80 and 99% on trach-mask of 35%. General: She was sleeping. She was arousable. She responded to questions appropriately with gestures and mouthing words. HEENT: Anicteric sclerae. Moist mucous membranes. Nasopostpyeloric tube in place. Neck: Supple. Cardiovascular: Tachycardia with a 3 out of 6 systolic murmur heard throughout the precordium. Pulmonary: Lungs clear to auscultation bilaterally. Abdomen: Soft and nontender but with decreased hypoactive bowel sounds. Extremities: Warm. There were 2+ dorsalis pedis pulses bilaterally. No edema. CONDITION ON DISCHARGE: On [**2115-6-28**], the patient was medically stable for discharge to a facility from which she can receive further care. She will continue to require hemodialysis, as well as possibly respiratory support due to continued secretions requiring suction through tracheostomy. DISCHARGE DIAGNOSIS: 1. Resolved respiratory failure status post tracheostomy. 2. Renal failure requiring hemodialysis. 3. Dysfunctional swallow requiring tube feeding. 4. Hypertension. 5. Systemic lupus erythematosus. 6. Hepatitis C. 7. Depression. 8. History of abuse. 9. Pancreatitis, resolved. DR.[**First Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 11-575 Dictated By:[**Last Name (NamePattern1) 15470**] MEDQUIST36 D: [**2115-6-28**] 11:09 T: [**2115-6-28**] 12:19 JOB#: [**Job Number 104633**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 16982**] Admission Date: [**2115-4-26**] Discharge Date: Date of Birth: [**2069-2-27**] Sex: F Service: MICU ADDENDUM: The patient remained in hospital three more days, awaiting bed availability at [**Hospital3 **]. The patient received one day of Ceptaz and ciprofloxacin this time for gram negative rods on gram stain. However, upon assessing the overall clinical picture, these organisms were determined to be colonization secondary to a tracheostomy and antibiotics were discontinued. There were no other changes in management during this time. On [**2115-7-4**], the patient was medically stable for discharge to [**Hospital3 **]. DR.[**First Name (STitle) 304**],[**First Name3 (LF) **] W. 11-575 Dictated By:[**Name8 (MD) 16983**] MEDQUIST36 D: [**2115-7-2**] 21:11 T: [**2115-7-2**] 23:22 JOB#: [**Job Number 16984**]

[ "571.2", "582.81", "577.0", "507.0", "518.81", "070.54", "584.5", "710.0", "478.34" ]

icd9cm

[ [ [] ] ]

[ "89.64", "31.1", "96.04", "96.72", "99.15", "96.71", "39.95", "96.6" ]

icd9pcs

[ [ [] ] ]

14791, 16351

8549, 8634

8652, 13743

2866, 3874

13758, 14468

7511, 7867

7890, 8356

8373, 8522

14493, 14770

32,286

192,715

51179

Discharge summary

report

Admission Date: [**2177-10-24**] Discharge Date: [**2177-11-3**] Date of Birth: [**2105-9-27**] Sex: M Service: MEDICINE Allergies: Sulfonamides / A.C.E Inhibitors / Angiotensin Receptor Antagonist / Keflex Attending:[**First Name3 (LF) 2145**] Chief Complaint: agitation Major Surgical or Invasive Procedure: Right thoracentesis History of Present Illness: 72 M with myelofibrosis with hepatic infiltration of extramedullary hematopoiesis, recurrent cellulitis, PVD; sent from nursing facility today with abnormal behavior and agitiation. Per family, patient has had decreased energy and more fatigue, ??????not himself?????? in past couple days. No specific localizing symptoms or complaints, though did note mild nonproductive cough and c/o shortness of breath last night; also with intermittent c/o RUQ pain today. Per [**Hospital1 1501**] notes, patient today alert but confused, apparently threw a diaper full of stool into the hallway. Also resistant to ADL care and taking meds. Temp mildly elevated to 100 axillary at [**Hospital1 1501**] today. Noted to have worsening leukocytosis on routine labs (gets frequent lab checks due to myelofibrosis history), 23K on [**10-21**]. Visited PCP [**Name Initial (PRE) 1262**]. Discussed starting interferon alpha for myelofibrosis with hepatic infiltration; this has not yet been started. . Patient seeing neuropsych providers for ongoing fluctuating mental status; antipsychotic meds being titrated. Unclear if this is dementia vs. ??????subacute delirium?????? of unknown cause. At heme visit on [**10-20**], noted to be A/O x3 but per hematologist, during visit intermittently confused and thinking that he was at his office, working. . In the ED, T98.3 (spike to 101.1), HR 89, BP 131/89, R22, 97% on RA. Never O2 requiring. CXR with RLL pneumonia. Abdominal ultrasound and abdominal CT done given pain. 1.5 L given, also received vanco and zosyn. Received morphine 4, haldol 2, olanzapine 10, Ativan 1 for agitation and premed prior to CT abdomen. Past Medical History: # myelofibrosis: JAK2 mutation (V617F) positive myeloproliferative neoplasm, (MPN)followed since [**2176-6-2**] # Portal hypertension, no clear etiology, ?related to hepatic infiltration of extramedullary hematopoiesis. # CKD, stage IV - baseline around 2.0 # PAF, now [**Year (4 digits) 4448**] dependence after AV nodal ablation (Currently with [**Company 1543**] Thera single chamber [**Company 4448**] programmed in the VVIR mode at 75 beats per minute). # sCHF EF 45% on [**4-10**] echo # recurrent LE cellulitis, with h/o MRSA # venous stasis ulcers # HTN # hyperlipidemia # h/o recurrent c diff colitis # hypothyroidism # diverticulitis # BPH # PVD # h/o sarcoid per records # s/p penile prosthesis # gastritis # insomnia # hypogonadism s/p hormonal treatment # pancreatitis c/b pseudocyst # diverticulitis s/p subtotal colectomy ([**2164**] per pt) # s/p cholecystectomy # s/p appendectomy Social History: Home: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] nursing home Occupation: retired trial lawyer [**Name (NI) 1139**]: smoked for 40yrs, quit in [**2151**] EtOH: previously heavy, quit in [**2151**] Drugs: denies Family History: Father died of MI at 56. Brother in late 60s with CAD, Parkinson's, and renal failure. Mother died of aortic stenosis in her late 80s Extensive family h/o alcohol abuse Physical Exam: Admission: General Appearance: Well nourished, No acute distress, lethargic but easily arousable. Somewhat noncooperative with exam. Eyes / Conjunctiva: PERRL, NC/AT, sclera anicteric Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal), ([**1-8**] SM at LUSB. Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Percussion: No(t) Resonant : ), (Breath Sounds: Crackles : R mid lung fields and base, L base, No(t) Wheezes : , Diminished: and poor effort) Abdominal: Soft, Bowel sounds present, Distended, No(t) Tender: , Obese, + HSM Extremities: Right: 1+, Left: 1+ edema. Bilat legs with healing ulcers scattered. No drainage, + surrounding erythema. Some with central necrotic eschars. Warm to touch. Skin: Not assessed Neurologic: Oriented to person, not to place or time (not responding to these questions). Moving all extremities spontaneously. . Discharge General Appearance: afebrile, well nourished, No acute distress, awake, alert,cooperative Eyes / Conjunctiva: PERRL, NC/AT, sclera anicteric Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal), ([**1-8**] SM at LUSB. Respiratory / Chest: mildly diminished in right lung base, altherwise clear Abdominal: Soft, Bowel sounds present, ND/NT, + HSM Extremities: Right: 1+, Left: trace edema. Bilat legs with healing ulcers scattered. No drainage, + surrounding erythema. Some with central necrotic eschars. Warm to touch. Neurologic: Oriented to person, place and time. Answers questions appropriately 80% of the time, but does demonstrate mild confusion at night Pertinent Results: CBC [**2177-10-24**] 09:47AM [**Month/Day/Year 3143**] WBC-38.9*# RBC-3.74* Hgb-8.9* Hct-30.3* MCV-81* MCH-23.7* MCHC-29.3* RDW-22.5* Plt Ct-482* [**2177-10-25**] 03:47AM [**Month/Day/Year 3143**] WBC-45.9* RBC-3.39* Hgb-8.2* Hct-27.5* MCV-81* MCH-24.3* MCHC-30.0* RDW-22.5* Plt Ct-427 [**2177-10-26**] 04:02PM [**Month/Day/Year 3143**] WBC-62.9* RBC-3.41* Hgb-8.4* Hct-30.6* MCV-90 MCH-24.6* MCHC-27.5* RDW-22.2* Plt Ct-482* [**2177-10-28**] 05:50AM [**Month/Day/Year 3143**] WBC-36.7* RBC-3.63* Hgb-8.5* Hct-30.9* MCV-85 MCH-23.5* MCHC-27.7* RDW-22.4* Plt Ct-467* [**2177-10-31**] 07:20AM [**Month/Day/Year 3143**] WBC-21.9* RBC-4.00* Hgb-9.3* Hct-34.7* MCV-87 MCH-23.2* MCHC-26.7* RDW-20.8* Plt Ct-560* [**2177-11-2**] 06:40AM [**Month/Day/Year 3143**] WBC-16.1* RBC-3.76* Hgb-8.8* Hct-31.8* MCV-85 MCH-23.4* MCHC-27.7* RDW-22.2* Plt Ct-495* [**2177-11-3**] 06:50AM [**Month/Day/Year 3143**] WBC-13.8* RBC-3.94* Hgb-9.5* Hct-33.3* MCV-85 MCH-24.1* MCHC-28.6* RDW-21.1* Plt Ct-497* [**2177-10-24**] 09:47AM [**Month/Day/Year 3143**] Neuts-94* Bands-1 Lymphs-3* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1* [**2177-10-27**] 02:05AM [**Month/Day/Year 3143**] Neuts-96.6* Lymphs-2.4* Monos-0.9* Eos-0 Baso-0.1 [**2177-11-3**] 06:50AM [**Month/Day/Year 3143**] Neuts-86.2* Bands-0 Lymphs-9.8* Monos-1.6* Eos-1.5 . Coags [**2177-10-24**] 09:47AM [**Month/Day/Year 3143**] PT-17.9* PTT-30.1 INR(PT)-1.6* [**2177-10-25**] 03:47AM [**Month/Day/Year 3143**] PT-20.9* PTT-35.2* INR(PT)-2.0* [**2177-10-27**] 02:05AM [**Month/Day/Year 3143**] PT-19.0* PTT-30.2 INR(PT)-1.8* [**2177-11-1**] 06:55AM [**Month/Day/Year 3143**] PT-18.1* PTT-33.7 INR(PT)-1.7* [**2177-11-3**] 06:50AM [**Month/Day/Year 3143**] PT-16.9* PTT-34.3 INR(PT)-1.5* [**2177-11-3**] 06:50AM [**Month/Day/Year 3143**] Plt Smr-HIGH Plt Ct-497* [**2177-10-24**] 09:47AM [**Month/Day/Year 3143**] Ret Man-5.3* . Chem 7 [**2177-10-24**] 09:47AM [**Month/Day/Year 3143**] Glucose-91 UreaN-73* Creat-1.9* Na-133 K-5.2* Cl-98 HCO3-21* AnGap-19 [**2177-10-25**] 03:38PM [**Month/Day/Year 3143**] Glucose-127* UreaN-85* Creat-2.5* Na-136 K-4.9 Cl-105 HCO3-15* AnGap-21* [**2177-10-26**] 04:02PM [**Month/Day/Year 3143**] Glucose-161* UreaN-93* Creat-2.5* Na-136 K-5.8* Cl-109* HCO3-8* AnGap-25* [**2177-10-28**] 05:50AM [**Month/Day/Year 3143**] Glucose-62* UreaN-91* Creat-2.2* Na-149* K-4.0 Cl-113* HCO3-20* AnGap-20 [**2177-10-31**] 05:00AM [**Month/Day/Year 3143**] Glucose-81 UreaN-51* Creat-1.7* Na-146* K-4.3 Cl-116* HCO3-18* AnGap-16 [**2177-11-1**] 06:55AM [**Month/Day/Year 3143**] Glucose-72 UreaN-35* Creat-1.4* Na-144 K-4.3 Cl-114* HCO3-22 AnGap-12 [**2177-11-2**] 06:40AM [**Month/Day/Year 3143**] Glucose-71 UreaN-27* Creat-1.2 Na-140 K-4.1 Cl-113* HCO3-19* AnGap-12 [**2177-11-3**] 06:50AM [**Month/Day/Year 3143**] Glucose-61* UreaN-22* Creat-1.2 Na-140 K-4.3 Cl-108 HCO3-22 AnGap-14 . LFT's [**2177-10-24**] 09:47AM [**Month/Day/Year 3143**] ALT-39 AST-60* LD(LDH)-427* CK(CPK)-76 AlkPhos-216* TotBili-2.5* DirBili-1.5* IndBili-1.0 [**2177-10-26**] 03:28AM [**Month/Day/Year 3143**] ALT-38 AST-66* LD(LDH)-457* AlkPhos-185* TotBili-1.7* [**2177-10-28**] 05:50AM [**Month/Day/Year 3143**] ALT-45* AST-69* LD(LDH)-387* AlkPhos-158* TotBili-1.3 [**2177-11-3**] 06:50AM [**Month/Day/Year 3143**] ALT-42* AST-62* AlkPhos-217* TotBili-1.0 [**2177-10-24**] 09:47AM [**Month/Day/Year 3143**] Lipase-23 . MISC [**2177-10-24**] 09:47AM [**Month/Day/Year 3143**] CK-MB-NotDone [**2177-10-24**] 09:47AM [**Month/Day/Year 3143**] cTropnT-0.04* [**2177-10-25**] 03:47AM [**Month/Day/Year 3143**] CK-MB-3 cTropnT-0.05* proBNP-[**Numeric Identifier 32331**]* [**2177-10-25**] 10:09PM [**Month/Day/Year 3143**] CK-MB-3 cTropnT-0.05* [**2177-10-24**] 09:47AM [**Month/Day/Year 3143**] Albumin-4.1 Calcium-9.4 Phos-4.4 Mg-2.5 [**2177-10-26**] 06:20PM [**Month/Day/Year 3143**] Calcium-8.7 Phos-6.2* Mg-3.0* [**2177-10-31**] 05:40PM [**Month/Day/Year 3143**] TotProt-5.4* Albumin-3.3* Globuln-2.1 [**2177-11-3**] 06:50AM [**Month/Day/Year 3143**] Albumin-3.3* Calcium-8.5 Phos-3.1 Mg-2.2 [**2177-10-27**] 02:05AM [**Month/Day/Year 3143**] Vanco-10.5 [**2177-10-24**] 09:47AM [**Month/Day/Year 3143**] Free T4-1.1 [**2177-10-24**] 09:47AM [**Month/Day/Year 3143**] Ammonia-26 [**2177-10-24**] 09:47AM [**Month/Day/Year 3143**] Hapto-162 [**2177-10-24**] 09:52AM [**Month/Day/Year 3143**] Lactate-1.8 [**2177-10-25**] 05:26AM [**Month/Day/Year 3143**] Lactate-2.1* [**2177-10-25**] 10:30PM [**Month/Day/Year 3143**] Lactate-2.0 . Pleural Fluid: WBC RBC Polys Lymphs Monos Eos Meso Macro 369* 148* 14* 28* 0 1* 9* 48* TotProt Glucose Creat LD(LDH) Amylase Albumin 2.3 111 1.5 244 32 1.5 pH 7.451 . Cultures UA neg [**Month/Day/Year **] Cx: neg Rapid Viral Screen: neg [**Month/Day/Year **] Cx: neg . Imaging Studies: . ECG [**2177-10-24**]: Ventricularly paced rhythm. Underlying rhythm is atrial fibrillation. Compared to the previous tracing of [**2177-7-11**] there is no significant diagnostic change. . CXR [**2177-10-24**]: IMPRESSION: New opacity within the right lung base, worrisome for pneumonia. . [**2177-10-24**] RUQ US: IMPRESSION: Patient status post cholecystectomy. Mild ascites and pleural effusion. . [**2177-10-24**] CT-HEAD: IMPRESSION: No acute intracranial process. . [**2177-10-24**] CT-ABD/PEL: IMPRESSION: 1. Limited study due to lack of oral and IV contrast demonstrating interval increase in size of right- sided pleural effusion. 2. Ascites. 3. Splenomegaly with extensive perisplenic, perigastric, and retro-peritoneum collateral circulation. 4. No evidence of bowel obstruction or pneumatosis. No free air. 5. Unchanged urinary bladder stone. . CXR [**2177-10-25**]: IMPRESSION: Right effusion. Right lower lobe opacifications persist consistent with pneumonia. . CXR [**2177-10-27**] : IMPRESSION: No significant change. . RENAL US [**2177-10-27**] : IMPRESSION: 1. No hydronephrosis. 2. Right pleural effusion and ascites. 3. Splenomegaly. . CXR [**2177-10-31**]: Comparison is made to [**10-25**] and 23, [**2176**] exams. Given differences in semi-upright to upright technique, the moderate right pleural effusion with adjacent opacity reflecting either underlying pneumonia or compression atelectasis is likely not significantly changed from [**10-26**] but has clearly progressed from [**10-24**]. More oblong density projecting over the right hemithorax is consistent with worsened lower lobe and likely middle lobe atelectasis/collapse. . CXR [**2177-10-31**]: post-thoracentesis: IMPRESSION: Interval decrease in right-sided pleural effusion with no pneumothorax. Patchy right upper lobe consolidation. . CXR [**2177-11-2**]: Comparison is made to the prior study from [**2177-10-31**]. The heart is markedly enlarged. Mediastinum is within normal limits, but aortic arch is calcified. There is a small right pleural effusion, which has increased since the prior study. There is right lower lobe atelectasis. There is continued right middle lobe consolidation consistent with pneumonia, containing air bronchograms. Left lung is relatively clear. Right-sided [**Month/Day/Year 4448**] is present with dual leads in right atrium and right ventricle. Brief Hospital Course: 72 M with myelofibrosis and extramedullary/liver hematopoiesis, PVD, recurrent cellulitis; admited with acute on chronic altered mental status and pneumonia. He was intially admitted to the ICU but was transfered out after three days. He did not require intubation or ventilatory support. . # Pneumonia. Fever, leukocytosis, infiltrate on CXR. O2 sats excellent and hemodynamically stable. CAP vs. HCAP (lives in nursing home and frequent hospital exposure) vs. aspiration. Localized likely to RLL. Vanc/zosyn and levofloxacin given empirically. Levofloxacin was discontinued after 2 days, when legionella antigen found to be negative. The patient received a 8 day course of Vanc/zosyn. His fever and leukocytosis improved. 6 days into his hospital stay he complained of positional SOB worse when lying down. He was found to have a unilateral right sided effusion that had developed since admission. A thoracentesis was performed: 1800cc clear, light yellow fluid removed, no empyema, transudate, culture negative. The etiology of his pleural effusion is somewhat unclear but may be [**1-4**] IVF in the MICU, heart failure or ascites. Since thoracentesis, the patient has had no difficulty breathing. He has had O2 saturations 97-100% on RA and did not require oxygen at any time. . # Altered mental status. An ongoing issue for several months, has seen outpatient neurobehavioral specialist. He has had recurrent delerium atrributed to narcotics and various infections, most frequently cellulitis. On admission, he was lethargic and disoriented, thought to be due to pneumonia. Hepatic encephalopathy was also considered given hepatic infiltration of extramedullary hematopoiesis and ascites although the patient had no asterixis or clonus. He was started on lactulose without improvement and with worsening metabolic acidosis in the ICU; lactulose was stopped. He was noted to have a minimal amount of ascites that appears to be attributed to portal hypertension. He did not have a paracentesis given the small amount of ascitis and the fact that he was treated with Zosyn. However, he should have a paracentesis to rule out SBP the next time he is admitted with AMS. He also developed hypernatremia [**1-4**] to NPO status several days into admission. He was treated with IVF D5 with resolution. As his mental status improved, he was cleared by speech and swallow to eat. He was then able to drink normally, allowing his sodium remain WNL. His delerium improved during his hospital and at the time of discharge his mental status was at baseline per his family. . # Cellulitis. Bilat LEs with erythema, edema, warmth. Scabs over legs as above. Has severe PVD, seen vascular in the past as well as wound consult. Received clindamycin during last admit in late [**Month (only) 359**]. It is unclear if he truly had cellulitis vs venous status during this admission. However, the antibiotic for HCAP would also have treated cellulitis. He was followed by the wound care nurse. . # Leukocytosis. Treating for pneumonia and cellulitis as above. Given history of C.diff and recent clindamycin use, C.diff was considered although the patient only had diarrhea once with lactulose. Patient also with history of myelofibrosis and extramedullary hematopoiesis. Per hematologist, often tends to spike high WBC counts in times of stress and infection due to disordered cell production. Hydroxyurea was continued at the current dose. His leukocytosis trended down from a high of 60 to 13 (which is his baseline). . # Myelofibrosis/anemia: Hydroxyurea and epogen continued. Patient also has iron deficiency that may be contributing to anemia. He had been on a course of ferrlecit infusions as an outpt. He received one dose while here on 11/31. Interferon was held during acute illness, but he should restart. . # CHF, systolic dysfunction: Initially lasix and metoprolol were held in the setting of possible SIRS physiology. These were restarted soon after he was transfered from the MICU to the floor. Not on ACEI or [**Last Name (un) **] due to angioedema. . # ARF on CKD. Baseline Cr of 2.0, increased up to 2.3-2.5. Urine lytes suggested prerenal. Urine eos negative. Renal U/S w/o acute pathology. His cr improved to 1.2 over his hospital stay. . # Metabolic acidosis. Worsening metabolic acidosis (bicarb as low as 8), likely secondary to worsening renal failure and to diarrhea from lactulose. Lactate wnl. His acidosis and bicarb resolved. . # Hepatitis. ?cirrhotic physiology with chronically elevated INR, AST>ALT; mildly elevated bilirubin (not seen in recent past). Has ascites on imaging. Thought to be due to infiltration of extramedullary hematopoeitic cells given severe myelofibrosis. He has had intermitted low level elevations in transaminases over the past year. He should have this followed as an outpt. An appointment with his gastroenterologist was made. . # Vitamin D deficiency: Vit D in [**7-/2177**] 17 but does not appear to have been placed on vit D supplements or received replacement therapy. He should have 50,000 units vit D. once a week for 8 weeks. He was given one dose on [**12-2**]. He was also started on Vit D 400units [**Hospital1 **]. Medications on Admission: - vit C 500 [**Hospital1 **] - vit B complex daily - pentoxyfylline 400 TID - oxycodone 5 q6h PRN - simvastatin 10 daily - seroquel 25 mg at 8pm, 12.5 QAM, 12.5 [**Hospital1 **] prn agitation - bisacodyl 10 daily prn - MOM prn - compazine [**Hospital1 **] prn - MVI - levothyroxine 125 daily - allopurinol 100 daily - ASA 81 daily - FeSo4 325 daily - hydroxyurea alternating 500 mg/1000mg daily - epogen 4000 units Qmonday - lasix 40 mg daily - interferon alfa-2b - 1.5 million units MWF at HS. - metoprolol 25 mg daily No antibiotics x one month per family (per [**Hospital1 1501**] notes, ?on clinda in early [**Month (only) **]) Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO TID (3 times a day). 4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 11. Hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO EVERY OTHER DAY (Every Other Day). 12. Epoetin Alfa 2,000 unit/mL Solution Sig: 0.5 ml Injection QMOWEFR (Monday -Wednesday-Friday). 13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 14. Quetiapine 25 mg Tablet Sig: 1.5 Tablets PO QPM (once a day (in the evening)). 15. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 18. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 19. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 21. Compazine 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for nausea. 22. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 23. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 24. Interferon Alfa-2B 6,000,000 unit/mL Solution Sig: 1.5 million units Injection three times a week, QHS on MWF. 25. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (SA) for 7 weeks: start on [**2177-11-8**]. 26. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Primary: Delirium Pneumonia Acute Renal Failure, resolved Transudative pleural effusion Secondary: Myelofibrosis Anemia Vitamin D Deficiency chronic systolic CHF, LVEF 45% chronic kidney disease hx small ascites Discharge Condition: Stable for rehab Discharge Instructions: You were admitted to the hospital because of your pneumonia and change in your mental status. You have been treated with antibiotics for pneumonia and you have improved. Your mental status improved slowly. You had fluid in your right lung that was drained and tested. Please call your doctor or go to the emergency room for: -fever or shaking chills -shortness of breath -chest pain -change of mental status -any new or concerning symptoms Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone: [**Telephone/Fax (1) 608**] Please call Dr. [**First Name (STitle) **], your PCP for [**Name Initial (PRE) **] follow up appointment in the next [**12-4**] weeks. Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2177-11-6**] 9:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2177-11-10**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2177-11-10**] 9:00 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone: ([**Telephone/Fax (1) 2233**] Date/Time: [**2177-11-21**] 8:00am [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

[ "707.21", "486", "428.22", "289.83", "707.05", "585.4", "268.9", "V45.01", "584.9", "682.6", "428.0", "276.2", "573.3", "440.20", "427.31", "707.12", "403.90" ]

icd9cm

[ [ [] ] ]

[ "34.91" ]

icd9pcs

[ [ [] ] ]

20656, 20729

12451, 17622

346, 368

20986, 21005

5245, 10034

21496, 22513

3252, 3422

18305, 20633

20750, 20965

17648, 18282

21029, 21473

3437, 5226

297, 308

396, 2058

2080, 2979

2995, 3236

10051, 12428

25,189

137,662

51823

Discharge summary

report

Admission Date: [**2205-8-6**] Discharge Date: [**2205-8-7**] Date of Birth: [**2158-6-23**] Sex: F Service: MEDICINE Allergies: Penicillins / Bactrim / Sulfa (Sulfonamide Antibiotics) / Benadryl Attending:[**First Name3 (LF) 3984**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 47 y/o female with a history of common variable immunodeficiency, granulomatous cirrhosis, CRI with recent admission for gram-positive bacteremia who presents with hypotension. The patient was noted to have systolic blood pressures in the 90s yesterday post full course of dialysis. She presented to interventional radiology this morning for therapeutic paracentesis and was noted to have systolic blood pressures in the 80s. At that time, she had no specific complaints outside of her baseline shortness of breath that is thought to be related to her significant ascites. 4 days prior, the patient began to experience blood covered stool. She has had this previously in the setting of coagulopathy with liver disease. . In the ED inital vitals were, 96 88 81/49 24 88% RA. With concern for sepsis, she was started on Cefepime and Vancomycin. She also was hypoxemic to 94% on 5L NC. Oxygen saturation fell to 77% and she was placed on a NRB. In addition to vanc and cefepime, she was given 1L NS and 25g 5% albumin. Labs were notable for a lactate of 7, a white count of 11.3 with 75% neutrophils and 5 bands. Past Medical History: MEDICAL & SURGICAL HISTORY: 1. Common variable immunodeficiency complicated by: -E. coli bacteremia [**11-1**] treated with 3 days IV cefepime switched to oral cipro for 14-day course, presumed source was GI -recurrent CMV disease (adenopathy, [**Month/Year (2) 15482**] suppression, colitis) requiring IV foscarnet, now on valganciclovir suppression -HPV related vulvo-anal and vocal cord disease s/p laser fulguration -[**Doctor First Name **] adenitis and recurrence with [**Doctor First Name **] enteritis on [**Doctor First Name 107290**] for secondary PPX due to intolerance/failure of azithromycin -granulomatous hepatitis with cholangitic overlay presumed to be from CVID, and clinical cirrhosis -pulmonary disease with some fibrosis s/p wedge resection [**6-25**] with chronic interstitial pneumonitis with mild-moderate inflammatory component interstitial fibrosis, patchy acute organizing pneumonitis -intermittent recurrent diarrhea/colitis 2. Bleeding disorder - possible PAI-1 deficiency 3. S/p splenectomy for symptomatic hypersplenism and refractory ITP; incidentally found large B cell lymphoma with splenectomy -s/p 6 cycles of CHOP [**10-27**] - [**2-26**] 4. Chronic LE lymphedema 5. Bilateral arthropathy . Past Surgical history: 1. hysterectomy [**3-/2198**] for intractable HPV cervical disease 2. Splenectomy [**9-/2198**] for ITP 3. Multiple colposcopies/laser cervical operations and partial vulvectomy 4. Exploratory laparotomy for small bowel obstruction on [**12-3**] Social History: Denies tobacco or alcohol. Married and living with husband. Previously employed as a paralegal, but now on disability secondary to multiple medical conditions. Has VNA assistance for medication management. Family History: Common variable immune deficiency in twin sister who passed from metastatic anal carcinoma and in older brother. [**Name (NI) **] brother is healthy without immunodeficiecny. [**Name (NI) **] mother died of lymphoma at 52 and had similar symptoms, but was never diagnosed with CVID. Father with hypertension. Physical Exam: Vitals: T98.3 BP 96/57 HR 79 RR 22 O2 Sat: 99% on 12 L NRB General: Alert, oriented, is tachypneic, is in pain. HEENT: Sclera anicteric, MMM, face mask on with NRB Neck: supple, neck veins are distended, no LAD Lungs: b/l crackles + at bases, no rhonchi. b/l VBS + CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: distended. BS +. small midline hernia in upper abdomen, umbilicus is everted. Dilated superficial veins are +. Non tender, free fluid + Ext: b/l LE edema +. Rt LE is warm and erythematous, also tender however per husband, this has improved after antibiotic treatment but never got back to basleine. Access:Rt IJ tunneled cath +, no discharge/tenderness/erythema. Pertinent Results: [**2205-8-7**] 04:16AM BLOOD WBC-10.2 RBC-2.59* Hgb-7.8* Hct-24.6* MCV-95 MCH-30.1 MCHC-31.7 RDW-26.2* Plt Ct-132* [**2205-8-7**] 03:28AM BLOOD WBC-9.7 RBC-2.59* Hgb-7.7* Hct-24.3* MCV-94 MCH-29.9 MCHC-31.8 RDW-26.1* Plt Ct-129* [**2205-8-6**] 10:29AM BLOOD WBC-10.7 RBC-3.23* Hgb-9.8* Hct-30.9* MCV-96 MCH-30.3 MCHC-31.7 RDW-27.1* Plt Ct-154 [**2205-8-6**] 09:50AM BLOOD WBC-11.3*# RBC-3.27* Hgb-9.9* Hct-30.9* MCV-95# MCH-30.3 MCHC-32.0 RDW-26.4* Plt Ct-167# [**2205-8-7**] 03:28AM BLOOD Neuts-66 Bands-1 Lymphs-9* Monos-8 Eos-2 Baso-0 Atyps-0 Metas-10* Myelos-4* NRBC-20* [**2205-8-7**] 02:25AM BLOOD Neuts-UNABLE TO Lymphs-UNABLE TO Monos-UNABLE TO Eos-UNABLE TO Baso-UNABLE TO [**Doctor Last Name **]-UNABLE TO [**2205-8-6**] 10:29AM BLOOD Neuts-72* Bands-5 Lymphs-5* Monos-7 Eos-0 Baso-1 Atyps-0 Metas-10* Myelos-0 NRBC-17* [**2205-8-6**] 09:50AM BLOOD Neuts-75* Bands-1 Lymphs-6* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-11* Myelos-0 NRBC-14* [**2205-8-7**] 03:28AM BLOOD Hypochr-NORMAL Anisocy-3+ Poiklo-2+ Macrocy-3+ Microcy-1+ Polychr-1+ Ovalocy-1+ Target-2+ Schisto-1+ [**2205-8-6**] 10:29AM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-3+ Macrocy-3+ Microcy-1+ Polychr-1+ Ovalocy-OCCASIONAL Target-3+ Acantho-OCCASIONAL [**2205-8-6**] 09:50AM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-2+ Macrocy-3+ Microcy-1+ Polychr-2+ Ovalocy-OCCASIONAL Target-3+ Acantho-OCCASIONAL [**2205-8-7**] 04:16AM BLOOD Plt Smr-LOW Plt Ct-132* [**2205-8-7**] 03:28AM BLOOD Plt Smr-LOW Plt Ct-129* [**2205-8-7**] 02:25AM BLOOD PT-15.7* PTT-36.5* INR(PT)-1.4* [**2205-8-6**] 10:29AM BLOOD Plt Smr-NORMAL Plt Ct-154 [**2205-8-6**] 10:29AM BLOOD PT-15.7* PTT-35.4* INR(PT)-1.4* [**2205-8-6**] 09:50AM BLOOD Plt Smr-NORMAL Plt Ct-167# [**2205-8-6**] 09:50AM BLOOD PT-15.7* INR(PT)-1.4* [**2205-8-7**] 02:25AM BLOOD Glucose-62* UreaN-37* Creat-2.8* Na-132* K-4.3 Cl-91* HCO3-25 AnGap-20 [**2205-8-6**] 10:29AM BLOOD Glucose-54* UreaN-31* Creat-2.5* Na-134 K-4.3 Cl-92* HCO3-26 AnGap-20 [**2205-8-6**] 09:50AM BLOOD Glucose-54* UreaN-30* Creat-2.5*# Na-133 K-5.1 Cl-91* HCO3-27 AnGap-20 [**2205-8-7**] 02:25AM BLOOD ALT-19 AST-58* LD(LDH)-297* AlkPhos-205* TotBili-2.7* [**2205-8-6**] 10:29AM BLOOD ALT-25 AST-84* AlkPhos-274* TotBili-2.2* [**2205-8-6**] 09:50AM BLOOD ALT-28 AST-100* AlkPhos-275* Amylase-39 TotBili-2.3* [**2205-8-7**] 02:25AM BLOOD Albumin-3.7 Calcium-9.3 Phos-1.7* Mg-2.0 [**2205-8-6**] 10:29AM BLOOD Albumin-2.5* [**2205-8-6**] 09:50AM BLOOD Albumin-2.5* [**2205-8-7**] 02:51AM BLOOD Type-[**Last Name (un) **] pO2-37* pCO2-35 pH-7.49* calTCO2-27 Base XS-3 [**2205-8-6**] 10:33PM BLOOD Type-[**Last Name (un) **] pO2-45* pCO2-36 pH-7.48* calTCO2-28 Base XS-3 [**2205-8-7**] 02:51AM BLOOD Lactate-4.2* [**2205-8-6**] 10:33PM BLOOD Lactate-5.6* [**2205-8-6**] 10:34AM BLOOD Lactate-7.0* K-4.5 [**2205-8-6**] 10:34AM BLOOD Hgb-9.5* calcHCT-29 [**2205-8-6**] 05:41PM ASCITES TotPro-0.9 Glucose-71 Creat-2.4 Amylase-11 TotBili-0.4 Albumin-LESS THAN [**2205-8-6**] 04:59PM OTHER BODY FLUID WBC-60* RBC-200* Polys-11* Lymphs-75* Monos-0 Macro-14* [**2205-8-6**] 9:50 am BLOOD CULTURE Blood Culture, Routine (Preliminary): GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY. These preliminary susceptibility results are offered to help guide treatment; interpret with caution as final susceptibilities may change. Check for final susceptibility results in 24 hours. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ GRAM NEGATIVE ROD(S) | AMPICILLIN------------ R AMPICILLIN/SULBACTAM-- R CEFTAZIDIME----------- R CIPROFLOXACIN--------- S GENTAMICIN------------ S MEROPENEM------------- S TOBRAMYCIN------------ S [**2205-8-6**] CXR: Limited study, cardiomegaly, bibasilar atelectasis. [**2205-8-7**] Echocardiography: The left atrium is mildly dilated. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is markedly dilated with mild global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. Compared to the prior study dated [**2205-7-10**] (images reviewed), the degree of ascites has decresed. Other findings are similar Brief Hospital Course: Ms. [**Known lastname **] is a 47 y/o female with a history of common variable immunodeficiency, granulomatous cirrhosis, CRI with recent admission for gram-positive bacteremia who presents with hypotension. . # Severe sepsis with hypotension but no organ failure: Possible sources included right leg cellulitis, line-related, ascites (SBP). Blood cultures were positive for gram negative rods. She also underwent a diagnostic paracentesis. She was started on broad spectrum IV antibiotics, and was treated with albumin 1.5 mg/kg for suspected SBP and for paracenesis. She was given midodrine and IV fluids to maintain BP above 90/50. However, following extensive discussion with her with involvement of all her long-term caregivers (including immunology, ID, pulmonary, renal, oncology, palliative care), the decision was made to transition her to home hospice and treat with comfort measures only. Her code status was changed to DNR/DNI. Following discharge she will continue a two week course of PO ciprofloxacin as a temproizing measure. . # Hypoxia, dyspnea: Chest X-ray showed no evidence of pneumonia. Likely hypoventilation from ascites. Her code status was DNI. She had a paracentesis with removal of 2 L ascites. Echocardiography showed an unchanged ejection fraction. She was discharged home with home oxygen to alleviate her symptoms. We liaised with hospice to ensure that she will be given morphine to alleviate air hunger as required. . # Cirrhosis: She underwent a paracentesis with removal of two litres ascites. She was also given albumin and fluid to improve intravascular volume. . # ESRD: She started HD 2 months ago, and her weight has been gradually trending up. She was seen by nephrology during this hospitalization, but following extensive consideration (see above), she decided to discontinue hemodialysis. She will no longer receive HD following discharge. . # Hematochezia: Chronic from intraabdominal wounds. She had one bowel movement with bloody stool during this hospitalization. Her recent hematocrit has been stable. # Anemia: Likely multifactorial from rectal bleeding, coagulopathy, esrd, chronic disease. Her hematocrit was stable during this hospitalization. # CVID: Continued voriconazole and chlorhexidine prophylaxis. . # Pulmonary Hypertension: Echocardiography showed a small pericardial effusion but no other new changes. . # Arthropathy: Held hydroxychloroquine, but restarted at the time of discharge. Medications on Admission: 1. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane QID (4 times a day) as needed. 3. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. voriconazole 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 7. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 11. citalopram 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: Six (6) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 14. midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 15. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for diarrhea: Titrate to [**12-27**] bowel movements per day. 16. neomycin-polymyxin-HC 3.5-10,000-1 mg-unit/mL-% Drops, Suspension Sig: Four (4) Drop Otic TID (3 times a day) for 8 days. 17. vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous HD PROTOCOL (HD Protochol). Disp:*14 Recon Soln(s)* Refills:*0* 18. ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln Injection 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Home Oxygen 2. Commode 3. Bed 4. Cipro 250 mg/5 mL Suspension, Microcapsule Recon Sig: One (1) Suspension, Microcapsule Recon PO once a day for 12 days: End: [**8-19**]. Disp:*12 Suspension, Microcapsule Recon(s)* Refills:*0* 5. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane QID (4 times a day). 6. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. voriconazole 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 8. midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 10. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO three times a day. 12. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO twice a day. 13. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO once a day. 14. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 16. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Tablet, Rapid Dissolve(s) 17. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: Five (5) Capsule, Delayed Release(E.C.) PO three times a day: with meals. Capsule, Delayed Release(E.C.)(s) 18. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 19. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO twice a day. 20. neomycin-polymyxin-HC 3.5-10,000-10 mg-unit-mg/mL Drops, Suspension Sig: Four (4) drops Ophthalmic three times a day. Discharge Disposition: Home With Service Facility: [**Hospital3 **]Hospice Discharge Diagnosis: Primary: -gram negative sepsis Secondary: -common variable immunodeficiency Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Ms. [**Known lastname **], It was a pleasure to look after you as a patient at the [**Hospital1 1535**]. You were admitted with a blood infection and low blood pressure. We treated you with antibiotics and fluids. We also noted that you have bloody stool. During you hospitalization, you were seen by the pulmonary, infectious disease and palliative care teams. As we have discussed, you will go home with full support from hospice. Your team of doctors [**First Name (Titles) **] [**Last Name (Titles) 18**] [**Name5 (PTitle) **] continue to be available at any time to help address pain or any emergent issues. We made the following changes to your medications: -started ciprofloxacin. Please continue taking your other medications as usual. Followup Instructions: Department: [**Name5 (PTitle) **] When: WEDNESDAY [**2205-8-21**] at 8:40 AM With: [**Year (4 digits) **] [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: WEDNESDAY [**2205-8-21**] at 10:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: RHEUMATOLOGY When: THURSDAY [**2205-12-12**] at 1:45 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2205-8-7**]

[ "578.1", "995.92", "279.06", "V66.7", "289.4", "573.1", "572.4", "571.5", "V45.79", "V49.86", "287.31", "585.6", "787.91", "518.0", "789.59", "458.29", "079.4", "716.99", "202.80", "786.05", "457.1", "078.5", "V45.11", "286.7", "416.8", "038.40" ]

icd9cm

[ [ [] ] ]

[ "39.95", "54.91" ]

icd9pcs

[ [ [] ] ]

15288, 15342

9296, 11765

337, 344

15463, 15463

4335, 7401

16376, 17430

3278, 3589

13579, 15265

15363, 15442

11791, 13556

15600, 16242

2791, 3038

3604, 4316

7445, 9273

16271, 16353

286, 299

372, 1515

15478, 15576

1537, 2768

3054, 3262

58,187

151,959

42841

Discharge summary

report

Admission Date: [**2121-2-8**] Discharge Date: [**2121-2-18**] Date of Birth: [**2066-12-17**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 371**] Chief Complaint: Trauma: Fall,[**2109**]5 feet onto concrete Major Surgical or Invasive Procedure: [**2121-2-8**] 1. Repair of scalp laceration ( staples removed [**2121-2-18**]) [**2121-2-11**]: 1. Posterior cervical laminectomy, C5 and C6, with medial facetectomy and foraminotomy. 2. Posterolateral arthrodesis, C4 to C6. 3. Posterolateral instrumentation, C4 to C6. 4. Application of local autograft and allograft. 5. Open treatment of fracture, C4-C5 and C5-C6. History of Present Illness: 54yo M w/ETOH presents after falling 15ft from a balcony onto concrete. Unknown LOC at scene. Arrived at OSH with GCS 14 but developed acutely altered MS and was emergently intubated and transferred to [**Hospital1 18**]. Had obvious degloving injury to scalp but no imaging performed at OSH. Past Medical History: PMH: bilateral carpal tunnel, depression PSH: bilateral shoulder surgery for "bone spur", "neck surgery" Social History: Daily EtOH. Family History: Non-contributory. Physical Exam: On admission: O: T: BP: 118/82 HR: 58 R 16 98% (intubated) O2Sats Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRLA EOMs: could not assess Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: intubated/sedated, Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements could not be assessed given level of sedation and hard collar IX, X: intact gag reflex Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Stength could not be formally assessed but less spontaneous movement of left arm/leg. Sluggish response to noxious stimulation on the left as well. Sensation: Withdraws to noxious over all extremities but slower and with marked delay on the left arm/leg Reflexes: B T Br Pa Ac Right Left Toes mute b/l Physical examination upon discharge: [**2121-2-18**]: Vital signs: t=98, hr=76, bp=140/80, rr=16, oxygen sat=97% room air General: Conversant, NAD CV: ns1, s2, -s3, -s4 LUNGS: clear ABDOMEN: soft, non -tender EXT: left arm strength +3/+5, left leg +5/+5, right arm strength +5/+5, right leg +5/+5, decreased sensation finger-tips left hand, full finger flexion/ext. bil., + dp bil., no pedal edema bil. NEURO: alert and oriented x 3, speech clear, no tremors, full EOM's, patch left eye. staples post. aspect of neck, mild erythema staple sites, no exudate, head staples removed [**2121-2-18**] Pertinent Results: INJURIES: - 8mm epidural hematoma - Skull fx: RIGHT parietal/temporal bone extending to sphenoid sinus - C5 vertebral body burst fx - C4 spinous process fx - Scalp laceration/degloving IMAGING: MRI spine: C5 & C6 fx, mild compression T1-4; Abnormal signal within the intraspinous region and the cervical region indicates injury to the ligaments with slightly more pronounced injury at C4-5 level extending to the ligamentum flavum indicating injury but no buckling of the ligament to suggest disruption identified; Moderate spinal stenosis at C5-6 level due to the central disc herniation which indents the spinal cord and mild spinal stenosis is seen at C4-5 and C6-7 levels; Subtle increased signal in the anterior portion of the spinal cord at C4 level could be due to cord contusion. No abnormal signal is seen on susceptibility images to indicate hemorrhage associated with contusion. No evidence of prevertebral soft tissue abnormality. CTA head (repeat):Stable 8mm R parietal epidural hematoma, no mass effect. No carotid injury. Hypoplastic R vertebral art, dominant L vertebral art. No vascular injury. CT torso: Subtle non-displaced sternal fx; small bilat pleural effusions, likely atelectasis w/ imposed aspiration. No acute abdominal or pelvic trauma CT head (first): RIGHT parietal hematoma 8mm. Mildly displaced R skull fx parietal/temporal bones to R sphenoid, runs close to R carotid canal. CTA head to r/o carotid injury CT c-spine: C5 vertebral body fracture, no retropulsion; C4 mildly displaced fracture inferior facet CXR: No acute process Right knee: No fracture or dislocation [**2121-2-13**]: head cat scan: Possible minimal increase in right parietal epidural hematoma without expected evolution of internal blood products may indicate more acute hemorrhage. No increased mass effect identified. Recommend short interval imaging follow-up. [**2121-2-13**] 04:45AM BLOOD WBC-10.8 RBC-3.38* Hgb-10.5* Hct-29.8* MCV-88 MCH-31.1 MCHC-35.3* RDW-13.5 Plt Ct-190 [**2121-2-12**] 05:09AM BLOOD WBC-12.5* RBC-3.48* Hgb-10.9* Hct-30.6* MCV-88 MCH-31.2 MCHC-35.5* RDW-13.5 Plt Ct-159 [**2121-2-11**] 01:25AM BLOOD WBC-12.4*# RBC-3.36* Hgb-10.6* Hct-29.3* MCV-87 MCH-31.4 MCHC-36.0* RDW-13.4 Plt Ct-143* [**2121-2-13**] 04:45AM BLOOD Plt Ct-190 [**2121-2-10**] 12:40PM BLOOD PT-10.9 PTT-26.5 INR(PT)-1.0 [**2121-2-9**] 05:12AM BLOOD Fibrino-243 [**2121-2-13**] 04:45AM BLOOD Glucose-101* UreaN-14 Creat-0.8 Na-139 K-3.3 Cl-104 HCO3-23 AnGap-15 [**2121-2-12**] 05:09AM BLOOD Glucose-108* UreaN-11 Creat-0.7 Na-139 K-3.4 Cl-104 HCO3-26 AnGap-12 [**2121-2-13**] 04:45AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.1 [**2121-2-8**] 04:51PM BLOOD ASA-NEG Ethanol-26* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2121-2-10**] 12:59PM BLOOD freeCa-1.07* [**2121-2-10**] 10:33AM BLOOD freeCa-1.11* Brief Hospital Course: 54 year old gentleman admitted to the acute care service after a 15 foot fall from a balcony. Upon arrival to the emergency room, he was collared and intubated/sedated. He was bradycardic with a heart rate in the 40's, but maintained his systolic blood pressure in the 100s. Accurate neuro exam delayed due to sedation and possible paralytics administered at outside hosptial, but patient only moving the right side of his body, no movement in the LUE or LLE. A head cat scan was done which showed evidence of 8mm RIGHT sided epidural hematoma without midline shift or signs of herniation as well as underlying skull fracture. Additionally,he was found to have multiple injuries including C5 burst fx, C4 spinous process fx. He was given cryoglobulin for elevated fibrinogen in the emergency room and typed and crossed. He was admitted to Trauma intensive care unit for close monitoring. Neurosurgery was consulted and recommended a repeat head cat scan to evaluate any changes in the epidural hematoma; this was found to be unchanged after 3 hours, and there was no need for operative intervention. He was noted to be moving all four extremities. The degloving injury to the scalp was irrigated with several liters of saline and stapled with good hemostasis. He was taken to the operating room on HD# 3 for a posterior fusion of his cervical spine [**2-11**] with placement of a hemovac drain. He tolerated the procedure well with a 100cc blood loss. He was transported back to the intensive care unit after the procedure and was extubated without incident. Because of his history of ETOH, he was placed on a CIWA scale. On POD #1 he was transferred out of the unit to the surgical floor. He had the foley catheter removed and had no difficulty voiding. He continued on a CIWA scale and was noted to be quite restless. On POD# 2 the hemovac from his neck was removed. He was placed on a regular diet and was started on Zyprexa for agitation. He was being evaluated throughout by physical therapy who noted left arm weakness compared to right. On POD #3, he was started on bedtime seroquel which helped with his periods of restlessness and allowed him to sleep during the night. To provide him with comfort, he was switched from a [**Location (un) 2848**] J to a soft collar. He was instructed to wear the soft collar at all times until his follow-up with Dr. [**Last Name (STitle) 1352**]. His heparin was resumed on POD# 2. On POD #3, he developed a sudden onset of diplopia. A head cat scan was done which showed a minimal increase in the right parietal epidural hematoma. Neurosurgery was consulted and no further imaging recommended. His left arm weakness was addressed with Ortho-Spine, who felt that the weakness was related to a spinal contusion, and should improve over a period of time. He also complained of double vision and so was seen by opthamology who attributed the double vision to a left superior oblique palsy related to the trauma. They recommended patch for comfort and evaluation by neuro opthamologist prior to discharge. The neuro opthamologist stated that he wear the eye patch for 6 months and follow up if no improvement in symptoms. His vital signs have remained stable and he is afebrile. He is tolerating a regular diet. He was been seen by Social service who has been providing support to his family. He is is preparing for discharge to a rehabilitation facilty where he can further regain his strength and mobility. Medications on Admission: Celexa, Vitamins, Fish oil Discharge Medications: 1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): stop date [**2-17**]. 4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 9. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 11. olanzapine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. quetiapine 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 19504**] of [**Location (un) 30940**] - [**Location (un) 30940**] Discharge Diagnosis: 1. C5 anterior vertebral body fracture. 2. C4 facet fracture. 3. Possible spinal cord injury. 4. Epidural hematoma 5. Scalp laceration 6. Temporal bone fracture Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Needs soft collar until follow-up with Ortho-spine Discharge Instructions: You were transferred to [**Hospital1 18**] from an OSH after sustaining a 15 foot fall onto concrete with multiple injuries including neck fractures of your cervical spine, which required surgical intervention. On discharge you were kept in a soft collar that should be continued until your follow-up appointment with Dr. [**Last Name (STitle) 1352**]. This soft collar should be worn AT ALL TIMES. Also, avoid lifting anything greater than 10 pounds. Other injuries include an epidural hematoma and scalp laceration. The scalp laceration was repaired with staples. Please take all medications as directed. The staples in your neck will be removed at the rehabilitation facility on [**2-24**]. Followup Instructions: Department: ORTHOPEDICS When: MONDAY [**2121-3-31**] at 10:40 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: SPINE CENTER When: MONDAY [**2121-3-31**] at 11:00 AM With: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 8603**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RADIOLOGY When: WEDNESDAY [**2121-3-12**] at 10:45 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: WEDNESDAY [**2121-3-12**] at 11:45 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage You have an appointment scheduled for [**2121-8-20**] at 1pm in the [**Hospital 8095**] clinic, the telephone number is #[**Telephone/Fax (1) 253**], [**Hospital Ward Name 23**] building [**Location (un) 442**], [**Hospital1 1170**], [**Location (un) **]., [**Location (un) 86**]. Completed by:[**2121-2-18**]

[ "305.01", "873.0", "276.2", "729.89", "801.26", "378.51", "806.05", "368.2", "991.6", "E884.1", "286.6", "806.00", "780.09" ]

icd9cm

[ [ [] ] ]

[ "94.62", "84.52", "81.62", "96.71", "81.03", "86.59", "03.09" ]

icd9pcs

[ [ [] ] ]

10231, 10336

5630, 9100

315, 690

10541, 10541

2794, 5607

11492, 12886

1188, 1207

9178, 10208

10357, 10520

9126, 9155

10770, 11469

1222, 1222

231, 277

2209, 2775

718, 1013

1543, 2192

1236, 1492

10556, 10746

1035, 1143

1159, 1172

7,107

173,988

8878

Discharge summary

report

Admission Date: [**2152-7-30**] Discharge Date: [**2152-8-4**] Date of Birth: [**2067-11-11**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Bactrim / IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 2145**] Chief Complaint: Fever, lethargy, abdominal pain Major Surgical or Invasive Procedure: NONE History of Present Illness: 84 yo female with COPD, dCHF, HTN, HL, colon cancer s/p resection presents with fever, lethargy, and abdominal pain. She was in her usual state of health until she went grocery shopping with her neighbor and began falling asleep. Her neighbor decided to bring her to the emergency department. She denied any cough or any other associated symptoms. Of note, the patient had a recent EGD 1 week ago. She is also on 2LNC at rest and 4LNC with exertion at baseline. . In the ED, the patient had the following vital signs: 101 84 93/44 14 98% 10L Non-Rebreather. Her blood pressure dropped as low as 64/30 and she was started on peripheral levophed until CVL access was attained. Tmax was 102R. She was guiac negative. CXR revealed LLL pneumonia. She underwent bilateral LE U/S for her LE edema that was negative for DVT. CT abdomen/pelvis w/o contrast confirmed LLL PNA. Labs were notable for a WBC of 14.4 with a left shift (87% N, 4% band). VBG revealed 7.35/73/61/42 with normal lactate. The patient was given ceftriaxone 1gm and levoquin 1gm IV for CAP coverage. She was given vancomycin 1gm for ?cellulitis. She was given acetaminophen for fever. Given her persistent hypotension, she was started on a small dose of norepinephrine gtt with good effect. She received 1L of NS and made 500cc of urine. A subclavian line was misplaced initially, and was repositioned prior to transfer. Last set of vitals prior to transfer: 101 77 103/63 17 100%4LNC. . ROS: (+)She reports constipation and poor adherance with her bipap. (-)She denied any chest pain, shortness of breath, cough, sputum, fevers, chills, sweats, nausea, vomitting, diarrhea, black, bloody stools, weakness on one side of the body or the other, dysuria. No recent travel or sick contacts. Past Medical History: 1) Diastolic congestive heart failure (NYHA class IV) 2) Atrial fibrillation (refuses coumadin) 3) Symptomatic bradycardia status post VDD pacemaker in [**11/2143**] 4) Obstructive sleep apnea (on CPAP at 8-10 cm of H2O) 5) Coronary artery disease 6) Hyperlipidemia 7) Hypertension 8) Colon cancer s/p resection 9) COPD (on O2 2-4 liters at home) 10) Bronchiectasis 11) GERD 12) Pulmonary hypertension 13) Anemia 14) Pneumonia ([**2145**]) 15) Acute respiratory failure in [**3-/2144**] and again in [**3-/2145**] 16) History of methicillin resistant Staphylococcus aureus in her sputum following hernia repair and again in [**3-/2145**] with documented pneumonia . Past surgical history: 1) Status post hernia repair. 2) Status post appendectomy. 3) Status post total abdominal hysterectomy. 4) Status post back surgery. 5) Status post right total hip Social History: Lives in [**Location 686**]. Worked as a printer many years ago. Not married and does not have any children. No family in the area. Uses a walker or wheelchair at baseline. Patient is quite independent, and she manages her finances, cooks, and cleans herself. She is accompanied to the supermarket. Patient quit smoking >25 years ago. Drinks one whiskey a week. No illicit drug use. Family History: Sister has endometriosis and breast cancer Physical Exam: On admission: GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, CV: RR, S1 and S2 wnl, no m/r/g RESP: CTA b/l except rales at the bases with fair air movement throughout ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c, 3+ edema of LLE, 2+ edema of RLE SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. On discharge: Vitals: 98.2 76 116/62 18 96 2L GEN: A/Ox3, pleasant, comfortable, NAD CV: RR, S1 and S2 wnl, no m/r/g RESP: crackles at the bases B/L with fair air movement throughout ABD: soft, NT, ND EXT: 2+ edema of LLE, 1+ edema of RLE, erythema of LLE improved with small residual anterior region of tibia remaining. Pertinent Results: Admission Labs: [**2152-7-30**] 10:34PM BLOOD Hgb-10.3* calcHCT-31 O2 Sat-87 COHgb-2 MetHgb-0 [**2152-7-30**] 10:34PM BLOOD Type-[**Last Name (un) **] pO2-61* pCO2-73* pH-7.35 calTCO2-42* Base XS-10 Comment-GREEN TOP [**2152-7-30**] 07:40PM BLOOD Lactate-1.7 [**2152-7-31**] 03:40AM BLOOD Calcium-7.7* Phos-3.4 Mg-1.8 [**2152-7-31**] 03:40AM BLOOD CK-MB-2 cTropnT-0.07* proBNP-7662* [**2152-7-30**] 07:34PM BLOOD ALT-17 AST-25 AlkPhos-94 TotBili-0.3 [**2152-7-30**] 07:34PM BLOOD Glucose-99 UreaN-18 Creat-0.8 Na-139 K-3.4 Cl-92* HCO3-36* AnGap-14 [**2152-7-30**] 07:34PM BLOOD PT-13.2 PTT-28.0 INR(PT)-1.1 [**2152-7-30**] 07:34PM BLOOD WBC-14.4*# RBC-4.08* Hgb-12.5 Hct-37.6 MCV-92 MCH-30.7 MCHC-33.3 RDW-13.4 Plt Ct-246 IMAGING: [**2152-7-30**] LE US: No DVT. Calf veins not well assessed. [**2152-7-30**] AB CT: IMPRESSION: 1. No evidence of bowel perforation. 2. Left lower lobe pneumonia. Emphysema [**2152-7-30**] CXR: Left lower lobe pneumonia. Mild CHF. [**2152-7-31**] CXR: Compared with earlier the same day (7:22 a.m.), the right apical pneumothorax is no longer seen distinctly visible. Otherwise, no significant change is detected. MICRO: [**2152-7-30**] BLOOD CXS: pending [**2152-7-30**] URINE CXS: no growth [**2152-7-31**] SPUTUM CXS: [**2152-7-31**] 3:22 am SPUTUM Source: Expectorated. GRAM STAIN (Final [**2152-7-31**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2152-8-2**]): MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. LABS ON DISCHARGE: [**2152-8-2**] 06:55AM BLOOD WBC-7.8 RBC-3.41* Hgb-10.3* Hct-32.0* MCV-94 MCH-30.2 MCHC-32.2 RDW-13.8 Plt Ct-213 [**2152-7-30**] 07:34PM BLOOD Neuts-87* Bands-4 Lymphs-3* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-3* [**2152-8-4**] 05:48AM BLOOD Glucose-79 UreaN-11 Creat-0.7 Na-140 K-3.7 Cl-101 HCO3-35* AnGap-8 [**2152-8-4**] 05:48AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.0 Brief Hospital Course: 84 yo female with COPD, diastolic CHF, HTN, hyperlipidemia, history of colon cancer s/p resection who presented with fever, lethargy, and abdominal pain, and was transferred to the ICU for hypotension and concern for sepsis with pulmonary source. . #. Severe sepsis: Patient presented with 2/4 SIRS criteria positive, fever, white count, with presumed pulmonary source and hypotension requiring pressors resulting in diagnosis of severe sepsis. Possible concominant left lower extremity cellulitis was considered as a source on admission as well. She was at risk for health care associated organisms. Also given recent EGD 1 week PTA, also concern for aspiration. U/A clear, blood cxs without growth, and urine legionella was negative. Considered relative adrenal insufficiency given fluticasone inhaler (last documented oral steroid use in our OMR is [**2150**]), however cortisol was elevated. She was weaned from pressors after receiving 3 L fluid treated with vancomycin, cefepime, levofloxacin and her hypotension resolved. . #. Pneumonia: Patient was on baseline 2L at home but hypoxia on admission was likely secondary to pneumonia on top of known COPD, OSA with associated cor pulmonale. Hypercarbia likely chronic due to retention from bronchiectasis, kyphosis, OSA. BNP was elevated suggesting a component of HF, however no evidence of volume overload on CT. She was continued on BIPAP. Patient had radiographic evidence of left lower lobe pneumonia and was treated with Vancomycin and cefepime for a total of 14 day course ending [**2152-8-13**]. Sputum Cx grew out MRSA however this was unclear as to whether this was a 'contaminant' or a true MRSA pneumonia given her baseline colonization. Her oxygen status improved to her baseline 2L of O2. An iatrogenic small right apical pneumothorax was discovered s/p central line placement which resolved without further intervention. . #. CAD: Asymptomatic. Pt was ruled out for MI with EKG's without acute changes and CKMB's flat however she did have mildly elevated troponins of unknown clinical significance. She was continued on ASA and simvastatin. . #. dCHF/cor pulmonale: No evidence of pulmonary edema on CT, torsemide and spironoactone was held given hypotension initially. Her last echo [**1-6**] reveals normal EF, diastolic dysfunction. . #. A fib: Rate controlled, refuses warfarin. She was continued on aspirin. Bblocker was held given COPD. . # Abd pain: with normal CT abd/pelvis, no BM in several days. Improved with bowel regimen. . #. OSA: BIPAP was continued. . #. COPD: Stable, without wheezes at present. Surprisingly undewhelming spirometry. Patient likely with concominant interstitial disease and kyphosis contributing. Fluticasone and standing albuterol/ipatroprium were continued. . Contact: (HCP) [**Name (NI) **] [**Name (NI) 30908**], friend phone number: [**Telephone/Fax (1) 30909**] Code: FULL CODE (confirmed) . Transition of care: pending completion of IV Vanc and Cefepime on [**2152-8-13**], her PICC line can be discontinued. Her weight on discharge is 147 lbs. Pending labs: blood cultures [**2152-7-30**] Medications on Admission: ALBUTEROL SULFATE - 1.25 mg/3 mL Solution for Nebulization - 1 nebulizer(s) by mouth every 4 hours as needed for shortness of breath / wheezing to use with nebulizer AZELASTINE - 137 mcg (0.1 %) Aerosol, Spray - 2 sprays intranasal twice daily BIPAP AUTO SV 11/9/6, 4 LITERS OXYGEN N.C. - (For complex SDB (RDI 45/AHI 36/71%, [**2151-5-5**] PSG)) - Dosage uncertain FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays intranasal once daily FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 100 mcg-50 mcg/Dose Disk with Device - 1 puff by mouth in the morning and 1 puff at night GABAPENTIN - 400 mg Capsule - 2 Capsule(s) by mouth three times a day [**Last Name (un) **] - - USE AS DIRECTED MORPHINE - 60 mg Tablet Extended Release - 1 Tablet(s) by mouth twice a day OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - one Capsule(s) by mouth daily OXYGEN - (Prescribed by Other Provider) - - 2liters NC q24h POTASSIUM CHLORIDE [KLOR-CON 10] - 10 mEq Tablet Extended Release - 1 Tablet(s) by mouth twice a day PRIMIDONE - 50 mg Tablet - 2 Tablet(s) by mouth at night SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - Inhale contents of 1 capsule daily TORSEMIDE - 20 mg Tablet - 2 Tablet(s) by mouth once a day Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1 Tablet(s) by mouth daily CALCIUM CARBONATE [TUMS EXTRA STRENGTH SMOOTHIES] - (Prescribed by Other Provider) - 750 mg Tablet, Chewable - 2 Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth daily DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day FERROUS GLUCONATE - 240 mg (27 mg Iron) Tablet - 1 Tablet(s) by mouth daily MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. albuterol sulfate 1.25 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. azelastine 137 mcg Aerosol, Spray Sig: Two (2) sprays Nasal twice a day. 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) sprays Nasal once a day. 5. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 7. morphine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. 10. primidone 50 mg Tablet Sig: Two (2) Tablet PO at bedtime. 11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 14. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. ferrous gluconate 240 mg (27 mg iron) Tablet Sig: One (1) Tablet PO once a day. 20. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 21. cefepime 1 gram Recon Soln Sig: One (1) gram Injection Q12H (every 12 hours) for 9 days: To finish on [**2152-8-13**]. 22. vancomycin 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous Q 12H (Every 12 Hours) for 9 days: To finish on [**2152-8-13**]. 23. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Pneumonia Left leg cellulitis Secondary: Chronic Diastoloic congestive heart failure Bronchiectasis Methicillin resistent staph aureus colonization Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to [**Hospital1 69**] for fever, lethargy, and abdominal pain. You were found to have pneumonia and left lower leg cellulitis. You were treated with antibiotics and a "PICC" IV line was placed for you to continue these antibioitcs at rehab. Your breathing improved and fevers went away with treatment. MEDICATION CHANGES: START: vancomycin 500mg IV BID and cefepime 1 gram IV q12 until [**2152-8-13**] Please otherwise resume your home medications. Followup Instructions: Please follow-up with your primary care doctor after you leave the rehabilitation facility. Otherwise, please follow-up with the appointments listed below: Department: CARDIAC SERVICES When: MONDAY [**2152-8-21**] at 3:00 PM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2152-8-5**]

[ "785.52", "995.92", "427.31", "272.4", "V43.64", "416.9", "414.01", "682.6", "428.0", "V64.2", "038.9", "327.23", "V45.01", "428.32", "V10.05", "285.9", "530.81", "494.0", "V02.54", "401.9", "482.42" ]

icd9cm

[ [ [] ] ]

[ "86.09" ]

icd9pcs

[ [ [] ] ]

14949, 15015

7556, 10666

368, 375

15217, 15217

4385, 4385

15887, 16471

3464, 3509

12729, 14926

15036, 15196

10692, 12706

15393, 15714

2871, 3037

3524, 3524

4052, 4366

15734, 15864

296, 330

7159, 7533

403, 2160

4402, 7140

3538, 4038

15232, 15369

2182, 2848

3053, 3448

63,968

157,488

45122

Discharge summary

report

Admission Date: [**2146-10-22**] Discharge Date: [**2146-10-28**] Date of Birth: [**2070-4-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 12**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Bronchoscopy, no intervention History of Present Illness: Pt is a 76 yo M with PMHx of stage IV NSCLC who presents with three weeks of productive cough. The cough is productive of white sputum, no hemoptysis. The day prior to admission he stated he closed a garage door with his right hand then began having left lower chest pain. The pain was worse with inspiration. It prevented him from taking a deep breath in. He states that since the pain started he has also been short of breath at rest. In the ED, initial vital signs were: T 102.1 P 130s SBP 200s R 30s O2 sat 88% RA. He was wheezing on exam and had CXR c/w LLL PNA. EKG showed sinus tachy with nonspecific lateral ST-T changes. He was given nebs, fluids, morphine, vanco/levo/flagyl and had improvement in VS to HR 120s, BP 170s, RR 30, 100% 2L. Labs notable for stable HCT at 27, stable Cr at 1.4, and lactate 1.1, neg CE x1, and was transferred to the [**Hospital Unit Name 153**]. In the [**Hospital Unit Name 153**], he was breathing at 40, which decreased to ~13/minute with morphine and nebulizers. He was treated with vancomycin and levofloxacin, with intention to add anaerobic coverage if decompensated. . On arrival to the OMED floor, he is comfortable and satting 100% on 4L nasal cannula. He reports that his shortness of breath is much improved and has no current complaints. Past Medical History: Past Onc History: - [**1-/2146**] CXR Noted to have ?lung nodule/mass; CT chest on [**2-16**] confirmed multiple lung nodules - [**3-/2146**] PET showed multiple FDG-avid nodules bilaterally - [**4-/2146**] Initial bronch showed malignant cells; CT-guided biopsy demonstrated non-small cell adenocarcinoma c/w NSCLC (although TTF-1 negative); MRI negative for intracranial metastasis - [**5-/2146**] Staging CT without extrathoracic metastasis - [**6-2**] C1D1 [**Doctor Last Name **]/taxol with reaction to taxol (hypertension); switched to [**Doctor Last Name **]/gemcitabine on [**6-23**] - Started Alimta [**2146-9-22**] . PMHx: Diabetes Mellitus - borderline Hypertension Hypercholesterolemia GERD Carpal tunnel syndrome Social History: Retired from [**Company **], worked as pizza delivery. Married. 60 pack years tobacco. Family History: Non contributory. Physical Exam: VS: T 99.5 HR 84 BP 134/67 O2 100% on 4L GEN: NAD, AOX3, no respiratory distress, able to speak in full sentences HEENT: MMM, EOMI, sclera slightly icteric, PERRL, conjunctiva pink CARDS: RRR, no m/r/g RESP: Dullness at bases bilaterally with diffuse rhonchi throughout ABD: soft, NT, ND, No masses or organomegaly, BS+ EXT: WWP, 1+ non pitting edema of ankles bilaterally symmetric NEURO: grossly normal Pertinent Results: ADMISSION LABS: [**2146-10-22**] 08:50PM PT-13.9* PTT-37.7* INR(PT)-1.2* [**2146-10-22**] 08:50PM PLT COUNT-212# [**2146-10-22**] 08:50PM NEUTS-82.7* BANDS-0 LYMPHS-10.4* MONOS-6.3 EOS-0.4 BASOS-0.1 [**2146-10-22**] 08:50PM WBC-7.4# RBC-3.07* HGB-8.6* HCT-27.2* MCV-89 MCH-28.2 MCHC-31.8 RDW-18.8* [**2146-10-22**] 08:50PM CK-MB-2 [**2146-10-22**] 08:50PM cTropnT-<0.01 [**2146-10-22**] 08:50PM CK(CPK)-245* [**2146-10-22**] 08:50PM estGFR-Using this [**2146-10-22**] 08:50PM GLUCOSE-117* UREA N-18 CREAT-1.4* SODIUM-138 POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14 [**2146-10-22**] 08:55PM LACTATE-1.1 [**2146-10-22**] 08:55PM COMMENTS-GREEN TOP [**2146-10-22**] 10:00PM URINE RBC-[**3-23**]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-<1 [**2146-10-22**] 10:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2146-10-22**] 10:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 . LABS ON DISCHARGE [**2146-10-27**] 12:00AM BLOOD WBC-5.1 RBC-2.98* Hgb-8.2* Hct-26.1* MCV-88 MCH-27.5 MCHC-31.4 RDW-18.6* Plt Ct-254 [**2146-10-27**] 12:00AM BLOOD Neuts-77.1* Bands-0 Lymphs-13.5* Monos-8.9 Eos-0.5 Baso-0.1 [**2146-10-27**] 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-1+ Spheroc-OCCASIONAL Ovalocy-1+ Schisto-1+ Tear Dr[**Last Name (STitle) **]1+ Acantho-1+ [**2146-10-27**] 12:00AM BLOOD Plt Ct-254 [**2146-10-27**] 12:00AM BLOOD Glucose-145* UreaN-20 Creat-1.3* Na-137 K-4.1 Cl-102 HCO3-24 AnGap-15 [**2146-10-27**] 12:00AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.9 . [**10-22**] ECG: Sinus tachycardia. Borderline low limb lead voltage. Prior anteroseptal myocardial infarction. Compared to the previous tracing of [**2146-9-6**] the rate has increased. Otherwise, no diagnostic interim change. . [**10-22**] CXR: 1. Mild interstitial edema. 2. Left lower lobe mass as seen on recent CT with new left-sided pleural effusion and left basilar atelectasis and/or pneumonia (likely post-obstructive). . [**10-23**] CXR: Mild interstitial edema is unchanged. Right lower lobe atelectasis is stable. There are low lung volumes. Cardiomediastinal silhouette is unchanged. Left lower lobe opacity consistent with a lung mass, better visualized in prior CT from [**9-6**], and post-obstructive pneumonitis is stable. The left lateral CP angle was not included on the film. Right subclavian catheter remains in place. . [**10-23**] PA/LAT CXR: Bibasilar atelectases have worsened. Minimally improved interstitial edema. No other change. . [**10-24**] CT Chest: 1. No CT evidence of pulmonary embolism. 2. Marked enlargement of left lower lobe mass and left hilar lymphadenopathy. The left lower lobe mass obstructs adjacent bronchi, resulting in post- obstructive atelectasis and/or consolidation within the lower lobe and inferior segment of the lingula. 3. New small pericardial and small left pleural effusion. 4. No significant change in right apical and superior segment right lower lobe pulmonary nodules, with morphology concerning for possible synchronous neoplasms. 5. Slight increase in left paratracheal and right hilar lymph nodes. Brief Hospital Course: A/P: 76 yo M with PMHx of stage IV NSCLC who presents with 3 wks of productive cough and now with hypoxia, tachycardia, and hypertension. . # PNEUMONIA: Clinical picture and chest xray most suggestive of LLL pneumonia, possibly post obstructive. Initially treated with vancomycin and levofloxacin; flagyl added for additional anaerobic coverage. Other considerations in the differential of shortness of breath include pulmonary embolism, ACS. CT chest showed LLL pneumonia. He was evaluated by IP via bronchoscopy; there was no stent placed. Radiation oncology saw the patient and set up a follow up appointment for additional consideration of radiation to the mass. He was discharged to complete a course of levofloxacin and metronidazole. . # COPD: emphysema per pulmonary notes but FEV1/FVC 105% of predicted and FEV1 85% of predicted in [**3-26**]. Given nebs during the hospitalization. . # Renal Failure: baseline Cr 1.4-1.7. Stayed at baseline throughout the admission. . # Hypertension: Continued lisinopril and HCTZ with holding parameters. . # Tachycardia: sinus tachycardia. Likely related to fever and pneumonia. Resolved for now, will continue to monitor. . # Hypercholesterolemia: continued statin. . # Pain: had pleuritic chest pain on admission. CTA negative for PE; thought secondary to pleural proximity of pneumonia. Treated with pain medications titrated to good effect. . # Lung Cancer: NSCLC, not currently on chemotherapy. Per onc notes previous chemo regimen has been palliative chemo. He has stage IV NSCLC. Further management per Dr. [**Last Name (STitle) 4149**]; follow up with rad-onc on [**11-2**], follow up with Dr. [**Last Name (STitle) 4149**] on [**11-3**]. Medications on Admission: Decadron 8 [**Hospital1 **] - peri chemo Doxazosin 2 daily Folic acid Neurontin 600 qhs HCTZ 12.5 daily Lisinopril 40 daily Prilosec 20 daily Zofran prn Oxycodone [**5-28**] q3h prn Compazine prn Simvastatin 20 daily Colace 100 [**Hospital1 **] MVI Discharge Medications: 1. Oxygen Oxygen 1-2L continues, pulse dose for portability 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:*21 Tablet(s)* Refills:*0* 3. Levofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q48H (every 48 hours). Disp:*2 Tablet(s)* Refills:*0* 4. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Folic Acid Oral 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Oral 10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. 11. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Post-obstructive pneumonia Stage IV non-small cell lung cancer Discharge Condition: Stable, afebrile, O2 sats < 88% with ambulation Discharge Instructions: You were admitted with pneumonia. You were treated with antibiotics and improved. You are being sent home to complete a course of antibiotics and with oxygen. You have follow up scheduled with Dr. [**Last Name (STitle) 4149**] and with Dr. [**Last Name (STitle) 39583**] in radiation oncology. . Please keep all your follow up appointments and take all medications as prescribed. If you develop any worsening shortness of breath, fevers, chills, abdominal pain, chest pain, weakness, numbness, or tingling, or other concerning symptoms, please seek medical attention immediately. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 19895**], MD Phone:[**0-0-**] Date/Time:[**2146-11-3**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 19895**], MD Phone:[**0-0-**] Date/Time:[**2146-11-3**] 10:00 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-11-1**] 8:30 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 39583**], MD. [**Last Name (Titles) 23**] [**Location (un) 442**]. Date/Time: [**2146-11-2**] 9:00AM

[ "600.00", "593.2", "403.90", "584.9", "354.0", "585.9", "530.81", "492.8", "427.89", "272.0", "790.6", "162.5", "486" ]

icd9cm

[ [ [] ] ]

[ "33.23" ]

icd9pcs

[ [ [] ] ]

9085, 9143

6218, 7912

335, 367

9250, 9300

3018, 3018

9928, 10471

2558, 2577

8212, 9062

9164, 9229

7938, 8189

9324, 9905

2592, 2999

276, 297

395, 1688

3034, 6195

1710, 2438

2454, 2542

2,446

121,561

27175

Discharge summary

report

Admission Date: [**2143-4-29**] Discharge Date: [**2143-5-9**] Date of Birth: [**2093-2-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2143-5-3**] Two vessel coronary artery bypass grafting(LIMA to LAD, vein graft to left PDA) and Aortic Valve Replacement utilizing a [**Street Address(2) 66683**]. [**Male First Name (un) 923**] mechanical valve. [**2143-5-1**] Emergent Fasciotomy of Left Upper Extremity [**2143-4-29**] Cardiac Catheterization Past Medical History: - Aortic stenosis - Hyperlipidemia - Hypothyroidism - Anemia - Depression/Anxiety - History of L carotid bruit - Hodgkin's disease: [**2116**], s/p chemo and XRT - Recent injury to L hand: laceration [**2-28**] power tool accident, multiple stitches on upper flexor surface of forearm and palm, dressing in place, stitches to be removed on Friday, on Keflex 500 [**Hospital1 **] Social History: 25 pk-yr smoking history, quit 17y ago; social EtOH Family History: Father with MI at 53yo and CABG in mid50s Physical Exam: Vitals- T 98.2, HR 90, BP 120s-130s/100-107, O2sat 99% RA General- awake and alert, lying flat in bed, NAD HEENT- sclerae anicteric, moist MM Neck- unable to assess JVD lying flat, systolic murmur radiating to carotids Lungs- CTAB anteriorly Heart- RRR, normal S1/S2, 3/6 SEM at RUSB Abd- mildly distended but soft, NT, NABS Ext- no LE edema, DP pulses 2+ b/l, feet warm and well-perfused, Neuro- grossly nonfocal Pertinent Results: [**2143-4-29**] Cath: 1. Two vessel coronary artery disease including severe (80%) LMCA stenosis 2. Moderate aortic stenosis with a mean gradient of 20mmHg and [**Location (un) 109**] of 0.98 cm2. 3. Hemodynamics: mildly elevated right heart filling pressure (RVEDP 12mmHg) and moderately elevated left heart filling pressure (LVEDP 21mmHg). Cardiac output 4.7 L/min, cardiac index of 2.4. 4. Normal ventricular function with EF 65%. 5. Ostial RIMA stenosis, patent LIMA. [**2143-5-9**] 07:50AM BLOOD Hct-25.7* [**2143-5-7**] 05:50AM BLOOD WBC-8.3 RBC-3.05* Hgb-9.4* Hct-27.6* MCV-91 MCH-30.7 MCHC-33.9 RDW-14.5 Plt Ct-379# [**2143-4-29**] 10:40AM BLOOD WBC-5.0 RBC-3.59* Hgb-11.9* Hct-32.8* MCV-91 MCH-33.3* MCHC-36.4* RDW-13.1 Plt Ct-351 [**2143-5-9**] 07:50AM BLOOD PT-25.4* INR(PT)-2.6* [**2143-5-7**] 05:50AM BLOOD Glucose-94 UreaN-22* Creat-0.9 Na-134 K-4.0 Cl-96 HCO3-29 AnGap-13 [**2143-4-29**] 10:40AM BLOOD Glucose-110* UreaN-14 Creat-0.8 Na-133 K-4.4 Cl-101 HCO3-25 AnGap-11 [**2143-5-6**] 05:17AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.9 Brief Hospital Course: Mr. [**Known lastname 40962**] [**Last Name (Titles) 1834**] elective cardiac catheterization for a positive stress test and was found to have severe left main coronary artery disease. He had an IABP placed after he had chest pain post-cath. His aortic valve was also evaluated during cath, and he was found to have mild to moderate aortic stenosis. He was admitted to the CCU to await CABG-AVR. He remained chest pain-free for the rest of his stay in the CCU. He was maintained on ASA and a high-dose statin. He was also put on a beta blocker that was titrated up for better perioperative beta blockade. He was also put on IV heparin for his IABP. He had a carotid US that showed less than 40% stenosis of his internal carotid arteries bilaterally. He was scheduled to go to the OR on [**5-1**] for CABG-AVR. However, he began to develop a hematoma in the area of his left forearm laceration in the early morning before his scheduled surgery. He had severe pain in his arm and hand, and there was concern for evolving compartment syndrome. His IV heparin was discontinued and Plastic Surgery was called for evaluation. They removed the stitches on his forearm to allow drainage of the hematoma. However, it continued to expand and the decision was made to take him for urgent fasciotomy to prevent compartment syndrome. As he would be receiving large amounts of IV heparin on bypass, Cardiac Surgery decided to postpone his CABG-AVR until the fasciotomy was performed and his wound was stable. He was taken for fasciotomy the morning of [**5-1**]. He was kept on IV Ancef postoperatively. On [**5-3**], Dr. [**Last Name (STitle) **] performed two vessel coronary artery bypass grafting and an aortic valve replacment with a St. [**Male First Name (un) 923**] mechanical valve. For further surgical details, please see seperate dictated op note. Following the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. The IABP was weaned and removed without complication. He initially required epicardial pacing for complete heart block. The EP service was consulted for potential pacemaker. Over several days, his native heart rate improved and complete heart block resolved. Pacemaker was therefore not indicated and Warfarin anticoagulation was initiated. On postoperative day three, he transferred to the SDU. He transiently required Heparin for a subtherapeutic INR. Warfarin was dosed for a goal INR between 2.0 - 3.0. Low dose beta blockade was intitated and advanced as tolerated. He remained in a normal sinus rhythm with no further episodes of heart block. Over several additional days, he made steady progress with physical therapy and continued to make clinical improvements with diuresis. The Plastic surgery team continued to follow his wound, which remained stable. He was cleared for discharge to home on postoperative six. Dr. [**Last Name (STitle) **] will monitor his Warfarin as an outpatient. He will also need to follow up with Plastic surgery as directed. His postop cardiac follow up appointment will be arranged in approximately 4 weeks. Medications on Admission: ASA 81mg qd Lipitor 20mg qd Synthroid 125mcg qd Prozac 40mg qd Keflex 500mg qid (for stitches) Valtrex 500mg qd Ibuprofen prn Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 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:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO QD (). Disp:*30 Tablet(s)* Refills:*2* 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed. Disp:*50 Tablet(s)* Refills:*0* 9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:*20 Tablet(s)* Refills:*0* 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. Disp:*40 Capsule, Sustained Release(s)* Refills:*0* 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO qpm: Take as directed. Daily dose may vary according to INR. Check INR [**5-13**] with results to Dr. [**Last Name (STitle) **] office. Disp:*60 Tablet(s)* Refills:*2* 13. Zantac 150 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: CAD and AS - s/p CABG and AVR, Compartment syndrome - s/p fasciotomy, HTN, elevated cholesterol, Hodgkins Lymphoma - s/p thoracotomy with chemotherapy and radiation, Hypothyroidism, Herpes Simplex, History of Zoster, Depression Discharge Condition: Stable. Good. Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Monitor Warfarin as outpatient with Dr. [**Last Name (STitle) **]. Warfarin should be adjusted for goal INR between 2.0 - 3.0. INR should be checked with 48-72 hours after discharge. Followup Instructions: Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**5-1**] weeks - call for appt. Plastic surgery hand clinic in [**1-28**] weeks, call ([**Telephone/Fax (1) 57665**] for appt or see Plastic surgeon in [**Hospital1 1474**] Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 1 weeks and for INR checks- call for appt. Local cardiologist, Dr. [**Last Name (STitle) **] in [**3-1**] weeks - call for appt. Completed by:[**2143-5-24**]

[ "285.9", "923.10", "E928.8", "411.1", "426.0", "414.01", "300.00", "746.4", "425.4", "428.0", "424.1", "401.9", "V10.72", "790.01", "909.2", "E879.2", "958.8" ]

icd9cm

[ [ [] ] ]

[ "37.23", "35.22", "83.14", "37.61", "36.11", "96.59", "88.56", "36.15", "86.22", "88.72", "97.44", "39.61", "88.53", "99.04" ]

icd9pcs

[ [ [] ] ]

7657, 7712

2696, 5847

330, 647

7984, 8000

1628, 2673

8501, 8959

1135, 1178

6023, 7634

7733, 7963

5873, 6000

8024, 8478

1193, 1609

280, 292

669, 1050

1066, 1119

29,436

141,068

48959

Discharge summary

report

Admission Date: [**2168-9-7**] Discharge Date: [**2168-9-20**] Date of Birth: [**2087-7-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9853**] Chief Complaint: Dyspnea. Major Surgical or Invasive Procedure: PICC line placement [**2168-9-16**]. History of Present Illness: 81 [**Hospital **] nursing home resident with multiple medical problems including [**Name2 (NI) **] palsy, mild mental retardation, who was admitted to [**Hospital 883**] Hospital in [**Month (only) 205**] and treated for urosepsis and a possible infectious eneterococcal endocarditis. She was treated for these and was doing well at her group home until [**9-7**] when she developed shortness of breath and tachypnea. . Of note, regarding her previous admission: she was admitted to [**Hospital 883**] Hospital from [**2168-7-15**] to [**2168-7-31**] for a urosepsis and infectious endocarditis. She presented hypotensive, T 100.1, minimally interactive and somewhat ill-appearing, and was given IV ceftriaxone 1gm in the ED. She was empirically started on vancomycin/ceftazidime and quickly defervesced (temp in [**Name (NI) **] unclear in d/c summary, but may be 100.1). Blood and urine cultures were sent. Urine cultures grew pseudomonas and 2 klebsiella colonies, sensitive to ciprofloxacin. 2/2 blood cultures on day of admission grew Enterococcus faecalis, sensitive to ampicillin. One subsequent blood culture had no growth. TTE was performed and showed tricuspid regurgitation (2+) and mitral regurgitation (1+) with a small, mobile mass on the TV c/w a torn cordae vs small vegetation. Because IV access was difficult to obtain (picc failed, hickman placement failed), the patient was started on oral ampicillin for enterococcal infectious endocarditis, which was to be complete a 5 week course of antibiotiocs (to [**2168-8-22**]), 500mg po qid. She also completed 1 week of IV antibiotics (vanco?) while in house. Ciprofloxacin 500mg [**Hospital1 **] was to be continued until [**2168-7-31**] for her UTI (a 14 day course). She should have had f/up with Dr [**First Name8 (NamePattern2) 233**] [**Last Name (NamePattern1) 102804**] (ID) at FH on [**8-24**]. . In the [**Hospital1 18**] ED, the patient was afebrile but tachypneic and tachycardic. T 99.0 HR 104 BP 148/67 RR 33 O2sat 96% on 2L. ECG showed atrial flutter/fibrillation, right bundle branch block, and new inconsistent ST depression in V3. Ciprofloxacin 500 mg was given (nursing record). She was deemed to be in CHF based on an elevated BNP ([**Numeric Identifier 16351**]) and elevated JVP (known TR). She improved with lasix and diuresis. Her aflutter improved with lopressor. Past Medical History: 1. Recent diagnosis of tricuspid endocarditis status post six-week course of ampicillin PO. 2. Mental retardation 3. Seizure disorder 4. Cerebral palsy 5. Legal blindness with optic atrophy 6. Severe sensorineural hearing loss 7. Status post left hip replacement in [**2159**] and [**2166**] 8. Osteoarthritis 9. Mood disorder 10. History of psychotic depression with auditory hallucinations 11. Hemorrhoids 12. Gastroesophageal reflux disease 13. Hypertension 14. Dysphagia 15. Asthma Social History: Lives in group home, has guardian who is case manager at group home. Has 4 siblings, and is closest to her 2 sisters, who live in [**Location (un) 8973**]. At baseline patient is blind, hard of hearing, and unable to take care of ADLs. Reportedly can be transfered to wheelchair. Denies tobacco, alcohol, or drug use. Family History: Non-contributory. Physical Exam: VS: T96, BP 87/45, P102, 98% on 4L NC GEN: Elderly woman, agitated with headshaking - able to say "leave me alone" but unable to verbalize name or any other answers clearly. HEENT: Sclera anicteric; severe diplopia (pt blind per hx) CV: [**Last Name (un) **] irregular, distant heart sounds, III/VI SEM at LUSB CHEST: CTA anteriorly ABD: Soft, non-distended, nontender EXT: WWP Pertinent Results: Labwork on admission: [**2168-9-7**] 04:15PM WBC-11.6*# RBC-3.08* HGB-9.5* HCT-29.7* MCV-96 MCH-30.7 MCHC-31.8 RDW-16.0* [**2168-9-7**] 04:15PM PLT COUNT-203 [**2168-9-7**] 04:15PM NEUTS-81.5* LYMPHS-11.9* MONOS-2.5 EOS-0.2 BASOS-0.7 [**2168-9-7**] 04:15PM GLUCOSE-232* UREA N-48* CREAT-1.4* SODIUM-135 POTASSIUM-7.6* CHLORIDE-103 TOTAL CO2-23 ANION GAP-17 [**2168-9-7**] 04:15PM CK-MB-NotDone proBNP-[**Numeric Identifier 102805**]* [**2168-9-7**] 04:15PM cTropnT-0.02* [**2168-9-7**] 04:15PM PHENYTOIN-14.5 . [**Date range (3) 102806**] BLOOD CULTURE **FINAL REPORT [**2168-9-10**]** Blood Culture, Routine (Final [**2168-9-10**]): REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ON [**2168-9-8**] @ 8:50 P.M.. ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. LINEZOLID SENSITIVITY REQUESTED BY DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (PAGER [**Numeric Identifier 102807**]) ON [**2168-9-10**]. HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml of gentamicin. Screen predicts NO synergy with penicillins or vancomycin. Consult ID for treatment options. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. BETA LACTAMASE NEGATIVE. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS | AMPICILLIN------------ <=2 S LINEZOLID------------- 2 S PENICILLIN G---------- 8 S VANCOMYCIN------------ <=1 S Anaerobic Bottle Gram Stain (Final [**2168-9-8**]): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. Aerobic Bottle Gram Stain (Final [**2168-9-9**]): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. . ECG Study Date of [**2168-9-7**] Atrial fibrillation with rapid ventricular response. Right bundle-branch block. Possible left posterior hemiblock. Non-specific ST-T wave changes. Low QRS voltage in the limb leads. Compared to the previous tracing of [**2167-7-29**] rapid atrial fibrillation is new. . CHEST (PORTABLE AP) Study Date of [**2168-9-7**] 4:03 PM AP UPRIGHT CHEST: Mild respiratory motion somewhat limits the evaluation. Moderate cardiomegaly is unchanged. There are bilateral Kerley B lines and perihilar haziness which represents mild CHF. Left lower lobe atelectasis is noted. The lungs are otherwise clear without evidence of consolidation, effusion, or pneumothorax. IMPRESSION: Mild CHF. . TTE (Complete) Done [**2168-9-8**] The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-6**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a moderate-sized (1.3 x 0.8 cm) vegetation on the anterior tricuspid leaflet. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Tricuspid valve vegetation. Mild symmetric LVH with preserved systolic function. Mildly dilated right ventricle with preserved systolic function. Mild to moderate mitral regurgitation. Moderate to severe tricuspid regurgitation. Compared with the report of the prior study (images unavailable for review) of [**2163-7-22**], tricuspid vegetation, tricuspid and mitral regurgitation are all new. . CHEST (PORTABLE AP) Study Date of [**2168-9-14**] IMPRESSION: Heart is persistently enlarged, and pulmonary vascularity appears engorged. Bilateral interstitial opacities likely reflect interstitial edema. Increasing focus of airspace disease in right infrahilar region may reflect either asymmetric pulmonary edema or a superimposed process such as aspiration or developing pneumonia. . PICC LINE PLACMENT SCH Study Date of [**2168-9-16**] PICC line placement with no immediate complication. . Labwork on discharge: Brief Hospital Course: 81 [**Hospital **] nursing home resident with multiple medical problems including [**Name2 (NI) **] palsy, mild mental retardation, who was admitted to [**Hospital 883**] Hospital in [**Month (only) 205**] and treated for urosepsis and a possible infectious eneterococcal endocarditis. She was treated for these and was doing well at her group home until [**2168-9-7**] when she developed shortness of breath and tachypnea. She was noted to be in new atrial fibrillation/flutter with rapid rate and congestive heart failure. . 1. Atrial fibrillation/flutter: The patient was was in new atrial fibrillation/flutter on presentation to the emergency department. Her shortness of breath and tachycardia improved with metoprolol 5 mg IV and metoprolol 25 mg PO. She was restarted on her home metoprolol 25 mg TID. Diltiazem was started for improved rate control, but this was discontinued after an episode of hypotension as below. The patient is discharged on metoprolol 12.5 mg [**Hospital1 **], with good control of heart rate 80-90s, although she has occasional brief second epidoses of tachycardia to the 120s. Her metoprolol can be titrated on discharge, with recomendation to initiate digoxin if her blood pressure does not permit increased blood pressure agents. Anticoagulation was discussed but not initiated during admission due to her comorbidities; this can be further discussed as an outpatient. . 2. Diastolic congestive heart failure: The patient was admitted with an episode of diastolic failure in the setting of atrial fibrillation/flutter with a rapid ventricular rate. She was noted to have a preserved ejection fraction on echocardiogram. She was ruled out for myocardial infarction with cardiac enzymes. Her initial BNP was 25,000, and she was diuresed with lasix the first day. She responded well to this and goal was for even throughout the rest of her admission. . 3. Endocarditis/Enterococcal bacteremia: The patient had received a six-week course of ampicillin PO due to inability to place intravenous access at [**Hospital 883**] Hospital. TTE here the day after admission showed a 1.3 cm vegetation of the tricuspid valve which had increased from her prior study at [**Hospital1 882**] in mid-[**Month (only) 205**]. Blood cultures were positive for Enterococcus faecalis from admission through [**2168-9-12**]. She remained afebrile without leukocytosis throughout. She was given Ampicillin IV for treatment, except for a two day period where she was without intravenous access and was treated with Linezolid PO. A PICC line was placed [**2168-9-16**]. She is being sent on Ampicillin IV to complete a six week course starting [**2168-9-13**], the first day of negative blood cultures. She was started on Streptomycin IM [**2168-9-16**] to complete a seven-day course for synergy with Ampicillin. When she has completed her seven-day course of Streptomycin, she should be started on a course of Ceftriaxone for synergy. She should have the following laboratories drawn: CBC, BMP, LFT weekly; ESR, CRP every other week. All laboratory results should be faxed to Infectious Disease R.Ns. at ([**Telephone/Fax (1) 18871**]. All questions regarding outpatient antibiotics should be directed to the Infectious Disease R.Ns. at ([**Telephone/Fax (1) 11581**] or . 4. Hypotension: The patient had an episode of hypotension [**2168-9-14**] likely related to initiation of diltiazem for rate control versus hypovolemia versus early sepsis/aspiration event. She was transferred to the intensive care unit overnight but was stable from transfer back to the floor the next day. There was no evidence of a cardiogenic etiology. The patient was given intravenous fluids and her antihypertensives were held with improvement. She was started on [**Month/Day/Year 102808**] and Flagyl for possible aspiration pneumonia, in addition to Ampicillin as above for endocarditis. Speech and Swallow was consulted as below for aspiration. Three days prior to discharge, her metoprolol was restarted at 12.5 mg [**Hospital1 **], with good control of heart rate 80-90s, and can be titrated as an outpatient as needed. . 5. Aspiration pneumonia: The patient was noted to have infiltrates suggestive of aspiration pneumonia on chest x-ray [**2168-9-13**] ordered due to hypotension as above. She is being treated with Ceftazixine and Flagyl started [**2168-9-13**] to complete a seven-day course. . 6. Tachypnea/agitation: The patient was observed to be occasionally agitated, mostly at night, with tachycardia and tachypnea up to the 40s, consistent with agitated derlium. Examination was otherwise unremarkable at these times. This was managed with Zydis 2.5 mg PRN with good effect. . 7. Presumptive obstructive sleep apnea: The patient was observed to require 2-3L O2 by nasal cannula at night to maintain oxygen saturations in the mid-90s. This was likely obstructive sleep apnea, as her 02 saturations off oxygen during daytime ranged from 93-97% on RA. . 8. Imparied glucose tolerance/diabetes: The patient's fasting serum glucose have been noted to be elevated. She was maintained in a diabetic diet with finger stick glucose as needed. . 9. History of seizure disorder: No evidence of active seizures. The patient was continued on keppra and dilantin. . 10. Anemia: Normocytic/macrocytic. Her anemia was stable during admission in the mid-20s, which is slighly lower from baseline high-20s. There were no signs or symptoms of active bleeding and her stool was guaiac negative. Evaluation is consistent with anemia of chronic disease, with B12 and folate within normal limits. . 11. Asthma: She was continued on Advair. . Diet: She was noted to aspirate on evaluation by Speech and Swallow and her diet was changed to ground solids with nectar-thickened liquids. . Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (guardian [**Telephone/Fax (1) 72440**]). [**Name (NI) **] [**Name (NI) **] (sister [**Telephone/Fax (1) 102809**]) from [**Location (un) 8973**]. . Code Status/Goals of Care: DNR/DNI after discussion with guardian and sister. . Disposition: Skilled Nursing Facility Medications on Admission: Advair Keppra 250 am, 500 pm Phenytoin 150 am, 200 pm Omeprazole 20 daily MVI Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Discharge Diagnosis: Primary: Atrial flutter Diastolic congestive heart failure Tricuspid valve endocarditis Aspiration pneumonia . Secondary: Mental retardation Seizure disorder Cerebral palsy Legal blindness with optic atrophy Severe sensorineural hearing loss Status post left hip replacement in [**2159**] and [**2166**] Osteoarthritis Mood disorder Psychotic depression with auditory hallucinations Hemorrhoids Gastroesophageal reflux disease Hypertension Dysphagia Asthma Discharge Condition: Afebrile, stable vital signs. Discharge Instructions: You were admitted with a fast heart rate and difficulty breathing. Your heart rate was controlled with medications and your were given diuretics to take fluid off from around your lungs. You were also noted to have a worsening infection in your heart and will be treated with intravenous antibiotics for at least six weeks. You are also being given antibiotics to treat a potential pneumonia. . Please contact a physician or report to an emergency department if you experience fevers, chills, chest pain, shortness of breath, palpitations, or any other concerning signs or symptoms. . Please take your medications as prescribed. - You should continue ampicillin, an antibiotic, to complete a six week course from start date [**2168-9-13**]. - You should continue [**Last Name (LF) **], [**First Name3 (LF) **] antibiotic, to complete a seven-day course started [**2168-9-13**]. - You should continue flagyl, an antibiotic, to complete a seven-day course started [**2168-9-13**]. - You should continue streptomycin, an antibiotic, to complete a seven-day course starting [**2168-9-16**]. - You should start ceftriaxone, an antibiotic, after completing the course of streptomycin (starting [**2168-9-23**]). - Your metoprolol was decreased to 12.5 mg twice daily. . Please keep your follow-up appointments as below. Followup Instructions: Follow-up with Infectious Disease: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2168-10-11**] 9:00 . Previously scheduled appointments: Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 3506**] Date/Time:[**2168-11-15**] 10:00 Completed by:[**2168-9-20**]

[ "455.6", "507.0", "428.0", "493.90", "421.0", "389.10", "401.9", "424.0", "427.32", "285.9", "530.81", "276.8", "317", "599.0", "428.31", "296.90", "343.9", "345.90", "787.20", "369.4", "V13.02", "041.04", "707.03", "276.0", "715.90", "427.31", "424.2", "790.7" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

14776, 14829

8498, 14648

323, 362

15330, 15362

4052, 4060

16727, 17166

3619, 3638

14850, 15309

14674, 14753

15386, 16704

3653, 4033

8475, 8475

275, 285

390, 2757

4074, 8460

2779, 3267

3283, 3603

17,162

130,451

8097

Discharge summary

report

Admission Date: [**2106-1-21**] Discharge Date: [**2106-2-6**] Date of Birth: [**2024-12-14**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2106-1-28**] Three Vessel Coronary Artery Bypass Grafting(left internal mammary to left anterior descending, vein grafts to obtuse marginal and posterior descending artery) on IABP [**2106-2-3**] AICD Implantation(Guidant Vitality DS DR [**Last Name (STitle) **] [**Name (STitle) **]) History of Present Illness: Mr. [**Known lastname 22771**] is an 81 year old Spanish speaking male who was recently diagnosed with pulmonary embolus in [**2105-12-6**] and has been anticoagulated with Warfarin. Since that time, he has continued to complain of pleuritic chest pain. On the day of admission, the patients VNA found him diaphoretic and complaining of chest pain, which was exacerbated by exertion. The chest pain was substernal and did not radiate. EMS was notified. At time of EMS arrival, his systolic blood pressure was in the 80's. He received Aspirin and 250 cc of normal saline. While in the EW, he continued to complain of chest pain. EKG was remarkable for diffuse anterolateral ST depressions and T wave inversions. He was started on intravenous Heparin and Integrilin while being loaded with Plavix. Cardiac enzymes were elevated: CK 703, MB 65, Troponin 0.59. An echocardiogram revealed severe hypokinesis of the anterior septum and extensive apical akinesis. Overall left ventricular systolic function was moderately to severely depressed with an ejection fraction of 30%. Cardiology activated the cath lab but Mr. [**Known lastname 22771**] initially refused. He was therefore admitted to [**Hospital Ward Name 121**] 2 for further medical management and evaluation. Past Medical History: History of Pulmonary Embolus, Hypertension, GERD, s/p Appendectomy Social History: Lives with his grandson, not working. Denies tobacco, alcohol and illicit drug use. No past IVDU. Family History: Denies premature CAD. Both parents died at a very old age. Physical Exam: Vitals: T 96.7, BP 100/50, HR 54, RR 18, SAT 100% on 2L General: elderly male in no acute distress HEENT: oropharynx benign, MMM, PERRL, EOMI Neck: supple, no JVD, Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal, alert and oriented Pertinent Results: [**2106-1-21**] 01:30PM BLOOD WBC-4.3 RBC-3.75* Hgb-11.5* Hct-33.1* MCV-88 MCH-30.6 MCHC-34.7 RDW-13.8 Plt Ct-241 [**2106-1-21**] 04:27PM BLOOD PT-43.0* PTT-34.6 INR(PT)-4.9* [**2106-1-21**] 01:30PM BLOOD Glucose-135* UreaN-36* Creat-1.3* Na-138 K-4.0 Cl-106 HCO3-22 AnGap-14 [**2106-1-21**] 01:30PM BLOOD CK(CPK)-703* [**2106-1-21**] 01:30PM BLOOD CK-MB-65* MB Indx-9.2* [**2106-1-22**] 10:00AM BLOOD Calcium-8.7 Phos-2.7# Cholest-148 [**2106-1-25**] 04:10PM BLOOD %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE [**2106-1-22**] 10:00AM BLOOD Triglyc-193* HDL-41 CHOL/HD-3.6 LDLcalc-68 [**2106-2-5**] 10:58AM BLOOD WBC-8.8 RBC-3.73* Hgb-11.4* Hct-33.1* MCV-89 MCH-30.6 MCHC-34.6 RDW-14.4 Plt Ct-356 [**2106-2-6**] 05:05AM BLOOD PT-34.1* INR(PT)-3.7* [**2106-2-6**] 05:05AM BLOOD UreaN-19 Creat-1.0 K-4.6 [**2106-2-5**] 10:58AM BLOOD Glucose-114* UreaN-19 Creat-1.1 Na-129* K-5.0 Cl-96 HCO3-23 AnGap-15 [**2106-2-3**] 04:49PM BLOOD ALT-21 AST-23 AlkPhos-64 Amylase-33 TotBili-0.4 [**2106-2-5**] 10:58AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.8 [**2106-1-25**] 04:10PM BLOOD %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE [**2106-1-22**] 10:00AM BLOOD Triglyc-193* HDL-41 CHOL/HD-3.6 LDLcalc-68 [**2106-2-5**] 10:58AM BLOOD Digoxin-0.9 Brief Hospital Course: Mr. [**Known lastname 22771**] was admitted with a NSTEMI. Given his acute coronary syndrome, he initially remained on Integrilin. Heparin was not continued as his prothrombin time remained supratherapeutic. After discussion with his son, he became amenable to cardiac catheterization. For several days, he remained pain free on medical therapy and cardiac enzymes continued to trend down. On hospital day four, he experienced recurrent chest pain. He underwent cardiac catheterization on [**1-25**] which revealed a left dominant system with left main and LAD disease. The Left Main had a 70% long stenosis and the LAD had a 90% stenosis at its origin. The LCX was a large dominant vessel with only minor luminal irregularities and the RCA was a small non-dominant vessel with an ostial 40% stenosis and mild diffuse disease. Left ventriculography revealed severe systolic dysfunction with anterior, anteroapical and inferoapical akinesis. The ejection fraction was 25-30%. Based on the above results, cardiac surgery was consulted. He was deemed a surgical candidate but surgical intervention was initially delayed given his supratherapeutic prothrombin time and recent Plavix and Integrilin. He was maintained on Heparin and Nitro. Despite intravenous and medical therapy, he continued to experience recurrent angina. He was taken back to the cath lab for IABP insertion on [**1-27**]. His chest pain improved but due to his instability, he underwent surgical revascularization surgery with Dr. [**Last Name (STitle) 914**] on [**1-28**]. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU in stable condition. His CSRU was complicated by recurrent ventricular fibrillation. The EP service was consulted. He was started on Amiodarone and required multiple defibrillations. A repeat echocardiogram was performed and showed no major change from a previous preop echocardiogram. His overall left ventricular systolic function remained moderately to severely depressed. There was global hypokinesis with akinesis of the distal LV and apex. No LV thrombus was seen. Given concern for ischemia as a source for his ventricular dysrhythmias, repeat cardiac catheterization was performed to assess graft patency. All three grafts were found to be patent. An ICD was placed on [**2106-2-3**]. Subsequently he made steady improvement and was anticoagulated for atrial fibrillation. Warfarin was dosed for a goal INR between 2.0 - 3.0. He tolerated medical therapy which included Amiodarone, Digoxin, and beta blockade. No further ventricular rrhythmias were noted. Digoxin levels were monitored and titrated accordingly. He was eventually cleared for discharge and transferred to rehab on [**2106-2-6**]. He will follow up with Dr. [**Last Name (STitle) 914**] as directed and will follow up with the EP service on [**2-11**]. Medications on Admission: 1.Aspirin 81 mg Tablet, One (1) Tablet, PO DAILY 2.Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3.Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4.Pantoprazole 40 mg Tablet, Delayed Release PO Q24H (every 24 hours). 5.Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY 6.Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: for chest pain. 7.Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual up to 3 times: may take every 5 minutes x 3 for chest pain. 8.Oxycodone-Acetaminophen 5-500 mg Capsule Sig: [**12-7**] Capsules PO every eight (8) hours as needed for pain for 7 days: for pain. Disp:*21 Capsule(s)* Refills:*0* 9.Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): No coumadin today- [**2106-2-6**].(INR 3.7 on [**2-5**] and [**2-6**]- no coumadin given on [**2-5**]). Recheck [**2-7**] and adjust dose accordingly. Tablet(s) 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: Roscommon Discharge Diagnosis: Coronary Artery Disease - s/p CABG, NSTEMI, Postoperative Ventricular Fibrillation - s/p AICD placement, Congestive Heart Failure, Pulmonary Embolus, Hypertension, GERD, s/p Appendectomy Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [**Last Name (STitle) 914**] in [**3-10**] weeks - call for appt. Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**1-8**] weeks - call for appt. Local cardiologist in [**1-8**] weeks - call for appt. EP Service, Device Clinic, [**Hospital Ward Name 23**] 7 on [**2106-2-11**] @ 1130AM. Completed by:[**2106-4-7**]

[ "E849.7", "414.01", "E878.2", "410.71", "427.5", "428.0", "530.81", "401.9", "427.41", "997.1", "416.8", "415.19" ]

icd9cm

[ [ [] ] ]

[ "99.62", "36.15", "88.53", "97.44", "37.94", "37.26", "37.23", "36.12", "99.20", "39.61", "99.04", "88.56", "38.93", "37.61", "99.60" ]

icd9pcs

[ [ [] ] ]

8537, 8573

3844, 6733

331, 621

8803, 8809

2619, 3821

9127, 9490

2139, 2199

7546, 8514

8594, 8782

6759, 7523

8833, 9104

2214, 2600

281, 293

649, 1916

1938, 2007

2023, 2123

61,078

101,372

39675

Discharge summary

report

Admission Date: [**2130-10-2**] Discharge Date: [**2130-10-4**] Date of Birth: [**2085-9-4**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 5810**] Chief Complaint: Stridor Major Surgical or Invasive Procedure: mechanical ventilation Extubation History of Present Illness: Ms. [**Known lastname 87445**] is a 45F with schizoaffective disorder, polysubstance dependence, and SAH s/p coiling L MCA aneurysm [**2130-7-2**] and repeat coiling for recannalization on [**9-20**], [**2129**] who initially presented to OSH ED with sore throat x 1 week. Neck X-ray was performed and revealed possible thickened epiglottis but she left the ED AMA prior to finalized [**Location (un) 1131**]. She then returned to the OSH ED at approximately 10pm with new onset stridor and hoarseness. She was also noted to be altered with slurred speech and there was concern for intoxication. She was intubated with a 7-0 ETT for airway protection with emesis noted post-intubation. CT neck reportedly revealed thickened epiglottis and CT head was negative for acute process. She received Ceftriaxone, Decadron 10mg IV, and was transferred here by [**Location (un) 7622**]. She received pancuronium, 4mg IV versed, 4mg IV ativan at OSH. Labs there remarkable for ABG 7.40/53/75, WBC 4.6. In [**Hospital1 18**] ED, initial vs were: 98.6 77 101/76 16 96%. She was given propofol for sedation. CXR confirmed ETT placement. ENT was consulted and epiglottis was visualized and felt to be slightly inflamed. They recommended continuing dex 10mg IV q8 and antibiotics and plan for extubation when has cuff leak. Neurosurgery was also notified. VS prior to transfer: 98.6 113/74 72 16 100% on AC FiO2 100% Vt500 RR16 PEEP 5. On the floor, she is intubated and sedated. Past Medical History: - Asthma - h/o polysubstance abuse - ADHD - Depression/anxiety vs bipolar disorder - Schizoaffective disorder - s/p overdose [**2125**] c/b respiratory failure - SAH s/p coiling L MCA aneurysm [**7-/2130**] with recannalization on MRI and repeat coiling [**2130-9-20**] Social History: - originally from [**Male First Name (un) **]; has a son and a daughter but no contact info at time of admission - Tobacco: denied at osh - per her nephew, she was a heavy smoker in past - Alcohol: denied at osh after extubation here, denied any substance use, reported only taking prescribed medications Family History: unable to otbain at time of admission Physical Exam: Physical Exam on Arrival to ICU: VS: Tcurrent: 36.2 ??????C, HR: 79, BP 104/70, RR 18, O2Sat 98% on CMV/Assist. PEEP 5, FiO2 50%, RR 18, ABG: 7.51/41/205//9 General: Intubated, sedated HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL, 2mm Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally with crackles R base, no wheezes or ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No lesions or rashes. Pertinent Results: [**2130-10-2**] 02:05AM BLOOD WBC-11.1* RBC-3.59* Hgb-11.4* Hct-34.4* MCV-96 MCH-31.9 MCHC-33.2 RDW-13.3 Plt Ct-279 [**2130-10-2**] 05:52AM BLOOD WBC-9.3 RBC-3.65* Hgb-11.8* Hct-35.4* MCV-97 MCH-32.3* MCHC-33.3 RDW-13.1 Plt Ct-281 [**2130-10-2**] 05:52AM BLOOD Neuts-91.1* Lymphs-7.1* Monos-1.0* Eos-0.3 Baso-0.5 [**2130-10-3**] 04:37AM BLOOD WBC-15.7*# RBC-3.67* Hgb-11.6* Hct-35.0* MCV-95 MCH-31.8 MCHC-33.3 RDW-12.8 Plt Ct-286 [**2130-10-2**] 02:05AM BLOOD PT-12.7 PTT-24.1 INR(PT)-1.1 [**2130-10-3**] 04:37AM BLOOD PT-12.6 PTT-123.1* INR(PT)-1.1 [**2130-10-2**] 02:05AM BLOOD Fibrino-335 [**2130-10-2**] 05:52AM BLOOD Glucose-167* UreaN-10 Creat-0.6 Na-141 K-4.1 Cl-101 HCO3-29 AnGap-15 [**2130-10-2**] 03:00AM BLOOD ALT-12 AST-18 LD(LDH)-157 AlkPhos-75 TotBili-0.2 [**2130-10-2**] 02:05AM BLOOD Lipase-22 [**2130-10-2**] 05:52AM BLOOD Calcium-9.5 Phos-2.7 Mg-2.1 Iron-66 [**2130-10-2**] 05:52AM BLOOD calTIBC-326 Ferritn-21 TRF-251 [**2130-10-2**] 03:00AM BLOOD VitB12-393 Folate-9.5 [**2130-10-2**] 07:36PM BLOOD Vanco-5.2* [**2130-10-2**] 02:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-POS Tricycl-NEG [**2130-10-2**] 03:14AM BLOOD Type-ART Temp-37.0 Rates-/16 Tidal V-500 FiO2-100 pO2-205* pCO2-41 pH-7.51* calTCO2-34* Base XS-9 AADO2-488 REQ O2-80 -ASSIST/CON Intubat-INTUBATED Comment-GREEN TOP [**2130-10-2**] 01:54PM BLOOD Type-ART Rates-/16 Tidal V-450 PEEP-5 FiO2-40 pO2-137* pCO2-48* pH-7.39 calTCO2-30 Base XS-3 Intubat-INTUBATED Vent-CONTROLLED [**2130-10-2**] 12:13PM BLOOD Lactate-4.4* [**2130-10-2**] 01:54PM BLOOD Lactate-2.2* HISTORY: Epiglottitis with intubation, to assess for acute abnormality. FINDINGS: In comparison with the study of [**10-2**], the endotracheal and nasogastric tubes have been removed. The atelectatic streak in the left mid zone has cleared. At the current time, there is no evidence of acute pneumonia or vascular congestion or pleural effusion. Brief Hospital Course: Assessment and Plan: 44 year old woman with schizoaffective disorder and SAH s/p coiling L MCA aneurysm transferred from OSH with with epiglottitis and resp distress now intubated. . #. Epiglottitis/Hypercarbic Respiratory Failure: Patient initially presented to OSH with sore throat and was found to have imaging (Neck X ray and CT per report) consistent with epiglottitis. ABG also consistent with hypercarbia and respiratory acidosis with concomitant metabolic alkalosis. She left OSH ED and subsequently presented with stridor and was intubated for airway protection. Epiglottitis can be caused by thermal or inhalational injury but is more commonly caused by infection. The most common bacterial causes include H flu, strep pneumo, beta hemolytic strep and staph aureus but viral causes are also possible. Patient was intially treated with decadron and empiric ceftriaxne. She was on insulin ss while on steroids. Rapid resp viral panel sent, antigen was negative, viral cultures pending at the time of discharge; blood cx sent and were no growth. Patient was evaluated by ENT with laryngoscopy while intubated and again after extubation. Initial impression was that epiglottis was mildly inflamed. After she was extubated, she had another endoscopic exam and was noted to have some vocal cord dysfunction, improved with relaxation techniques and no obvious epiglottitis. Patient was transferred to the floor on [**10-3**] and continued to do well. Still had a sore throat, but no wheezing or shortness of breath, no dysphagia. ENT also recommended increasing omprazole to 40 mg daily. Have scheduled outpt ENT follow-up . # PEA cardiac arrest- this occured while in ICU, patients pulse returned after 1 minute or so of chest compressions. Etiology was felt to be possibly secondary to biting the tube versus related to propofol. Patient had some pleuritic chest pain related to chest compressions later in hospital course, treated with ibuprofen, tylenol and one dose oxycodone. patient has oxycodone at home still for headaches and continue to take these as needed for chest pain as well. #. Anemia: HCT at current baseline 30-32 with high normal MCV. . #. h/o SAH and MCA aneurysm s/p coiling [**2130-7-2**] and repeat coiling [**2130-9-1**]: Neurosurgery aware. No current active issues - continue aspirin 325mg PO daily , has f/u scheduled with Neurosurgery. . #. Asthma: Continue albuterol prn (MDI while intubated) although no current wheezing on exam . #. Schizoaffective disorder: - continued home seroquel - restarted home benzos, trazodone and gabapentin . #. h/o Polysubstance abuse: had urine tox positive for benzos (gets these rx), amphetamines (on adderal) and barbiturates (on butalbital for migraines). Denied current substance use. #. ADHD: Held adderal in icu, restarted prior to discharge. Medications on Admission: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain fever. 2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 7. trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 9. amphetamine-dextroamphetamine 5 mg Tablet Sig: Four (4) Tablet PO bid (). 10. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 11. quetiapine 100 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). Discharge Medications: 1. quetiapine 50 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 2. quetiapine 50 mg Tablet Sig: Six (6) Tablet PO QHS (once a day (at bedtime)). 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 4. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 6. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. omeprazole 20 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* 8. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 9. amphetamine-dextroamphetamine 5 mg Capsule, Sust. Release 24 hr Sig: Four (4) Capsule, Sust. Release 24 hr PO bid (). 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every [**5-9**] hours. 11. trazodone 50 mg Tablet Sig: Three (3) Tablet PO ONCE (Once). 12. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: Vocal cord dysfunction Epiglottitis Cardiac arrest Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with wheezing and difficulty breathing and required intubation. You also had a cardiac arrest which lasted a short period with return of your heart beat with cpr/chest compressions. The likely cause of the wheezing was vocal cord dysfunction, although a viral illness and or gastric reflux may have been contributing. There was initially concern about epiglottitis (inflammation of the epiglottis), but this only mildly inflamed when they looked with a camera in your throat. You will need to take a higher dose of omeprazole (40mg) and will need to follow-up with ENT and pcp as scheduled. You should continue your other outpatient medications as you did previously Followup Instructions: Name: [**Last Name (LF) **], [**First Name3 (LF) **] V. MD Address: [**Location (un) 3881**],[**Apartment Address(1) 3882**], [**Location (un) **],[**Numeric Identifier 3883**] Phone: [**Telephone/Fax (1) 2349**] Appointment: Friday [**2130-10-6**] 1:30pm Name: [**Last Name (LF) 1447**],[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Location (un) **] FAMILY PRACTICE Address: [**Street Address(2) 75551**] [**Apartment Address(1) 87446**], [**Location (un) **],[**Numeric Identifier 75553**] Phone: [**Telephone/Fax (1) 44915**] Appointment: Wednesday [**2130-10-11**] 2:00pm

[ "295.70", "790.92", "786.52", "464.30", "285.9", "276.7", "478.5", "314.01", "288.60", "E932.0", "V45.89", "427.5", "493.90", "530.81" ]

icd9cm

[ [ [] ] ]

[ "99.60", "31.42", "96.71" ]

icd9pcs

[ [ [] ] ]

10204, 10210

5149, 7971

279, 315

10305, 10305

3206, 5126

11165, 11813

2445, 2484

9038, 10181

10231, 10284

7997, 9015

10456, 11142

2499, 3187

232, 241

343, 1812

10320, 10432

1834, 2105

2121, 2429

49,378

197,074

48171

Discharge summary

report

Admission Date: [**2110-1-20**] Discharge Date: [**2110-1-22**] Service: SURGERY Allergies: Lisinopril / Simvastatin Attending:[**First Name3 (LF) 1234**] Chief Complaint: Carotid Artery Stenosis Major Surgical or Invasive Procedure: PROCEDURE: Left carotid endarterectomy with bovine pericardial patch angioplasty PROCEDURE: Evacuation of left neck hematoma. History of Present Illness: The patient is an elderly female who was found to have a 90% carotid stenosis. Given her advanced age, she recovered nicely from colectomy and was very concerned about stroke. She understood the risks of the procedure, including stroke, cranial nerve injury and bleeding. After long discussions with her and her family, she decided that she would prefer an endarterectomy as opposed to watchful waiting where she was already on full medical management Past Medical History: - Carotid artery stenosis: 80-99% on L, 40-59% on R by doppler (4/[**2108**]). Bruit found incidentally on exam (asymptomatic at that time); twice was supposed to have repair, but delayed [**1-28**] anemia. - Coronary artery disease w/ h/o silent anterior MI in [**2094**]: Echo [**2094**], estimated LVEF>55%, LV hypertrophy, anteroseptal hypokinesis, mild-moderate MR. [**First Name (Titles) 25209**] [**Last Name (Titles) 101551**] scan [**2094**]: Severe defect over the anterior and apical walls, which partially improves to a moderate defect on resting images. - Hypertension: pt uncertain of baseline BP - Colon cancer: diagnosed by colonoscopy [**2109-7-1**]: A ulcerated 2 cm mass of malignant appearance was found in the proximal ascending colon. - Gastric ulcers: diangosed by endoscopy [**2109-7-1**] - Anemia: believed to be [**1-28**] GI bleed from cancer, ulcer - IVC filter: patient unsure of why it was placed - Right humerus and pelvic fracture: motor vehicle accident. R arm hardware. - Asthma: hospitalized 8-9 years ago O/N, was not intubated Social History: Never smoked. Does not drink alcohol. Retired. Ambulates without assistive devices. No falls. Lives alone. Son who used to live with her, passed away last year at age 62 with heart attack. Daughter (health care proxy, [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 101552**]) lives ~10 miles away. Family History: No known history of stroke or premature coronary artery disease. Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [**Doctor Last Name **], pt, dp lle - palp fem, [**Doctor Last Name **], pt, dp Pertinent Results: [**2110-1-22**] 04:29AM BLOOD WBC-10.3# RBC-3.14* Hgb-8.9* Hct-26.4* MCV-84 MCH-28.3 MCHC-33.8 RDW-16.6* Plt Ct-160 [**2110-1-22**] 04:29AM BLOOD Plt Ct-160 [**2110-1-22**] 04:29AM BLOOD Glucose-92 UreaN-20 Creat-0.9 Na-143 K-4.0 Cl-108 HCO3-28 AnGap-11 [**2110-1-22**] 04:29AM BLOOD Glucose-92 UreaN-20 Creat-0.9 Na-143 K-4.0 Cl-108 HCO3-28 AnGap-11 [**2110-1-20**] 04:59PM BLOOD lucose-153* Lactate-1.9 Na-135 K-4.1 Brief Hospital Course: Mrs. [**Known lastname **],[**Known firstname **] was admitted on [**1-20**] with Carotid artery stenosis. She agreed to have an elective surgery. Pre-operatively, she was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. It was decided that she would undergo a: A Corotid enderectomy She was prepped, and brought down to the operating room for surgery. Intra-operatively, she was closely monitored and remained hemodynamically stable. She tolerated the procedure well without any difficulty or complication. Post-operatively, she was extubated and transferred to the [**Month/Year (2) 13042**] for further stabilization and monitoring. While in the [**Name (NI) 13042**], pt had expanding hematoma. It was decided to take her back to The OR for evacuation. She was prepped, and brought down to the operating room for surgery. Intra-operatively, she was closely monitored and remained hemodynamically stable. She tolerated the procedure well without any difficulty or complication. Post-operatively, she was extubated and transferred to the [**Name (NI) 13042**] for further stabilization and monitoring. She was then transferred to the VICU for further recovery. While in the VICU she recieved monitered care. When stable she was delined. Her diet was advanced. A PT consult was obtained. When she was stabalized from the acute setting of post operative care, she was transfered to floor status On the floor, she remained hemodynamically stable with his pain controlled. She progressed with physical therapy to improve her strength and mobility. She continues to make steady progress without any incidents. She was discharged home in stable condition. He JP was DC'd. Medications on Admission: ALBUTEROL 90MCG Aerosol Fluticasone-Salmeterol [Advair Diskus] 100 mcg-50 mcg/Dose Disk with Device 1 puff po as directed ASA 325 Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q6H (every 6 hours) as needed for wheeze: as directed . 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 6. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1) Inhalation once a day: or as directed. Discharge Disposition: Home Discharge Diagnosis: Carotid artery stenosis hematoma post op requiring evacuation Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Division of Vascular and Endovascular Surgery Carotid Endarterectomy Surgery Discharge Instructions What to expect when you go home: 1. Surgical Incision: ?????? It is normal to have some swelling and feel a firm ridge along the incision ?????? Your incision may be slightly red and raised, it may feel irritated from the staples 2. You may have a sore throat and/or mild hoarseness ?????? Try warm tea, throat lozenges or cool/cold beverages 3. You may have a mild headache, especially on the side of your surgery ?????? Try ibuprofen, acetaminophen, or your discharge pain medication ?????? If headache worsens, is associated with visual changes or lasts longer than 2 hours- call vascular surgeon??????s office 4. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 5. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? No excessive head turning, lifting, pushing or pulling (greater than 5 lbs) until your post op visit ?????? You may shower (no direct spray on incision, let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Temperature greater than 101.5F for 24 hours Bleeding, new or increased drainage from incision or white, yellow or green Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2110-1-31**] 11:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2110-12-25**] 1:00 Completed by:[**2110-1-22**]

[ "998.12", "493.90", "E849.7", "433.10", "412", "414.01", "401.9", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "86.09", "38.12", "39.98", "00.40" ]

icd9pcs

[ [ [] ] ]

5786, 5792

3318, 5052

255, 385

5898, 5898

2867, 3295

8868, 9204

2305, 2371

5233, 5763

5813, 5877

5078, 5210

6043, 8304

8330, 8845

2386, 2848

192, 217

413, 867

5912, 6019

889, 1964

1980, 2289

13,004

117,622

20824

Discharge summary

report

Admission Date: [**2140-6-2**] Discharge Date: [**2140-6-14**] Date of Birth: [**2089-3-11**] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This 51-year-old female with known history of diabetes mellitus and a strong family history for coronary artery disease awoke on [**2140-5-31**] with some crushing chest pain radiating to her left arm and back and felt very lightheaded. She went to an outside hospital where her Troponin was elevated and she ruled in for a non ST elevation myocardial infarction. She was transferred into [**Hospital1 69**] for cardiac catheterization on [**2140-6-2**]. PAST MEDICAL HISTORY: Insulin dependent diabetes mellitus. Status post cervical cancer in [**2127**] with hysterectomy. Status post cerebrovascular accident in [**2139-1-7**] with slurred speech and left sided weakness but no residual effect. Status post pin placement left knee. Status post appendectomy. Status post tonsillectomy and adenoidectomy. ALLERGIES: Levaquin. Morphine. Demerol. Both Morphine and Demerol produce nausea and vomiting. MEDICATIONS: 1. Aspirin 325 mg p.o. q day. 2. Insulin 70/30 mix 42 units q AM, 30 units q PM. 3. Glucophage 1000 mg p.o. twice a day. Cardiac catheterization was performed on [**2140-6-2**] on her admission with the following results. Ejection fraction 45%. Left ventricular end-diastolic pressure 29. Mild diffuse left main disease, moderate diffuse mid-LAD disease, severe diffuse mid to distal left anterior descending coronary artery, totally occluded left circumflex and severe diffuse disease of the right coronary artery. REVIEW OF SYMPTOMS: The patient reported an 80 pound recent weight loss that was intentional. She also admitted to frequent urinary tract infections, some wheezing and some abdominal pain with palpation which he has always had, the workup is negative. She also said she had no thyroid problems, bleeding or clotting problems. She worked as a manager of a convenience store, she had no tobacco or no alcohol history and no use of marijuana or cocaine and lived alone. PHYSICAL EXAMINATION: Her pulse is 106, blood pressure 138/73, respiratory rate 16. She is sating 97% on two liters. She was awake, and alert and oriented. Her pupils equal, round and reactive to light and accommodation. EOM's were intact. Her strength was equal upper extremities and lower extremities bilaterally. Her heart was regular rate and rhythm with no murmur, with no rub. Her abdomen was obese with positive bowel sounds, soft, nontender, with some tenderness to palpation as previously reported. The patient said her abdomen is always tender, the workup was negative prior to this admission. The patient did have some heme positive emesis in the catheter laboratory with small amount of not frank blood. Preop laboratory: White count 10.7, hematocrit 37.0, platelet count 250,000, sodium 136, K 4.2, chloride 102, CO2 24, BUN 21, creatinine 0.8 with a blood sugar of 360. Prothrombin time 13.2, INR 1.2, PTT 28.4, ALT 30, AST 109, alkaline phosphatase 79, total bilirubin 0.6, amylase 39, lipase was pending. Type and screen was placed on the computer. PHYSICAL EXAMINATION: Pulses: The right femoral was in a sheath but popliteal, dorsalis pedis, posterior tibial, radial were all 2+. On the left leg, femoral, popliteal, dorsalis pedis and posterior tibial and radial were all 2+. The patient had no bruits appreciated in either carotid artery. Her extremities had no edema or varicosities. Chest x-ray and urinalysis were ordered. Decision was made to try and get carotid ultrasounds prior to the operating room. Aggrastat was to be discontinued at midnight which the patient had been placed on after her cardiac catheterization. Later that evening the patient did complain of some heaviness in her chest with no shortness of breath, nausea, vomiting but a little bit of a cough. Blood pressure was 157 and then went down to 119/62, Heparin drip was to be started four hours after the sheath pull with a plan to start the patient on a Nitroglycerin drip if the chest pain returned. The patient was pain free later on, on Heparin drip. Dr. [**Last Name (STitle) 70**] saw the patient on the 28th and explained relative high risk of her case. He spoke to Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] to have him reassess the patient. The patient did go to the cardiac catheter laboratory on [**7-4**] for preoperative intra- aortic balloon in preparation of her surgery. The patient's height is 5 foot, 1 inches with a weight of 229 pounds. The balloon was placed in the left femoral artery on [**6-3**] prior to surgery and prior to the operating room she was on Heparin and Nitroglycerin drips. She also received Midazolam preoperatively and received 10 units of regular insulin sliding scale for a blood sugar of 361 at 10 o'clock that morning. Of note, the patient did not receive her carotid ultrasound due to the fact of her instability and intra-aortic balloon placement and moving to the operating room for her coronary surgery which was performed on [**6-3**] by Dr. [**Last Name (STitle) 70**] with a catheter coronary artery bypass grafting times three with a left internal mammary artery to the left anterior descending coronary artery, to the posterior descending coronary artery and to the obtuse marginal. The patient was transferred to the Cardiothoracic Intensive care unit on a Propofol drip at 30 mcs per kilo per minute and a Neo-Synephrine drip at 0.5 mcs per kilo per minute in stable condition. In the evening of [**2140-6-4**] there is no examination note to be found in the chart from postop day one on [**6-4**] however, there are a couple of events. The patient had already been extubated after her operation by the time she was seen by Anesthesia for the postop check. She was on Nordinone at that time for decreased cardiac output. She was otherwise stable. She was seen at 7 o'clock in the evening on postop day one by the Cardiology Fellow for a diffuse anterior ST elevation. She was hemodynamically stable without any symptoms. TTE was performed Stat which showed that the walls were contracting vigorously and laterally and at the septum but the anterior inferior walls were less well seen but appeared to contract well also. There was some trace MR with an injection fraction of greater than 50% No effusion was seen on parasternal and apical views, no subcostal views were performed due to habitus, wires and chest tube drains. The assessment by Dr. [**Last Name (STitle) 2232**] was that there was no evidence of acute ischemic territory on limited views and that he recommended if she became hemodynamically unstable or had symptoms to consider Transesophageal echocardiography. On the evening of [**2140-6-3**] the patient remained on Propofol and insulin drip. She was also started on Malarone drip but was extubated by the time Anesthesia saw her on postop day one. On postop day she remained on a Neo- Synephrine drip at 0.5 mcs per kilo per minute, on aspirin, Plavix, Lasix twice a day, and Lopressor twice a day, off her beta-blockade. She continued with perioperative Vancomycin for coverage. Her balloon was at 1-to-1. She was in sinus tach at 114, blood pressure of 92/73 with a cardiac index of 2.1 with the balloon on 1-to-1. She was sating 96% on three liters. Laboratory: White count 17.1, hematocrit 32.1, platelet count 140,000. Sodium 141, K 5.3, chloride 104, CO2 23, BUN 24, creatinine 1.5 with a blood sugar of 129 and a lactate of 1.2. INR of 1.3, Prothrombin time 13.8, PTT 29.1. Her pacing wires remain in place. She was tachycardiac as noted. Incisions were clean, dry and intact. She got a new A-line and the decision was made to at least discuss the Sinatracor. She received Lasix 60 mg times one to help boost her urine output. On postop day two at 11:30 in the morning her intra-aortic balloon pump was removed the Cardiology Fellow with good pulses and no hematoma formation On postop day three she remained on Neo-Synephrine drip at 0.25 mcs per kilo per minute, continuing with aspirin, Plavix, Lasix and Lopressor. She was also on an insulin drip at 3 units per hour, still slightly tachycardiac at 108 with a blood pressure of 127/03, cardiac index of 2.27, sating 96% on three liters with a blood gas of 7.31/50/87/26/-1. Labs: White count dropped to 11.8, hematocrit to 28.3, platelet count dropped again slightly to 113,000, BUN 27, creatinine 1.3, blood sugar of 80. Her lungs were coarse but relatively clear. Heart was regular in rate and rhythm with tachycardia. Incisions were clean, dry and intact. Her sternum is stable. Off Milrinone and the intra-aortic balloon pump. The chest tubes have been pulled on the evening prior, [**2140-6-5**]. The patient was seen and evaluated by Physical Therapy also. On postop day four the patient had been weaned off Neo- Synephrine, the Swann was discontinued. She was back on her insulin drip. Continuing with her oral medications when insulin drip was still at 3 units per hour, blood pressure 149/81, temperature maximum of 98.9, sinus tachycardia at 110. Lopressor at that time was at 25 mg twice a day. She was sating 97% on two liters nasal cannula. Her creatinine dropped to 1.0, blood sugar was at 93 in the morning, platelet count rose slightly to 150 and white count continued to drop to 9.1. Her heart was regular rate and rhythm. Her sternal incision was clean, dry and intact. Her lungs were clear bilaterally. Abdominal examination and leg incisional exams were benign. Her Lopressor was increased to 50 mg p.o. three times a day and the patient was encouraged to be out of bed and ambulating. She was also evaluated by case management. On postop day five she remained in CSRU and was weaned off her insulin drip, a new line was placed for monitoring. She remained at Lopressor 37.5 mg p.o. twice a day, she was in sinus rhythm at 95, with a blood pressure of 107/72, sating 96% now on room air with more normalization of her creatinine with a BUN of 29 and a creatinine of 0.9. K 4.0. white count 9.1, hematocrit 28.8 and her platelet count rose slightly to 165,000. She was quite sleepy but easily arouseable. Her examination was benign an d a discussion continued about whether or not to be able to transfer her to the floor. The patient was out of bed and ambulating in the CSRU. The patient was seen by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**], Cardiac Catheterization attending on [**2140-6-8**] who noted her continuing tachycardia and recommended increasing her Lopressor over the next 24 hours as her blood pressure would tolerate it. [**Last Name (un) 3208**]: The patient was screened for nutritional risks by the Clinical Nutrition team. The patient also had [**Last Name (un) 3208**] consult on [**2140-6-8**] for management of her diabetes mellitus. The patient also had a consult. The neurology stroke attending, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] saw the patient on [**2140-6-8**], was asked to consult by Dr [**Last Name (STitle) 70**] for a question of acute stroke verses old stroke that was expressed in this 51-year- old woman with a new hand paresthesia and an odd sensation. Please refer to her neurologic examination. She recommended getting an magnetic resonance imaging with DWI/MRA of brain to examine her for a new stroke and made other recommendations in terms of her laboratory work and blood pressure maintenance. She was noting that the patient may be re-expressing an old stroke or may have a new event and could not entirely rule out metabolic encephalopathy. Please refer to Dr.[**Name (NI) 31849**] examination note. The patient also was seen by Physical Therapy where she complained that she could not really feel that arm very well. The CT of her head on [**2140-6-8**] showed a wedge shaped area of parenchymal infarct in the posterior aspect of the right frontal lobe. This was likely recent and clinical correlation follow-up was recommended. There was no intracranial hemorrhage or hydrocephalus noted. The patient also had an MRA of the head done on [**2140-6-11**] which showed multiple acute infarcts involving the right posterior superficial water shed and bilateral deep water shed. Her territories and left cerebellar hemisphere indicative of acute infarcts and small vessel disease. The MRA of the head demonstrated normal flow signal within the arteries of anterior and posterior circulation which was normal MRA of the head. A limited carotid ultrasound was done due to the central line placement on [**2140-6-9**] which showed no evidence of stenosis in the right or left carotid arteries. The patient continued to work with physical therapy. On [**2140-6-9**] the patient was alert and awake and moving all extremities. Left side was stronger on [**6-9**] and had sensation to left lower extremity and halfway up distally of left upper extremity, was able to follow directions. Her mental status seemed to be improved. The patient from a respiratory point of view was better, was able to cough up her own sputum, was sating 97% on room air. On postop day six, [**2140-6-8**] the fluctuating neurologic deficits of the prior day which ultimately resulted in a diagnosis of stroke on CT of the head were noted. The patient remained on Neo-Synephrine drip at 1.8 with a blood pressure of 149/74 and sinus rhythm in the 90's. She is sating well on two liters nasal cannula. Her neurological status continued to be monitored. Previous results carotid ultrasound, and Magnetic resonance imaging of the brain were noted in the prior paragraph. On postop day seven, the patient had a stable neurologic status, had occipital headache overnight which resolved with Tylenol. She was on Neo-Synephrine drip at 04. Mcs per kilo per minute. She continued on aspirin, Plavix, Lasix and Metoprolol at 50 mg twice a day of Metoprolol as well as Lipitor and Protonix. Blood pressure is 132/83. Sating 97% on room air in sinus rhythm in the 90's. With laboratory as follows: White count 11, hematocrit 28, platelet count 312,000. Sodium 140, K 4.1. Chloride 104, CO2 28, BUN 21, creatinine 0.7, blood sugar 230,000. INR 1.4, Prothrombin times 14.5, PTT 26.1. Her heart was regular rate and rhythm. Her sternum was stable,, incision was clean, dry and intact. Cranial nerves 3 through 12 she was not in any apparent distress and was alert and oriented. Her Eoms were benign. Chest was clear bilaterally. She continued to improve and continue to get out of bed an d ambulate with physical therapy as tolerated. The patient was also seen again by [**Hospital 3208**] Clinic for management of her insulin and sugar control. Was followed daily the stroke consult team and [**Last Name (un) 3208**] as she remained in the hospital. She continued to work with physical therapy. On [**2140-6-11**] she was transferred out to the floor. In the evening on postoperative day 8, she was on the floor sating well 94% on room air. The blood pressure 100/58 with a heart rate of 94 and in sinus rhythm. Her fasting sugar was 114 that morning, she had some mild crackles left side greater than the right, her examination was otherwise unremarkable. Her right IJ line remained in place. Repeat labs were drawn. Her central line was discontinued later in the day and a follow-up Magnetic resonance imaging was to be scheduled. She continued also to see Occupational Therapy and [**Last Name (un) 3208**] Consult Physician all of whom noted her diagnosis with the neurologic deficits that have been identified. On postop day nine, she had some premature ventricular contractions on telemetry, she was shortness of breath and desated with some vigorous walking once but was okay and made a good recovery after that. She had a blood pressure of 102/76. Her examination was unremarkable. The patient continued to do well and was alert and oriented neurologically. Stroke consult recommended keeping her systolic blood pressure above 130. Her insulin at that time was Lispro 75/25 mixed and she was also on Metformin for sugar control which was managed by [**Last Name (un) 3208**] Consult recommendations. Seh continued to work with physical therapy, she continued to have some numbness of her hand but continued overall improvement. On [**2140-6-12**] she did have some diarrhea, C. Diff was sent. The patient was taking Tylenol for pain at that point with good relief. Remained afebrile with a blood pressure of 126/84, sating 97% on room air. On postop day ten, [**6-13**] she complained of some aching around her sternum. Telemetry showed a question of some PVCs. Her heart rate was 96 in sinus rhythm with a blood pressure of 134/83. Sating 94% on room air with a T-max of 99.4. She had some slight crackles bilaterally. She remained on strict I&O's. LAB: White count 8.1, hematocrit 23.3, sodium 142, K 4.7, BUN 20, creatinine 0.8 with a blood sugar of 91. Magnesium was given for repletion and a culture repletion and the culture for C. Diff was waited. The patient continued to receive p.o. Lasix and was very anxious to get home. The patient was seen again by Case Management on [**2140-6-13**]. The patient was also seen by Neurological again on [**2140-6-13**], she reported in the hallway that bothered her eyes and her vision blurred a little bit and objects were not well she reported in the hallway that light bothers her eyes, her vision blurred a little bit and objects were not well distinguished. She had no other visual field deficits and was able to see anything but the lights appeared extremely bright to her. ASSESSMENT: Follow-up with the Ophthalmologist and this was discussed with the patient by the Stroke Consult team and recommended to, continue her on aspirin, Plavix and a statin for stroke prevention. On postop day 11, [**2140-6-14**] which was the day of discharge the examination was as follows. The patient had a T-max of 99.5., was in sinus rhythm at 98 with a blood pressure of 101/68, sating 95% on room air. Her exam was completely unremarkable. Her chest X-ray showed bilateral pleural effusions. The C. Diff culture was negative and the patient continued to do very well with a plan for her to be able to go home that day. She had a final evaluation by physical therapy and was able to be discharged to home on [**2140-6-14**]. DISCHARGE DIAGNOSIS: Status post coronary artery bypass graft times three. Coronary artery disease. Status post cerebrovascular accident postoperatively. Insulin dependent diabetes mellitus. Obesity. Myocardial infarction. Cervical cancer. Old cerebrovascular accident. DISCHARGE MEDICATIONS: 1. Metoprolol 50 mg p.o. twice a day. 2. Potassium Chloride 20 mEq p.o. twice a day times seven days. 3. Colace 100 mg p.o. twice a day. 4. Aspirin 325 mg p.o. q day, delayed release Entericoated. 5. Protonix 40 mg delayed release Entericoated p.o. q day. 6. Lipitor 20 mg p.o. q day. 7. Metformin 1000 mg p.o. twice a day. 8. Plavix 70 mg p.o. q day. 9. Lasix 20 mg p.o. twice a day times seven days. 10. Insulin 70/30 suspension mix 42 units q AM, 30 units q PM. The patient was instructed to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] for her postoperative surgical visit in six weeks in the office. To follow-up with Dr. [**Last Name (STitle) **] of Neurology in one month. To follow-up with Dr. [**Last Name (STitle) 6984**] the primary care physician in two to three weeks and to see her Cardiologist also postoperative in approximately two to three weeks. The patient was discharged to home on [**2140-6-14**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2140-7-19**] 10:42:15 T: [**2140-7-19**] 12:43:29 Job#: [**Job Number 55491**]

[ "428.0", "997.02", "250.40", "583.81", "414.01", "410.71", "276.2", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "36.15", "36.12", "39.61", "37.61", "88.55", "37.22", "88.53" ]

icd9pcs

[ [ [] ] ]

18780, 20025

18500, 18757

3187, 18478

164, 622

645, 2085

13,528

190,250

28517

Discharge summary

report

Admission Date: [**2118-12-6**] Discharge Date: [**2118-12-10**] Date of Birth: [**2053-7-20**] Sex: F Service: CARDIOTHORACIC Allergies: Bactrim Attending:[**First Name3 (LF) 2969**] Chief Complaint: Severe COPD, Elective tracheostomy Major Surgical or Invasive Procedure: Open tracheostomy History of Present Illness: The patient is a 65 year-old female with a h/o severe COPD requiring constant BIPAP in order to ventilate and breath confortably. She was transferred from [**Hospital **] rehabilitation facility for an elective tracheostomy. Past Medical History: COPD Sleep apnea CAD with MI (stents and pacemaker) Afib HTN DM Diverticulitis. Social History: 50+ pack years smoking history. Family History: Mother deceased at 67 yoa throat ca Father deceased at 51 yoa oral cancer Pertinent Results: [**2118-12-10**] 05:49AM BLOOD WBC-18.7* RBC-3.61* Hgb-10.6* Hct-34.1* MCV-95 MCH-29.3 MCHC-30.9* RDW-20.6* Plt Ct-191 [**2118-12-9**] 02:23AM BLOOD WBC-15.5* RBC-3.21* Hgb-9.6* Hct-29.9* MCV-93 MCH-30.0 MCHC-32.1 RDW-21.0* Plt Ct-217 [**2118-12-8**] 03:17AM BLOOD WBC-14.6* RBC-3.36* Hgb-10.1* Hct-30.7* MCV-92 MCH-30.2 MCHC-32.9 RDW-20.3* Plt Ct-212 [**2118-12-7**] 04:43AM BLOOD WBC-15.1* RBC-3.25* Hgb-9.7* Hct-30.3* MCV-93 MCH-29.9 MCHC-32.1 RDW-20.6* Plt Ct-234 [**2118-12-6**] 09:11PM BLOOD WBC-15.5* RBC-3.29* Hgb-9.8* Hct-29.8* MCV-91 MCH-29.8 MCHC-32.9 RDW-20.4* Plt Ct-240 [**2118-12-10**] 05:49AM BLOOD Plt Ct-191 [**2118-12-9**] 02:23AM BLOOD Plt Ct-217 [**2118-12-7**] 04:43AM BLOOD PT-11.0 PTT-22.4 INR(PT)-0.9 [**2118-12-6**] 09:11PM BLOOD PT-11.4 PTT-22.3 INR(PT)-1.0 [**2118-12-10**] 05:49AM BLOOD Glucose-213* UreaN-25* Creat-0.5 Na-148* K-4.2 Cl-100 HCO3-44* AnGap-8 [**2118-12-6**] 09:11PM BLOOD Glucose-180* UreaN-26* Creat-0.7 Na-142 K-4.5 Cl-95* HCO3-45* AnGap-7* [**2118-12-10**] 05:49AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.4 [**2118-12-6**] 09:11PM BLOOD Calcium-9.6 Phos-5.4*# Mg-2.2 [**2118-12-10**] 05:54AM BLOOD Type-ART pO2-124* pCO2-92* pH-7.34* calTCO2-52* Base XS-18 [**2118-12-6**] 09:56PM BLOOD Type-ART pO2-96 pCO2-75* pH-7.39 calTCO2-47* Base XS-15 CHEST (PORTABLE AP) [**2118-12-8**] 7:13 PM CHEST (PORTABLE AP) Reason: eval ptx/ trach placement [**Hospital 93**] MEDICAL CONDITION: 65 year old woman sp trach REASON FOR THIS EXAMINATION: eval ptx/ trach placement INDICATION: 65-year-old woman, status post tracheostomy. Evaluate for pneumothorax and trach placement. COMPARISON: [**2118-12-6**]. PORTABLE AP CHEST RADIOGRAPH: Again seen is a pacemaker overlying the left hemithorax, with the leads in the right atrium and ventricle. There has been interval placement of a tracheostomy, with the tip in the mid trachea. The cardiac and mediastinal contours are within normal limits. There is underinflation of the lungs, and mild prominence of the pulmonary vasculature, which is likely unchanged accounting for differences in inspiration. No definite pleural effusions or pneumothorax is identified. There is a likely NG tube extending into the stomach, though the tip is not visualized on this image. IMPRESSION: Interval placement of tracheostomy, with the tip in the mid trachea. No pneumothorax. Brief Hospital Course: The patient is a 65 year-old female with a h/o severe COPD requiring constant BIPAP in order to ventilate and breath confortably. She was transferred from [**Hospital **] rehabilitation facility to Dr.[**Doctor Last Name 4738**] thoracic Surgery service for an elective tracheostomy. The patient underwent an open tracheostomy on [**2118-12-8**]. For details of the operation, please refer to the operative report. . On POD 1 the patient's propofol was discontinued and her vent was changed to pressure support . We plan on continuing her levoquin her one week for what is presumed to be a non-complicated urinary tract infection. The patient has a dobhoff in place and we are advancing her tube feeds to goal (65cc/hr nutren pulmonary 3/4 strength). The patient can have speak and swallow evaluation at [**Hospital **] rehab, she should follow up with Dr. [**Last Name (STitle) **] in approximately 2 weeks. Medications on Admission: Fosamax 70 qFri Lipitor 40 Daily Fragmin 2500 sc Daily Dapsone l00mg Daily Darbepoetin 50mcg Diltiazem 180mg [**Hospital1 **] Colace 100mg [**Hospital1 **] Prozac 20mg Daily Advair 250/50 mcg diskus Lantus 40U [**Hospital1 **] Imdur 30 Daily Lisinopril 10mg Daily Solumedrol 30 TID Remeron 15 qhs Risperidone 1mg [**Hospital1 **] Theophylline 250mg [**Hospital1 **] Spiriva 18mcg Ambien 5mg qhs Ativan 0.5 TID PRN Discharge Medications: 1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every Friday). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Theophylline 200 mg Capsule, Sust. Release 12HR Sig: One (1) Capsule, Sust. Release 12HR PO BID (2 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 14. MethylPREDNISolone Sodium Succ 30 mg IV Q8H 15. Fluconazole 400 mg IV Q24H 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 17. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. 18. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours). 19. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 20. Tube Feeds Tubefeeding: Nutren Pulmonary 3/4 strength; Starting rate: Goal rate: 65 ml/hr Residual Check: q4h Hold feeding for residual >= : 100 ml Flush w/ 50 ml water q8h Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Severe COPD, Elective tracheostomy Discharge Condition: Stable Discharge Instructions: Call Dr.[**Last Name (STitle) **] [**Name (STitle) 1092**] Surgery office [**Telephone/Fax (1) 170**]) for: fever, shortness of breath, chest pain, exscessive foul smelling drainage from incision sites *Continue old medications as previous to surgery as stated on discharge instructions *Take new medications as directed Followup Instructions: CAll Dr.[**Last Name (STitle) **] office for an appointment please schedule an appointment for 2 weeks. Follow up with your primary care doctor and your pulmonologist. Completed by:[**2118-12-10**]

[ "496", "V58.67", "401.9", "V45.01", "427.31", "V45.82", "412", "327.23", "414.01" ]

icd9cm

[ [ [] ] ]

[ "31.29" ]

icd9pcs

[ [ [] ] ]

6323, 6402

3216, 4129

310, 329

6481, 6490

847, 2232

6860, 7061

753, 828

4593, 6300

2269, 2296

6423, 6460

4155, 4570

6514, 6837

236, 272

2325, 3193

357, 584

606, 687

703, 737

30,934

192,745

31948

Discharge summary

report

Admission Date: [**2197-11-28**] Discharge Date: [**2197-12-6**] Date of Birth: [**2150-3-14**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: angina Major Surgical or Invasive Procedure: [**11-28**] CABG x 3 (LIMA-LAD / SVG-OM / SVG-RCA) History of Present Illness: 47 yo F preop for gastric bypass surgery in near future, with increasing anginal symptoms and DOE over past couple of months. Cath showed 3 VD, referred for surgery. Being followed for anemia, and received epogen preop as she is a jehovahs witness. Past Medical History: IDDM, retinopathy, morbid obesity, neuropathy, claudication laser eye surgery, c-sxn x3, carpal tunnel (L) Social History: works as HR assistant quit tobacco 14 years ago rare etoh Family History: + premature CAD Physical Exam: Admission VS:HR 92 RR 12 Gen:WDWN F in NAD Pulm: CTAB CV: RRR no M/R/G Abdomen: obese soft, NT Extrem: warm, well perfused. no edema. No varicose veins. 2+pp Discharge VS 98.6 76 110/68 20 93%RA Neuro: non focal exam Pulm: CTA-B CV: RRR, no murmur. Sternum stable, incision CDI Abdm: soft, NT/+BS Ext: warm, well perfused. 2+ pedal edema bilat Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 3679**] [**Hospital1 18**] [**Numeric Identifier 74892**] (Complete) Done [**2197-11-28**] at 10:11:32 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**] 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: [**2150-3-14**] Age (years): 47 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Chest pain. Coronary artery disease. Hypertension. ICD-9 Codes: 402.90, 786.51, 440.0 Test Information Date/Time: [**2197-11-28**] at 10:11 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW1-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Aortic Valve - Peak Gradient: 3 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 2 mm Hg Findings LEFT ATRIUM: Normal LA size. No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No spontaneous echo contrast in the body of the RA or RAA. A catheter or pacing wire is seen in the RA and extending into the RV. Dynamic interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Mildly dilated RV cavity. AORTA: Normal aortic diameter at the sinus level. Simple atheroma in aortic root. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild mitral annular calcification. No MS. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is normal in size. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No mass/thrombus is seen in the left atrium or left atrial appendage. No thrombus is seen in the left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. The right ventricular cavity is mildly dilated. 4. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. Trivial mitral regurgitation is seen. 7. There is no pericardial effusion. POST-CPB: On infusion of phenylephrine. Preserved biventricular systolic function. LVEF is 60 %. Trace MR. Aortic contour is preserved post decannulation. [**2197-11-28**] 01:34PM UREA N-15 CREAT-0.5 CHLORIDE-108 TOTAL CO2-26 [**2197-11-28**] 01:34PM WBC-25.5*# RBC-3.93* HGB-11.6* HCT-34.3* MCV-87 MCH-29.5 MCHC-33.9 RDW-14.5 [**2197-11-28**] 01:34PM PLT COUNT-267 [**2197-11-28**] 01:34PM PT-13.8* PTT-32.8 INR(PT)-1.2* [**2197-11-27**] 01:00PM ALT(SGPT)-14 AST(SGOT)-13 ALK PHOS-47 AMYLASE-36 TOT BILI-0.6 [**2197-11-27**] 01:00PM TOT PROT-7.0 ALBUMIN-4.2 GLOBULIN-2.8 [**2197-11-27**] 01:00PM URINE COLOR-Yellow APPEAR-SlCloudy SP [**Last Name (un) 155**]-1.036* [**2197-11-27**] 01:00PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG [**2197-11-27**] 01:00PM URINE RBC-230* WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2197-12-5**] 05:16PM 11.0 3.65* 10.5* 32.0* 88 28.7 32.7 14.3 397 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2197-12-5**] 05:16PM 397 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2197-12-6**] 10:45AM 13 0.6 4.6 RADIOLOGY Final Report CHEST (PA & LAT) [**2197-12-5**] 10:50 AM CHEST (PA & LAT) Reason: r/o ptx [**Hospital 93**] MEDICAL CONDITION: 47 year old woman with REASON FOR THIS EXAMINATION: r/o ptx HISTORY: 47-year-old female, rule out pneumothorax. COMPARISON: [**2197-12-4**]. CHEST, PA AND LATERAL: Small left apical pneumothorax is minimally decreased in size. Minimal increased opacification of the retrocardiac region is unchanged. Lungs are otherwise clear. Heart size is normal. Sternotomy wires are intact and unchanged. Hilar and mediastinal contours are normal. Tiny calcific density projecting over lateral aspect of the humeral head is seen likely represents calcific tendinitis. IMPRESSION: Small left apical pneumothorax, minimally decreased in size compared to prior study. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Brief Hospital Course: She was taken to the operating room on [**11-28**] where she underwent a CABG x 3(please see OR report for details). She tolerated the operation well and was transferred to the ICU in critical but stable condition on neo and propofol. She did well in the immediate post-op period, her anesthesia was reversed and she was extubated later that day. She was transferred to the floor on POD #1. She was transferred back to the unit on POD #2 for elevated blood sugars and was restarted on an insulin drip. She was seen by [**Last Name (un) **] for glucose management. Her epicardial wires were cut. On POD 3 she was found to have a greater than 50 % L pneumothorax and a chest tube was inserted, it was removed on POD7. Her Bblockade and diuretics continued to be titrated and on POD8 it was decided she was ready for discharge home. Medications on Admission: Glipizide XL 20' Metformin 1000" Lantus 35 HS ASA 81' Atenolol 12.5' Lipitor 40' Lisinopril 5' procrit Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. 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* 4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Glucotrol XL 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: Two (2) Tab,Sust Rel Osmotic Push 24hr PO once a day: resume preop dosing. 8. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day: resume preop dosing. 9. Lantus 100 unit/mL Solution Sig: Thirty Five (35) units Subcutaneous at bedtime: resume preop dosing. 10. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: CAD now s/p CABG PMH: IDDM, retinopathy, morbid obesity, neuropathy, claudication laser eye surgery, c-sxn x3, carpal tunnel (L) 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 or driving until follow up with surgeon. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (STitle) **] 2 weeks Dr. [**Last Name (STitle) 32255**] 2 weeks Dr. [**Last Name (Prefixes) **] 4 weeks Completed by:[**2197-12-6**]

[ "414.01", "362.01", "250.62", "512.1", "401.9", "413.9", "E878.2", "250.52", "357.2", "440.21", "278.01", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "34.04", "36.12", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

10649, 10698

8305, 9136

329, 382

10872, 10880

1285, 4532

883, 900

9289, 10626

7376, 7399

10719, 10851

9162, 9266

10904, 11156

11207, 11359

4581, 7339

915, 1266

283, 291

7428, 8282

410, 660

682, 791

807, 867

26,636

105,302

29129

Discharge summary

report

Admission Date: [**2191-2-28**] Discharge Date: [**2191-3-8**] Date of Birth: [**2153-2-2**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1283**] Chief Complaint: Stroke/Migraines Major Surgical or Invasive Procedure: [**2191-3-1**] - Minimally Invasive ASD Closure History of Present Illness: This 37-year-old patient with recent cerebrovascular accident was found to have a large atrial septal defect with a left-to-right shunt. Since her stroke, she has been placed Aspirin and Warfarin without further neurological incident. In view of the history of the stroke and the finding of the atrial septal, she was electively admitted for closure of the same through a minimally invasive approach. Prior to surgical intervention, Coumadin was stopped and she was admitted for heparinization. Past Medical History: Atrial Septal Defect, History of Stroke, Migraine Headaches Social History: Homemaker. Lives with husband and 4 children. Never smoked. Drinks a few alcoholic beverages per month. Family History: Noncontributory Physical Exam: 72 SR 100/60 69" 150 GEN: NAD HERAT: RRR, Nl S1-S2 LUNGS: CTA ABD: Benign EXT: Warm, well perfused, no c/c/e. 2+ pulses Pertinent Results: [**2191-2-28**] 08:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2191-2-28**] 10:30PM PT-15.2* INR(PT)-1.4* [**2191-2-28**] 02:37PM ALT(SGPT)-19 AST(SGOT)-36 LD(LDH)-408* ALK PHOS-36* TOT BILI-0.5 [**2191-2-28**] 02:37PM WBC-7.0 RBC-4.00* HGB-13.2 HCT-37.8 MCV-95 MCH-32.9* MCHC-34.8 RDW-12.6 [**2191-2-28**] 02:37PM %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE [**2191-2-28**] 02:37PM PLT COUNT-188 [**2191-2-28**] Admit Chest x-ray: The heart is not enlarged. The lungs show no evidence of acute infiltrate, pleural effusion, or pneumothorax. [**2191-3-7**] 06:25AM BLOOD WBC-5.1 RBC-2.76* Hgb-9.3* Hct-26.3* MCV-95 MCH-33.9* MCHC-35.5* RDW-13.2 Plt Ct-136* [**2191-3-8**] 06:30AM BLOOD Glucose-83 UreaN-6 Creat-0.7 Na-140 K-4.3 Cl-106 HCO3-27 AnGap-11 [**2191-3-7**] 06:25AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.9 [**2191-3-7**] Echo: The left atrium is mildly dilated. No residual flow across the interatrial septum is identified. The estimated right atrial pressure is 16-20 mmHg. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. The right ventricular cavity is mildly dilated with normal freewall motion. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. [**2191-3-6**] Chest x-ray: The heart, lungs, and mediastinum are within normal limits with no interval change compared to [**2191-3-4**]. Brief Hospital Course: Mrs. [**Known lastname 55205**] was admitted to the [**Hospital1 18**] on [**2191-2-28**] for surgical management of her atrial septal defect. On admission, Heparin was initiated as Coumadin was held for several days prior to admission. Routine preoperative evaluation was performed and she was cleared for surgery. On [**2191-3-1**], Mrs. [**Known lastname 55205**] was taken to the operating room where she underwent a minimally inavsive closure of her atrial septal defect. For further surgical details, please see seperate dictated operative note. Following the operation, she was brought to the CSRU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. She gradually weaned from Neosynephrine and chest tubes were removed without complication. Heart rate was mostly sinus bradycardia with periods of junctional rhythm. On postoperative day two, she transferred to SDU. The remainder of her hospital stay was complicated by polyuria, polydipsia and symptomatic hypotension with complaints of nausea and dizziness. A postoperative echocardiogram was unremarkable. Given concern for diabetes insipidus and/or adrenal insufficiency, the Endocrine service was consulted. Urine osmolality and [**Last Name (un) 104**] stim test was performed. All lab work was within normal limits. She was discharged to home on POD #6. Medications on Admission: Aspirin 81 qd Coumadin Discharge Medications: 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 2 weeks. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Home With Service Facility: VNA Carenetwork Discharge Diagnosis: ASD - s/p Minimally Invasive ASD closure Postop Junctional Rhythm Postop Symptomatic Hypotension with Polydipsia and Polyuria History of Stroke History of Migraine Headaches Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 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. 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. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 monnth ([**Telephone/Fax (1) 1504**] Follow-up with cardiologist Dr. [**Last Name (STitle) 5051**] in 2 weeks. Follow-up with pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) 32996**] in [**3-13**] weeks. Please call all providers for appointments Completed by:[**2191-3-8**]

[ "V12.59", "745.5", "997.1", "427.89", "458.29", "253.5" ]

icd9cm

[ [ [] ] ]

[ "35.71", "39.61" ]

icd9pcs

[ [ [] ] ]

5029, 5075

3010, 4387

293, 343

5293, 5300

1262, 2987

5812, 6154

1089, 1106

4460, 5006

5096, 5272

4413, 4437

5324, 5789

1121, 1243

237, 255

371, 868

890, 952

968, 1073

42,184

106,871

54647

Discharge summary

report

Admission Date: [**2131-10-10**] Discharge Date: [**2131-11-4**] Date of Birth: [**2093-4-27**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 32912**] Chief Complaint: 2cm cyst in body of pancreas with history of recurrent pancreatitis Major Surgical or Invasive Procedure: 1. Robotic-assisted minimally invasive distal pancreatectomy and splenectomy with intraoperative ultrasound. 2. Urgent exploratory laparotomy, oversewing and repair of splenic artery, and placement of intra-abdominal drain. 3. Exploratory laparotomy, lysis of adhesions, and drainage of left upper quadrant intra-abdominal fluid collection. History of Present Illness: 38 y/o female with a history of multiple episodes of pancreatitis and a cystic mass in the body of the pancreas who comes to the office for surgical evaluation. In short, her first episode of pancreatitis was in [**2130-2-28**], when she presented with epigastric pain radiating to the back. She was hospitalized, and CT of the abdomen showed a ~2 cm cystic mass in the body of the pancreas, and evidence of pancreatitis in the pancreatic tail. She was discharged and was doing well until [**2131-7-29**], when she again presented with epigastric pain radiating to the back. Work-up during her second hospitization was notable for triglyceride of 830, lipase of 782, and normal LFTs; MRCP showed no significant interval change in the pancreatic cystic mass, atrophy of the pancreatic tail, no biliary dilatation, no gallstones, no choledocholithiasis. Her pancreatitis was attributed to elevated triglycerides, and she was put on gemfibrazil. On [**2131-9-7**], she was seen outpatient in the HPB Surgery Clinic. It was recommended that she undergo fine needle aspiration of the cystic mass with endoscopic ultrasound. Since then, she's had another episode of pancreatitis, and GI performed FNA of the cyst, which was acellular with CEA of 43ng/Ml and amylase of 109,200. After being seen in surgery clinic twice by Dr. [**Last Name (STitle) **] for further evaluation, it was felt that she likely had a mucinous cystic neoplasm and that it was likely the cause of her recurrent pancreatitis. The patient was advised on her options, including imaging surveillance, no surgery, repeat endoscopic ultrasound to test the cyst fluid CEA, and surgical excision. The patient desired to proceed with surgical management, and the plan was made with the patient to perform a robotic assisted distal pancreatectomy and splenectomy. Past Medical History: Past medical history: HIV, Hepatitis B, hypertriglyceridemia, hypertension, anxiety, depression, genital herpes Past surgical history: c-section x3 Social History: She lives with her fiance and 3 children in [**Location (un) 5503**]. She smokes 1ppd x 10 years. Occasional social alcohol use, no history of drug use. Family History: No family history of pancreatic cancer or pancreatitis. Physical Exam: GENERAL: NAD, AOx3 CARDIOVASCULAR: RRR, no m/g/r LUNGS: CTAB ABDOMEN: soft, non-distended, mild peri-incisional tenderness to palpation, incisions healing well with no erythema or drainage, JP drain in place with minimal [**Doctor Last Name 352**] serous fluid in bulb and no surrounding erythema or drainage at insertion site. EXTREMITIES: warm and well perfused, no edema Brief Hospital Course: Ms. [**Known lastname **] is a 38 y/o female with a history of multiple episodes of pancreatitis and a cystic mass in the body of the pancreas who, after being seen in clinic by Dr. [**Last Name (STitle) **], decided to go forward with surgical management of her pancreatic cyst. On [**2131-10-10**] the patient underwent a robotic-assisted minimally invasive distal pancreatectomy and splenectomy with intraoperative ultrasound with no intraoperative complications. After a brief stay in the PACU, the patient arrived on the floor NPO, on IV fluids with a foley catheter, and a dilaudid PCA for pain control. During the first night after surgery, she became tachycardic, for which she received two 500cc LR boluses, and then a 1L LR bolus, and a hematocrit was checked that came back at 27.6, with a repeat hematocrit 4 hours later being 24.3. Given her persistent tachycardia and falling hematocrit, she was transfused one unit of blood and received a CT scan of the abdomen and pelvis on the morning of [**2131-10-11**] that showed the presence of hematoma adjacent to the divided pancreas without evidence of retroperitoneal hematoma related to the inferior epigastric artery. After discussion of the risks and benefits of surgery with the patient, and 2 telephone attempts to contact her significant other, she was taken to the operating room for urgent exploratory laparotomy. On operation, she was found to be bleeding from the edge of her intact splenic artery staple line, and underwent oversewing and repair of the splenic artery with placement of an intra-abdominal drain. On the evening following her re-operation, she acutely desaturated in to the 85% range and became tachycardic into the 140's, prompting a CTA of the chest that revealed no evidence of pulmonary embolism but did show a multifocal pneumonia. She was transferred to the ICU and started on Vancomycin and Zosyn, where she remained for 2 days receiving antibiotics another one unit of packed RBC's. She was transferred back to the floor, where she continued antibiotics and was started on a clear liquid diet while awaiting return of bowel function. On [**10-18**] her creatinine bumped to 1.4 from a baseline of 0.4, so her Vanc and Zosyn were stopped given she had received a 7 day course of antibiotics and was now experiencing acute kidney injury. She also became increasingly distended and had 3 episodes of bilious emesis, so an NG tube was placed to suction with an immediate return of 1.5 liters of bilious gastric fluid. It was felt that her renal failure was likely pre-renal azotemia and not a manifestation of bowel ischemia, and she was aggressively rehydrated and a renal consult was placed, who agreed that she was likely dehydrated and pre-renal due to rapid fluid shifts and fluid losses in the setting of a small bowel obstruction. A CT abdomen/pelvis was performed that showed a high grade small bowel obstruction in the LUQ in the area of the surgical bed, but given that she was only one week post-op it was felt that conservative management with NG tube and IV fluids would be the best course for the time being, and she was also started on TPN for nutrition. Unfortunately, after 3 days of NG tube suction she developed coffee-ground output with intermittent episodes of bright red bloody output from her NG tube despite being on a PPI twice daily, became tachycardic, and her hematocrit began to fall despite receiving 1 unit of packed RBC's, with a nadir of 18.0 on [**10-24**]. At this point she was again transferred to the ICU, where she was transfused a total of 3 more units of packed RBC's. Ms. [**Known lastname **] also failed to resume bowel function with consistently high NG tube outputs, and in combination with her new upper GI bleed it was now felt that she would need to be taken back to the OR for an EGD and exploratory laparotomy in the setting of a background concern for bowel ischemia. On operation and EGD she was found to have a non-bleeding ulcer, a retroperitoneal abscess in the left upper quadrant over which the proximal jejunum was densely adherent causing the proximal small-bowel obstruction, and viable non-ischemic bowel. After surgery she returned to the ICU, where she developed an anemia post-operatively on [**2131-10-26**] and was transfused with two units of ABO compatible pRBCS. Her pre-transfusion vital signs were: T=98 F, RR=30 on 2 L O2, HR=123, and BP=148/88. Without premedication, she was transfused with two complete units of pRBCs between 10:05 and 12:05AM on [**2131-10-26**]. At 15:35, her O2 sat dropped to 91% on 2L O2 and her oxygen was increased to 4L. A chest x-ray showed worsened interval pulmonary edema with bilateral pulmonary infiltrates. At about 20:00, her O2 sat dropped to 92% and her O2 was increased to 6L with duoneb treatment. Suspecting possible fluid overload, 20mg of IV lasix was also administered. Her O2 sat dropped transiently to 60% at 7AM the following morning and she was placed on a face mask for better oxygenation. Her O2 sat was stabilized and her interval chest x-rays showed no change. Echocardiogram showed normal ventricular function without signs of volume overload. Over the next two days, she weaned off oxygen support, and never had any other symptoms such as hives, jaundice, or hematuria. By [**10-29**] her pulmonary infiltrates were resolving on her chest xray, her creatinine was trending down, and her hemodynamics were overall stable with some tachycardia and episodes of hypertension that were treated with and responsive to lopressor and IV hydralazine, and she was ultimately deemed stable for transfer back to the floor. Her NG tube output was significantly decreased at the time of transfer, and the decision was made to remove it. Her platelet count continued to be in the 1000-1400 range and her GI bleed was resolved, so she was started on aspirin 325mg daily for anticoagulation in addition to her subcutaneous heparin. She continued on TPN for nutrition, and on [**11-1**] began passing flatus with a non-distended abdomen. Her diet was advanced to clears, which she tolerated, and was then advanced to full liquids the following day without issue. Her JP drain amylase was checked after she took in a full liquid diet and was found to be [**Numeric Identifier 15614**], but her JP drain output was consistently less than 10cc per day and it was felt that she was ready for a regular diet. She tolerated her regular diet and began having bowel movements. She remained stable hemodynamically, was ambulating and voiding without assistance, and her pain was well controlled on PO oxycodone. On [**2131-11-4**] she was deemed stable for discharge home, and the patient felt comfortable managing her JP drain at home given its low output and her experience with having JP drains at home in the past for her prior mastectomy, so she did not desire home services. She had already received her post-splenectomy vaccines pre-operatively in clinic, and her laparotomy staples and PICC line were removed just prior to discharge. She was given prescriptions for her new medicines, notably her oxycodone, PPI, and stool softeners, and was instructed to follow up in clinic with Dr. [**Last Name (STitle) **] in 2 weeks and to follow up with her primary care doctor as soon as possible, and was advised to call Dr. [**Last Name (STitle) **] with any questions or concerns. Discharge Disposition: Home Discharge Diagnosis: 1. Pancreatic mucinous cystic neoplasm (2.0 cm) with ovarian-type stroma and minimal epithelial atypia. 2. Post-operative splenic artery bleed 3. Multifocal pneumonia 4. acute kidney injury 5. small bowel obstruction 6. upper gastrointestinal bleed 7. gastric ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Stable. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-7**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please do not drive until you have seen Dr. [**Last Name (STitle) **] in follow up clinic. In particular, avoid driving or operating heavy machinery while taking your pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. We have added an additional blood pressure medicine to your home regimen, and you should see your primary care provider as soon as possible to follow up on your blood pressure control regimen. 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. JP Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever greater than 101 degrees). Please maintain suction of the bulb. Please note the color, consistency, and amount of fluid in the drain. Specifically, please keep records of how much fluid came out during each day (there are CC markers on the bulb that you can use to estimate the daily drainage before you empty the bulb for the day). Call Dr.[**Name (NI) 111777**] office if the amount increases significantly or changes in character. You may shower; wash the area gently with warm, soapy water, but otherwise please keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain is attached securely to your body to prevent pulling or dislocation. Followup Instructions: Dr. [**Last Name (STitle) **] would like to see you in clinic 2 weeks from when you were discharged from the hospital. Please call [**Telephone/Fax (1) 274**] to make this appointment. Please also follow up with your Primary Care Doctor as soon as possible, ideally within one week from discharge, for a wellness check and to go over your recent hospitalization and medication changes.

[ "311", "577.1", "305.1", "507.0", "577.2", "998.59", "401.9", "560.9", "276.52", "531.90", "272.1", "276.8", "V85.32", "486", "568.0", "560.1", "998.11", "578.9", "567.38", "300.00", "E878.8", "577.8", "785.0", "285.1", "276.3", "070.32", "799.02", "276.7", "997.49", "278.00", "584.5", "V08", "276.0", "518.52", "997.5", "211.6" ]

icd9cm

[ [ [] ] ]

[ "99.15", "45.13", "38.91", "38.97", "52.52", "39.31", "54.91", "54.59", "46.73", "41.5", "17.41", "54.12" ]

icd9pcs

[ [ [] ] ]

10808, 10814

3398, 10785

373, 716

11124, 11124

13381, 13770

2927, 2984

10835, 11103

11283, 13358

2726, 2740

2999, 3375

266, 335

744, 2568

11139, 11259

2612, 2703

2756, 2911

31,088

180,791

32344

Discharge summary

report

Admission Date: [**2190-12-19**] Discharge Date: [**2190-12-22**] Date of Birth: [**2111-4-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Acute coronary syndrome 3. Stenting of LAD and POBA of diagonal. History of Present Illness: 78 year old man has a history of CAD s/p 3V CABG, Diabetes, HTN, CRI and PVD s/p bilateral BKA??????s presented to OSH at 4am with sudden onset of chest pain. Pt c/o midsternal CP radiating to back, took 2 NTGs w/o relief. Denied N, V, or dizziness, admitted to SOA associated with CP. Pt c/o increased pain with inspiration, given ASA 81mg x2 en-route to OSH. Pt recieved Morphine, Lopressor, ASA 81 x 2(additional). Pt was started on NTG gtt and loaded with Clopidogrel 300mg and given tirofiban. Pt had [**7-6**] CP and had 1mm ST elevations in septal leads. At OSH, Troponin I 18.47, CK 497, CKMB 56.5 and transferred here for cath. Patient had ongoing chest pain. . In the cath lab, his SVG-LAD totally occluded, 5 stents placed to LAD. Patient continued to have chest pain while in cath lab. On tranfer to CCU, patient's VS were 97.8, 98, 152/110, 23, 91% 3L. . Patient denies N, V, DP. Admits to persistent CP on transfer to floor, worse with deep inspiration. Admits to persistent pain in bilateral lower extremities. Past Medical History: Diabetes MAT CAD CHF, last ECHO EF 60% ([**4-2**]) SVT HTN Hyperlipidemia DVT/PE s/p b/l BKA COPD Early Alzheimer's PVD Prostate CA s/p resection Gout Depression/anxiety Anemia Obesity Social History: Social history is significant for the absence of current tobacco use. There is a history of heavy alcohol consumption. Pt is divorced and lives alone, has services at home. Uses wheelchair at home. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: GENERAL: Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink NECK: Supple with no JVP. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Anteriolateral CTAB ABDOMEN: Soft, NT/ND, obese. EXTREMITIES: No c/c/e. Bilateral BKA. distal stumps warm. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal dopplerable Left: Carotid 2+ Femoral 2+ Popliteal dopplerable Pertinent Results: Echo [**2190-11-19**] The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with focal severe hypokinesis of the distal half of the anterior septum and anterior walls, and the distal lateral and distal inferior walls. The apex is mildly aneurysmal akinetic. No intravventricular thrombus is seen, but images are suboptimal. The remaining segments contract normally (LVEF = 35%). The aortic root is mildly dilated at the sinus level. The ascending aorta and aortic arch are mildly dilated. 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. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. IMPRESSION: Moderate regional left ventricular systolic dysfunction suggestive of CAD (mid-LAD distribution). [**11-18**] CXR Lungs are clear. No pleural effusion. Heart size top normal. Thoracic aorta tortuous or dilated, but unchanged. No pneumothorax. [**11-18**] Cardiac Cath 1. Selective angiography in this right dominant patient revealed severe native three vessel CAD. The left main had no significant stenosis. The LAD had proximal diffuse disease, a mid disrupted segment culminating in mid stenosis. The first large diagonal had an ostial 80% lesion. The LCX had a 60% OM. The RCA had diffuse disease to 80% distal and was a small vessel. There was some competetive flow from the very large slow flowing SVG-RCA. 2. Grafts angiography showed the SVG-RCA to be patent with very slow flow due to the tremendous size mismatch between graft and native vessel. The SVG-LAD was occluded and the LIMA-Diagonal is known atretic. 3. Limited hemodynamics with BP 117/74 with HR 79 in sinus. The patient tolerated the procedure very well. 4. Stenting of LAD with 5 Vision stents in overlapping fashion to the ostium. From distal to proximal they were 2.25x18, 2.5x23, 2.75x23, 2.75x28, 3.0x18 5. POBA of jailed diagonal with 2.5mm balloon. 5. Successful closure with Mynx. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Acute coronary syndrome 3. Stenting of LAD and POBA of diagonal. [**12-20**] EKG Sinus rhythm with premature atrial contractions. Extensive anterolateral myocardial infarction, age undetermined. Compared to tracing #2 the rate has decreased. The other findings are similar. Brief Hospital Course: 79 yo male with h/o 3V CABG (LIMA-D1, SVG-LAD, SVG-RCA), s/p balloon angioplasty to OM1 [**4-3**], DM, PVD s/p bilateral BKA presents with chest pain and 1mm STEMI in septal leads found to have occluded SVG-LAD now s/p 5 BMS. # s/p STEMI: Patient was transfered from OSH with elevated troponins and 1mm ST elevations in septal and lateral leads. At Cath, patient found to have complete occlusion of SVG-LAD graft. As a result, native LAD was stented and had 5 BMS placed to reopen the vessel. Patient had persistent chest pain during the procedure that persisted after transfer to floor. Patient was on Nitro gtt titrated to CP control that was weaned off. CK peaked at 523 on day of admission. On discharge patient will need to be on Aspirin, Plavix, Beta Blocker, ACE-I. Patient to follow up with Cardiology. - Continue ASA 325mg for 30 days and 81mg thereafter - Continue Plavix 75mg daily for minimum 1-3 months. - Continue Toprol XL 100mg daily - Continue Lisinopril 20mg daily - Continue Simvastatin 80mg daily # Chronic systolic heart failure: Echo [**2190-12-20**] shows EF 35% with moderate regional left ventricular systolic dysfunction with focal severe hypokinesis of the distal half of the anterior septum and anterior walls, distal lateral and distal inferior walls. The apex is mildly aneurysmal and akinetic. Mr. [**Known lastname 33754**] remained euvolemic on throughout his sat and was continued on his home dose of Lasix 40mg [**Hospital1 **]. # RHYTHM: Patient has history of paroxysmal Atrial Fibrillation however was in normal sinus rhythm throughout his stay. Additionally, he has a history of DVT/PE in the past. Mr [**Known lastname 33754**] was continued on Coumadin at 1 mg (MO,WE,FR) and 2mg ([**Doctor First Name **],TU,TH,SA). - As an outpatient, patient's INR will have to be checked and dose of Coumadin will have to be adjusted accordingly. # Diabetes: Patient was placed on an insulin sliding scale as an inpatient, switched back to home Glipizide on discharge. #COPD: Patient had been admitted while taking Prednisone 7.5mg daily, for unclear reasons. Mr. [**Known lastname 33754**]' PCP was [**Name (NI) 653**] and he is apparently taking this for a recent COPD exacerbation. Prednisone was continued throughout his stay and will be tapered by his PCP as an outpatient. #HTN: Controlled on Metoprolol, Lisinopril, and Imdur. Medications on Admission: ISOSORBIDE MONONITRATE 30mg daily DONEPEZIL 5 mg once a day FLUTICASONE [FLOVENT HFA] FUROSEMIDE 40 mg [**Hospital1 **] GABAPENTIN 300 mg three times a day GLIPIZIDE 5 mg twice a day TOPROL XL 100mg daily MIRTAZAPINE 15 mg q hs NITROGLYCERIN 0.4mg/hour Patch 24 hr - during the day NORTRIPTYLINE 25 mg q hs PREDNISONE 7.5 mg DAILY PRILOSEC 20mg [**Hospital1 **] ROPINIROLE 1 mg qHS SIMVASTATIN 20 mg DAILY TOLTERODINE 2 mg qam TRAMADOL 50 mg [**Hospital1 **] WARFARIN 3 mg DAILY MWF, 4mg T,Th, Sat,Sun AMBIEN 10mg qhs ASPIRIN 81mg daily FERROUS SULFATE 325mg daily THIORIDAzINE 100mg qhs Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 9. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO 3X/WEEK (MO,WE,FR). 12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA). 13. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 14. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a day. 17. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 19. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 20. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 21. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 22. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 23. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: Take 5 minutes apart x3, then call Provider. 24. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for constipation. 25. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 26. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 27. Outpatient Lab Work check INR, Creatinine, BUN on Friday [**2190-12-24**] and call results to Dr. [**Last Name (STitle) 17029**] at [**Telephone/Fax (1) 17030**] 28. Thioridazine 100 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: ST Elevation Myocardial Infarction Systolic Left Ventricular Dysfunction: EF 35% Diabetes Mellitus Type 2 Hypertension Coronary Artery Disease Chronic Kidney Disease Discharge Condition: stable Creat 1.5 BUN 30 K 3.8 hct 40 Plt 220 WBC 6.2 Discharge Instructions: You had a heart attack and a stent was placed in your left coronary artery. Your risk factors for heart disease are increased cholesterol, high blood pressure, and diabetes. Please take all of your medicines as ordered to control these risk factors. You should also consider going to cardiac rehab after you see your cardiologist, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**]. Physical therepy has seen you here and made recommendations about your activity. Your heart function is also weaker after your heart attack. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet, information was given to you on this. Fluid Restriction: 1500cc or about 8 cups per day . Medication changes: 1. Start clopodigrel daily for at least one month, do not miss any doses or discontinue this medicine unless Dr. [**Last Name (STitle) 11493**] tells you to. 2. Your Simvastatin was increased to 80 mg daily 3. You were started on Lisinopril 20 mg daily for your blood pressure and to decrease the workload of your heart. 4. Your metoprolol was changed to a long acting version 5. Your Furosemide was increased to 40 mg twice daily . Please tell your provider if you have any chest pain, trouble breathing, swelling, nausea, leg pain or any other unusual symptoms. Followup Instructions: Cardiology: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**1-13**] at 9:00am Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2191-2-21**] 3:00 . Primary Care: Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2515**] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 17030**] Date/Time: Friday [**2193-12-30**]:00am Completed by:[**2190-12-24**]

[ "V10.46", "294.10", "285.21", "428.0", "585.9", "274.9", "414.02", "440.20", "403.90", "331.0", "V49.75", "414.01", "250.00", "428.22", "300.4", "491.21", "427.31", "272.4", "410.11" ]

icd9cm

[ [ [] ] ]

[ "36.06", "00.41", "88.52", "37.22", "00.66", "00.48", "88.55" ]

icd9pcs

[ [ [] ] ]

10644, 10712

5163, 7545

327, 352

10922, 10977

2588, 4802

12375, 12901

1980, 2062

8184, 10621

10733, 10901

7571, 8161

4819, 5140

11001, 11767

2077, 2569

11787, 12352

277, 289

509, 1537

1559, 1747

1763, 1964

3,844

122,091

2865

Discharge summary

report

Admission Date: [**2140-1-22**] Discharge Date: [**2140-1-29**] Service: Urology CHIEF COMPLAINT: Status post left radical nephrectomy and splenectomy for renal cell carcinoma. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 13918**] was referred to Dr. [**Last Name (STitle) 4229**] from his primary care physician (Dr. [**First Name (STitle) 1313**]. Mr. [**Known lastname 13918**] was a healthy and active 88-year-old male with the only comorbidity of hypertension. He was diagnosed with an left renal mass that was 7 cm X 7 cm in diameter. There were also some lesions in the liver identified which were suggestive hemangioma and not metastatic fossae. He has no symptoms of hematuria, abdominal pain, weight loss, or fatigue. Otherwise, he is a very active gentleman and has come to [**Hospital1 69**] for elective removal of this renal mass. PAST MEDICAL HISTORY: 1. Hypertension. 2. History of transient ischemic attack in [**2132**] with some right-sided weakness that has completely resolved. 3. Status post open surgical removal of a left renal stone over 40 years ago. MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg p.o. q.d. 2. Hydrochlorothiazide 25 mg p.o. q.d. 3. Multivitamin one tablet p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: A retired polymer chemist. He does not smoke. He drinks one cup of coffee per day. He rarely drinks alcohol. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination his vital signs revealed blood pressure was 126/72, heart rate was 60, and respiratory rate was 14. Head, eyes, ears, nose, and throat examination was within normal limits. His lungs were clear to auscultation bilaterally. His heart was regular in rate and rhythm. His abdomen was soft and nontender. No palpable masses. No costovertebral angle tenderness. No lymphadenopathy. Genitourinary examination revealed he had a normal phallus, meatus, and testes. No inguinal hernia. His rectal examination revealed normal tone, a 45-g prostate, and no nodularity. His extremity examination was within normal limits. PERTINENT RADIOLOGY/IMAGING: A magnetic resonance imaging revealed simple bilateral renal cysts in addition to the large 7-cm left mid upper pole renal mass pressing on the splenic vein. [**Hospital 1749**] HOSPITAL COURSE: On [**2140-1-22**], the patient went to the operating room and underwent a left radical nephrectomy. During the operation, the splenic artery was injured secondary to the position of the mass abutting against the splenic artery. At that point, General Surgery was consulted, and the patient underwent a splenectomy on top of his left radical nephrectomy. The estimated blood loss was [**2136**] cc. The patient received 3 units of packed red blood cells in the operating room. He also received 5400 cc of crystalloid. Please refer to the official Operative Notes for all of the details. After the patient was sent to the Postanesthesia Care Unit, he was still intubated and went to the Intensive Care Unit secondary to the blood loss. The patient was in the Intensive Care Unit overnight, and the next morning was able to be extubated. The patient was also cycled on enzymes which were negative. After the patient was extubated on postoperative day one, the patient was quite stable and was able to be transferred to the floor. An nasogastric tube was left in place to decompress the stomach, and he was also on an epidural. On the floor, the patient did well over the next few days. Serial hematocrit levels were checked; which were stable initially. Immediately on transfer to the floor, over the next few days, the patient had some decreased mental status including agitation and sundowning. However, after a few days, this did clear. There were no focal abnormalities, just disorientation of mental status. The patient did require some intravenous Haldol with a good response, and the Dilaudid was removed the patient's epidural as narcotics were minimized. Also of note, the patient had some expiratory wheezing and some low oxygen saturations at times and received some albuterol nebulizers with a good response. On postoperative day four, the nasogastric tube was removed, and the patient began to ambulate. It was noted around postoperative day four that the hematocrit was slowly trending down, so the patient was transfused 2 units of packed red blood cells with a good response. By postoperative day seven, the patient was ready for discharge. He was tolerating a regular diet, and having bowel movements. The Foley catheter had been discontinued, and the patient was urinating on his own. Of note, the patient was given his remaining two vaccines because he had previously received a pneumovax vaccine. He received the H-flu and the meningococcus vaccine. His staples were also removed prior to discharge on postoperative day seven. CONDITION AT DISCHARGE: The patient's was stable; tolerating a regular diet, tolerating Tylenol for pain, ambulating, and having normal bowel movements. DISCHARGE STATUS: Discharge status was to home with [**Hospital6 3429**] for home physical therapy evaluation. DISCHARGE DIAGNOSES: 1. Status post left radical nephrectomy and splenectomy secondary to renal cell carcinoma. 2. Hypertension. MEDICATIONS ON DISCHARGE: 1. Atenolol 50 mg p.o. q.d. 2. Hydrochlorothiazide 25 mg p.o. q.d. 3. Multivitamin one tablet p.o. q.d. 4. Tylenol 325 mg to 650 mg p.o. q.4-6h. as needed. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to be seen by [**Hospital6 407**] in his home for a home physical therapy evaluation. 2. The patient was instructed to call Dr.[**Name (NI) 13919**] office to follow up with him and to go over the pathology at that time. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 13920**] Dictated By:[**Name8 (MD) 1750**] MEDQUIST36 D: [**2140-1-29**] 09:58 T: [**2140-1-29**] 10:18 JOB#: [**Job Number 13921**]

[ "292.12", "401.9", "998.2", "285.1", "E878.8", "189.0" ]

icd9cm

[ [ [] ] ]

[ "55.51", "41.5" ]

icd9pcs

[ [ [] ] ]

5178, 5289

5315, 5476

1131, 1277

2317, 4898

5509, 5996

4914, 5157

109, 189

218, 869

891, 1105

1294, 2299

7,183

169,653

52726

Discharge summary

report

Admission Date: [**2161-2-23**] Discharge Date: [**2161-3-3**] Date of Birth: [**2127-8-29**] Sex: F HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old woman with a history of asthma and essential hypertension who presented to the Emergency Room with a complaint of nausea, vomiting (nonbilious), abdominal pain, and throat tightness. In the Emergency Room, the patient was found to be hypotensive with systolic blood pressure of 50 and a heart rate of 40. Electrocardiogram was consistent with complete heart block. The patient was given 3 mg of atropine, and started on dopamine and intravenous fluids without response. Pacing wires were then placed, and the patient was given 7 liters of intravenous fluids, and Levophed and vasopressin 7.27/33/433, and the patient was subsequently intubated. Prior to admission, the patient was on verapamil for treatment of hypertension. Differential for new hypotension included verapamil overdose, and the patient was given calcium gluconate 4 ampules intravenously and insulin with no improvement in blood pressure. Following intubation, the patient was noted to be wheezing on examination. Given his history of asthma, the patient was started on intravenous Solu-Medrol and nebulizers. PAST MEDICAL HISTORY: 1. Essential hypertension; the family reported the patient took verapamil intermittently. 2. Asthma; on albuterol as needed. MEDICATIONS ON ADMISSION: Medications on admission included albuterol as needed and verapamil. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is married and lives with her husband and children. She works data entry and receptionist at a probation office. No history of tobacco or alcohol use. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed temperature was 97.4, heart rate was ventricularly paced at 82, blood pressure was 97/47 (on dopamine, Levophed, and vasopressin). In general, intubated. Cardiovascular revealed no murmurs, rubs or gallops. Pulmonary revealed expiratory wheezes, poor air movement. The abdomen was distended with no bowel sounds appreciated. Extremities revealed no clubbing, cyanosis or edema. No palpable lower extremity pulses. Rectal revealed menses, heme-positive. Pelvic revealed no tampon. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission revealed white blood cell count was 18.8, hematocrit was 36.4 (differential with 87.6% neutrophils, no bands, 10% lymphocytes), platelets were 394. INR was 1.4. Creatinine was 3.7, blood urea nitrogen was 30, potassium was 3.9. Amylase was 170, ALT was 30, AST was 26. Creatine kinase was 123. Total bilirubin was 0.4. Lipase was 27. Thyroid-stimulating hormone was 2.3. Toxicology screen was negative. Lactate was 12.8. Verapamil level was 2190 (normal 100 to 600). MICROBIOLOGY: Microbiology revealed blood cultures from [**2161-2-23**] revealed no growth to date. Urine culture on [**2-23**] with mixed bacterial flora consistent with contamination. Sputum culture from [**2-23**] with growth of oropharyngeal flora. Stool culture was negative for Clostridium difficile colitis. RADIOLOGY/IMAGING: CT of the abdomen without contrast revealed moderate ascites in the upper abdomen surrounding pancreas with adjacent focal dilated and thickened loops of small bowel. A follow-up CT on [**2-26**] showed resolved thickening and dilation of loops of small bowel, improved intra-abdominal ascites. Echocardiogram revealed left ventricular cavity size and systolic function were normal. Right ventricular chamber size and free wall motion were normal. Mitral regurgitation of 1+. Estimated pulmonary artery systolic pressure was normal. HOSPITAL COURSE: The patient is a 33-year-old woman with a history of essential hypertension and asthma who presented to the Emergency Department with a 1-day history of nausea and vomiting. The patient was found to be hypotensive on three pressors. The patient was intubated for progressive metabolic and respiratory acidosis. The etiology of hypotension was thought to likely be multifactorial included vomiting, decreased oral intake, complete heart block with poor forward flow, and possibly sepsis with lactate of 12.8 on admission. The patient was started on intravenous fluids and pressors (Levophed, dopamine, and vasopressin) for blood pressure support. The differential diagnosis for hypotension included sepsis as the patient presented with an elevated white blood cell count of 18.8 in the setting of receiving intravenous steroids. However, the patient was afebrile with no preceding illness. The patient was started on broad spectrum antibiotics and blood, urine, and sputum cultures were sent; and all showed no growth to date. Antibiotics were discontinued on hospital day five when cultures returned negative. In addition, a concern of pancreatitis with slightly elevated amylase but with a normal lipase. A CT scan of the abdomen was obtained which did not show evidence of pancreatitis. Verapamil level was sent for concern of verapamil overdose. In the Emergency Room, the patient was noted to be in complete heart block on electrocardiogram. Temporary pacing wires were placed at that time. The patient converted to a normal sinus rhythm on hospital day three, and temporary wires were removed. Verapamil level came back grossly elevated at 2190 (normal 100 to 600) indicating a verapamil overdose as the etiology of hypotension and complete heart block. During this hospital course, the patient's pressors were weaned. In addition, the patient blood pressure following Medical Intensive Care Unit course was elevated to the 150s. The patient was started on hydralazine and Norvasc prior to discharge. 2. PULMONARY: The patient was intubated with metabolic and respiratory acidosis. Following intubation, the patient was noted to have elevated plateau pressures with wheezing on examination. The patient was started on intravenous Solu-Medrol and nebulizers for presumed bronchospasm given history of asthma. The patient was subsequently extubated and had no further episodes of wheezing or shortness of breath. 3. INFECTIOUS DISEASE: On admission, the patient had a leukocytosis with left shift. Blood, urine, and sputum cultures were sent. The patient was started on empiric treatment with ceftriaxone, Flagyl, and vancomycin. Cultures returned negative, and antibiotics were discontinued. Leukocytosis was thought to be secondary to steroids given for treatment of bronchospasm. 4. RENAL: The patient presented with acute renal failure likely ischemic acute tubular necrosis in the setting of hypotension. Admission creatinine of 3.9 decreased to 0.9 at the time of discharge without intervention. 5. PSYCHIATRY: Verapamil level on admission was grossly elevated at 2190, indicating a verapamil overdose as the cause of hypotension. As verapamil is hepatically metabolized, acute renal failure would not explain the elevated level. A Psychiatry consultation was obtained. The patient denied taking overdose. She did recall confusion as to whether her medication was [**Hospital1 **] (as her prior antihypertensive had been) and thinks that she was taking verapamil [**Hospital1 **] x the several days prior to admission. In addition, the patient denied any suicidal ideation or intention. She denied a history of depression or mania. The patient was noted to lack insight into importance of taking medication properly and consistently. DISCHARGE DIAGNOSES: 1. Verapamil overdose. 2. Acute renal failure related to hypotension due to #1. 3. Complete heart block due to #1. 4. Anemia. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE FOLLOWUP: At discharge, the patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2161-3-5**] at 9:30 a.m. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 15868**] Dictated By:[**Last Name (NamePattern1) 1297**] MEDQUIST36 D: [**2161-8-4**] 18:14 T: [**2161-8-11**] 15:10 JOB#: [**Job Number 38841**]

[ "038.9", "276.5", "426.0", "584.5", "530.81", "276.2", "577.0", "518.81", "276.3" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7547, 7688

1436, 1544

3740, 7526

7703, 7739

7760, 8180

146, 1259

1281, 1409

1561, 3722

41,308

186,698

36152

Discharge summary

report

Admission Date: [**2124-12-31**] Discharge Date: [**2125-1-4**] Date of Birth: [**2103-4-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 358**] Chief Complaint: R Lower extremity DVT, Pulmonary embolism. Major Surgical or Invasive Procedure: None History of Present Illness: Mr [**Known lastname **] is a previously healthy 21 yo gentleman with no significant past medical history who presented to [**Hospital 4683**] hospital with a three week history of SOB, cough, intermittent chest pain and a three day history of right leg pain. He initially attributed these sxs to URI because his SOB started with cough and fever therefore he treated with aleve and mucinex. He finally went to the hospital when his SOB did not improve and he started experiencing leg pain. He has no history of recent trauma or prolongued periods of inactivity. On presentation to [**Hospital3 10310**] Hospital on [**12-29**] his D dimer was elevated at 7,959. He was given lovenox and sent for CT chest. ECG at that time showed new right bundle branch block compared to prior. CT showed massive bilateral pulmonary embolism involving both arteries. He was then started on heparin and was noted to be subtheraputic prior to episode of pleuritic chest pain [**12-30**] in right lower back radiating to the shoulder. At that time patient was noted to have HR 11, but stable BP and O2 sat 93-96% 2LNC. Heparin was increased from 1100 to 1200 units, and a 5,000 unit bolus was given. Patient's pain was treated with 6mg morphine iv and the patient was transferred to [**Hospital1 **] ICU for [**Hospital 35455**] medical care. Past Medical History: ADD Suicide Attempt for which he was hospitalized at BayRidge Finger Fracture Social History: Pt lives with his mother and works at the fish counter at stop & shop. He has a 16 month daughter for whom he is a caretaker along with his wife. Social drinker, [**2-2**] ppd smoker x5 years. States he does not plan to continue smoking. Family History: Father HTN, Mother asthma, ? clot in legs, Uncle with multiple MIs. No known family history of clotting disorders. Physical Exam: Vitals: Tm 98 BP 131/58 HR 90 RR 20 02 sat 92-98% RA General: NAD HEENT: PERRL, EOMI, OP clear Neck: no LAD, supple Heart: RRR, 1/6 systolic ejection murmur Lungs: CTAB no wheezes, crackles, rhochi Abd: +BS, NTND, soft Ext: 1+ pitting edema on the R side to mid-calf. Neuro: alert and oriented x3 Psych: appropriate Skin: no rashes Pertinent Results: [**2125-1-4**] 06:40AM BLOOD WBC-7.4 RBC-4.21* Hgb-12.4* Hct-35.2* MCV-84 MCH-29.3 MCHC-35.1* RDW-12.9 Plt Ct-311 [**2125-1-4**] 06:40AM BLOOD PT-27.6* INR(PT)-2.8* [**2125-1-3**] 06:45AM BLOOD PT-20.9* PTT-34.7 INR(PT)-2.0* [**2125-1-2**] 09:20AM BLOOD PT-15.5* PTT-51.5* INR(PT)-1.4* [**2125-1-1**] 02:57AM BLOOD PT-16.9* PTT-72.4* INR(PT)-1.5* [**2124-12-31**] 01:14PM BLOOD PT-18.6* PTT-78.3* INR(PT)-1.7* [**2124-12-31**] 05:45AM BLOOD PT-15.8* PTT-35.8* INR(PT)-1.4* [**2125-1-4**] 06:40AM BLOOD Glucose-100 UreaN-7 Creat-0.9 Na-138 K-4.1 Cl-103 HCO3-25 AnGap-14 [**2125-1-1**] 02:57AM BLOOD Calcium-8.2* Phos-4.5 Mg-2.3 CTA chest from [**Hospital3 10310**] loaded into PACS system at [**Hospital1 18**]: (not final): large saddle embolus. Possible small pulmonary infarctions of R lung. ECHO: [**2125-1-1**] The left atrium and right atrium are normal in cavity size. The right atrial pressure is indeterminate. Premature appearance of microbubbles are seen in the left atrium with cough (but not with rest or post-Valsalva release). Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2124-12-31**], a patent foramen ovale is identified on the current study and the estimated pulmonary artery systolic pressure is higher. Right ventricular cavity size/systolic function and the pericardial effusion are similar. ECHO: [**2124-12-31**] The left atrium is normal in size. The right atrial pressure is indeterminate. 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 moderately dilated with severe global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. 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. There is no mitral valve prolapse. There is atleast mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Right ventricular cavity enlargement with severe free wall hypokinesis. Pulmonary artery systolic hypertension. LOWER EXTREMITY ULTRASOUND [**12-31**]: 1. Right lower extremity occlusive thrombus extending from the mid superficial femoral vein to the popliteal vein. 2. No evidence of DVT involving the left lower extremity. Brief Hospital Course: Mr [**Known lastname **] was admitted to the ICU for observation and transferred to the medicine wards after one day without complication. He was not treated with thrombolytic therapy as his blood pressure remained stable. His condition continued to improve with no worsening of symptoms and improving oxygen saturations at rest and with exertion. Anticoagulation was well tolerated therefore an IVC filter was not placed. He was observed for 3 days without worsening of symptoms or complications. His EKG showed evidence of right heart strain and a S1Q3T3 pattern on EKG. Anticoagulation with warfarin was initiated with INR monitoring as described below: [**1-4**]: 7.5 mg [**1-3**]: 7.5 mg [**1-2**]: 10 mg [**1-1**]: 10 mg [**2125-1-4**] INR(PT)-2.8* [**2125-1-3**] INR(PT)-2.0* [**2125-1-2**] INR(PT)-1.4* [**2125-1-1**] INR(PT)-1.5* [**2124-12-31**] INR(PT)-1.7* [**2124-12-31**] INR(PT)-1.4* On the day of discharge he was ambulating without difficulty and maintaing sats of 92-98% on room air while ambulating. He has been scheduled for anticoagulation follow-up on [**1-5**] and hematology work-up in [**Month (only) 956**]. Of note, Factor V Leiden testing was performed at [**Hospital3 10310**] prior to this admission and found to be negative. In addition to anticoagulation the patient will require follow-up for his right heart strain. His echo findings did reveal a moderately hypokinetic right ventricle. Medications on Admission: None Discharge Medications: 1. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a day: Take 2 tablets (5mg) on Mon, Wed, Fri and 3 tablets (7.5mg) on Tues, Thurs, Sat, Sun. Disp:*90 Tablet(s)* Refills:*5* 2. Compression stockings Graduated compression stockings, > 30mm Hg Discharge Disposition: Home Discharge Diagnosis: Right lower extremity deep vein thrombosis and pulmonary embolism. Discharge Condition: Stable, saturating 92-98% on RA while ambulating. Discharge Instructions: You were admitted to our hospital for a right lower leg deep vein thrombosis (clot) which embolized (migrated) to your lung, causing you to be short of breath. You were treated in the ICU for your compromised respiratory status and anticoagulation to prevent further propogation of the clot. It is extremely important for you to continue your anticoagulation medications at home and follow up with your PCP and nurse practitioner [**First Name (Titles) **] [**Hospital3 10310**] hospital. Please return to the emergency room if you experience additional SOB, chest pain or any other symptoms that are concerning to you. Followup Instructions: Please follow-up with the nurse practicioner and [**Hospital 2786**] clinic tomorrow ([**1-4**]) at [**Hospital3 10310**] Hospital. The appointment is scheduled for noon tomorrow, please arrive 15 minutes early to complete paperwork. The office can be found at [**Hospital3 10310**] hospital on the [**Location (un) **] ([**Telephone/Fax (1) 4688**] fax [**Telephone/Fax (1) 81987**]). You also have an appointment scheduled with your PCP, [**Name10 (NameIs) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Hospital3 10310**] Hospital Primary Care on Tuesday [**1-9**] at 12:15. Finally, we have scheduled a hematology follow-up appointment for you with Dr. [**Last Name (STitle) 2805**] at [**Hospital3 **] on [**3-29**] at 10:30 (Building: [**Hospital Ward Name 23**] Floor:9 [**Telephone/Fax (1) 3062**]).

[ "305.1", "314.01", "416.8", "278.00", "415.19", "453.41" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7483, 7489

5716, 7152

357, 364

7600, 7652

2583, 5693

8323, 9168

2097, 2215

7207, 7460

7510, 7579

7178, 7184

7676, 8300

2230, 2564

275, 319

392, 1721

1743, 1823

1839, 2081

68,664

140,145

40742

Discharge summary

report

Admission Date: [**2124-6-26**] Discharge Date: [**2124-7-1**] Date of Birth: [**2060-3-13**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: seizure Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 11950**] is a 64 yo M with h/o NIDDM, HTN, HL who presents with new onset seizures. The pt was feeling unwell with N/V 1 day prior to presentation, and went to [**Hospital3 **] where workup was negative and he was D/Ced home. On the day of presentation, the patient (who lives with his son) was fine in the morning. However, in the afternoon he seemed diaphoretic and chilled. His son thought he seemed "out of it." He was focusing on something behind his son rather than making eye contact, and would answer "I'm ok" at first, but later was not speaking or responding. His son suggested he lie down, which he did, and he was rolling back and forth in bed toward and away from the fan. The son did not notice any facial droop, focal weakness, or incontinence. He called EMS, who brought patient to [**Hospital3 **]. The pt reportedly had 1 seizure in the ambulance with rightward gaze deviation, and received 5 mg Valium. In the ED, the attending witnessed another GTC with R gaze deviation. The patient received 2 mg Ativan, 1 g Dilantin. He was intubated for airway protection and started on propofol. Head CT showed chronic L parietal infarct, C-spine was normal, and CT C/A/P was unrevealing. LP was significant for 26 WBC (10 L, 16 MONOs), 2 RBCs with normal protein and glucose (opening pressure not reported). The pt then received Decadon 10 mg, acyclovir, CTX, amp, and vanco. Per son, the patient did have a [**2060**]0 days ago with possible head trauma, though his only visible injury was to his foot. He has no history of seizure. He was not ill besides 1 day of N/V. Past Medical History: - NIDDM c/b neuropathy - HTN - HL - GERD Social History: lives with son, recently moved from [**Name (NI) 108**] 6 months ago to be closer to family. Not married. Retired veteran. Smokes less than 1pk/day, occasional marijuana, no ETOH or IVDU. Uses cane to ambulate, independent in ADLs. Family History: negative for stroke, seizure. + for DM, breast CA Physical Exam: At admission: General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W 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 Skin: no rashes or lesions noted. Neurologic: -Mental Status: off propofol 5 minutes (longer than that, he fought vent)--> eyes barely open to sternal rub, does not follow any commands. -Cranial Nerves: PERRL 5 to 2mm and brisk. Eyes midline. No facial droop. -Motor: Normal bulk, tone throughout. No adventitious movements, such as tremor, noted. Uses bilateral upper extremities to localize pain in the contralateral pain with antigravity strength. Withdraws purposefully bilaterally in lower extremities. -Sensory: intact to pain throughout -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2+ 2+ 2+ 2+ 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. . Discharge: General: Awake, cooperative, NAD. Asterixis bilat R>L. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W 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 Skin: no rashes or lesions noted. . Neurologic: -Mental Status: Alert and partially oriented knew in hospital not which and knows month/year not date. Speech fluent. Poor memory but improving - not able to [**First Name8 (NamePattern2) **] [**Doctor Last Name 1841**] backwards but can to DOW backwards. . -Cranial Nerves: PERRL 4 to 2mm and brisk. Eyes midline. Intact VOR. No facial droop. Good facial power. Tongue protrudes midline. Good palatal elevation. -Motor: Normal bulk, tone throughout. Good power throughout save knee flexion on the left and otherwise full. -Sensory: Normal to light touch buit decreased sensation to ankle bilaterally on temp sensation -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Adductor reflex Plantar response was flexor bilaterally Pertinent Results: Admission labs: [**2124-6-25**] 11:40PM PT-14.0* PTT-31.2 INR(PT)-1.2* [**2124-6-25**] 11:40PM WBC-9.0 RBC-4.96 HGB-13.9* HCT-42.4 MCV-86 MCH-28.1 MCHC-32.9 RDW-14.5 [**2124-6-25**] 11:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2124-6-25**] 11:40PM LIPASE-165* [**2124-6-25**] 11:40PM UREA N-11 CREAT-1.6* . Risk factors: [**2124-6-29**] 06:15AM BLOOD %HbA1c-6.5* eAG-140* [**2124-6-29**] 06:15AM BLOOD Calcium-9.1 Phos-2.3* Mg-2.1 Cholest-338* [**2124-6-29**] 06:15AM BLOOD Triglyc-258* HDL-42 CHOL/HD-8.0 LDLcalc-244* . Other pertinent labs: [**2124-6-26**] 04:23AM BLOOD ALT-10 AST-11 LD(LDH)-238 AlkPhos-139* TotBili-0.2 [**2124-6-28**] 06:35AM BLOOD ALT-6 AST-11 AlkPhos-107 TotBili-0.4 [**2124-6-27**] 02:59AM BLOOD Phenyto-11.1 [**2124-6-28**] 06:35AM BLOOD Phenyto-10.3 [**2124-6-25**] 11:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2124-6-26**] 01:25AM BLOOD Type-ART Temp-37.6 Rates-/14 Tidal V-500 PEEP-5 FiO2-100 pO2-503* pCO2-32* pH-7.30* calTCO2-16* Base XS--9 AADO2-195 REQ O2-40 -ASSIST/CON Intubat-INTUBATED [**2124-6-25**] 11:49PM BLOOD Glucose-216* Lactate-2.8* Na-140 K-4.0 Cl-113* calHCO3-16* . Discharge labs: . .Urine: [**2124-6-26**] 01:00AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010 [**2124-6-26**] 01:00AM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2124-6-26**] 01:00AM URINE RBC-1 WBC-3 Bacteri-MOD Yeast-NONE Epi-0 [**2124-6-26**] 01:00AM URINE Mucous-RARE [**2124-6-26**] 01:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . Microbiology: [**2124-6-29**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-PENDING [**2124-6-26**] MRSA SCREEN MRSA SCREEN-Negative [**2124-6-26**] URINE URINE CULTURE-Negative [**2124-6-25**] BLOOD CULTURE Blood Culture, Routine-No growth to date [**2124-6-25**] BLOOD CULTURE Blood Culture, Routine-No growth to date . [**Hospital3 17163**] LP 2 RBCs, 26 WBC with 10 lymphocytes and 16 monocytes, with no growth on CSF culture. HSV PCR negtive at <80 copies Brief Hospital Course: Primary diagnosis: 1) Seizures likely secondary to left parietal brain lesion 2) Left parietal brain lesion ? subacute arterial/venous infarct vs other cause following head injury . Secondary diagnoses: Difficult to control hypertension ? renal artery stenosis Acute renal failure which settled . . . 64 yo M with h/o NIDDM, HTN, HL, with heavy cannabis use who presents with 2 seizures of unknown etiology. Patient remembers fall and head injury 10 days prior to presentation but only visible injury was to his foot. Initially had N/V and abdominal pain 1 day prior to presentation, went to [**Hospital3 **] where workup was negative. On the day of presentation patient felt unwell - diaphoretic and chilled and was less responsive - staring and roaming eyes. Had GTC seizure in ambulance and had further seizure in [**Hospital3 17162**] ED with R gaze deviation. He was intubated for airway protection and started on propofol. Head CT showed chronic L parietal infarct, C-spine was normal, and CT C/A/P was unrevealing save bilateral renal masses whcih were likely cysts. LP was significant for 26 WBC (10 L, 16 MONOs), 2 RBCs with normal protein and glucose (opening pressure not reported). Patient was treated with Dexamethasone 10 mg, acyclovir, CTX, ampicillin, and vanco and was transferred to [**Hospital1 18**]. There was no growth on CSF culture and HSV PCR negative and antibiotics and then acyclovir were stopped. The small number of cells was felt not to be encephalitis and could represent post-stroke and seizure changes. Patient was transferred to the neuro ICU at [**Hospital1 18**]. Patient was started on IV fosphenytoin in the ICU and transitioned to po phenytoin with no further seizures. MRI showed a small focus of altered signal intensity in the left parietal lobe with areas of mineralization, cortical thickening, edema and gyriform enhancement with a smaller focus more posteriorly in the left post parietal/occipital lobe junction and was felt to be venous vs subacute arterial infarct although diagnosis is uncertain and will have to be monitored with repeat interval scan. EEG showed diffuse slowing consistent with propofol use but no seizure activity. Patient was successfully extubated and transferred to the neurology floor. Neurological examination on transfer was in keeping with mild encephalopathy was nonfocal and there was poor memory and attention which improved and was felt due to post-ictal state. Patient had a markedly abnormal lipid panel and was started on atorvastatin. CTA showed no evidence of AVM, or any other vascular anomalies and stable hypodensity in left parietal and left occipital lobe with mild atherosclerotic plaquing in the left carotid artery at the origin of the left internal carotid artery which was not hemodynamically significant. BP was very high and difficult to control requiring PRN medications and these was evidence of right kidney smaller than left on renal ultrasound suggesting possible renal artery stenosis. There were also multile bilateral cysts without a solid component. Will need o/p follow-up with a renal doppler U/S. On discharge, phenytoin was stopped after starting levetiracetam 1g [**Hospital1 **] [**6-30**]. Patient has neurology follow-up and should book a repeat MRI scan with contrast on this day to monitor and further characterise this lesion. . . # Left parietal lesion of unclear etiology and seizures: Patient presented with 2 GTC seizures 10 days post fall with head injury per patient and patient was intubated for airway protection. CSF showed 26 WBC (10 L, 16 MONOs), 2 RBCs with normal protein and glucose. No growth on culture and HSV PCR was negative. CT torso was apparently negative at the OSH. MRI showed a small focus of altered signal intensity in the left parietal lobe with areas of mineralization, cortical thickening, edema and gyriform enhancement with a smaller focus more posteriorly in the left post parietal/occipital lobe junction and was felt to be venous vs subacute arterial infarct although diagnosis is uncertain and will have to be monitored with repeat interval scan. Patient was started on IV fosphenytoin in the ICU and was transitioned to po pheytoin. Patient had no further seizueres. EEG showed diffuse slowing consistent with propofol use but no seizure activity. Patient was ecxtubated and transferred to the neuro floor. Neurological examination ontransfer was nonfocal and there is poor memory and attention. Risk factors were addressed and HbA1c was 6.5%. Patient had a markedly abnormal lipid profile with Chol 338 TGCs 258 LDL 244 and was started on atorvastatin 20mg. Echo cardiogram showed no cardiac cuase for stroke with no ASD/VSD or PFO. EF was 60%. Ascending aorta was mildly dilated at 3.6cm and no vegetations or significant valvular defects were seen. Patient was initially mildly encephalopathic and was disoriented with mild R asterixis. Aseriixis resolved and patient cleared with residal poor memory. RPR was non-raective. CTA to evaluate intra/extracranial vessels showed no evidence of AVM, or any other vascular anomalies and stable hypodensity in left parietal and left occipital lobe with mild atherosclerotic plaquing in the left carotid artery at the origin of the left internal carotid artery which was not hemodynamically significant. Patient noted night sweats and cough past few weeks. CT-CAP at OSH showed clear lungs per report and showed bilateral renal masses which likely reprsent cyst. Renal U/S showed multiple bilateral renal cysts withoutr solid component and R kidney smaller than L suggesting possible renal artery stenosis. Raised inflamatory markers ESR 37 CRP 72. On discharge, phenytoin was stopped after starting levetiracetam 1g [**Hospital1 **] [**6-30**]. Patient has neurology follow-up on [**2124-8-15**] and should book a repeat MRI scan with contrast on this day to monitor and further characterise this lesion. . # HLD: Significantly elevated lipids Chol 338 TGCs 258 LDL244. We started atorvastatin 20mg. . # Very difficult to control HTN: HTN and SBP often spiking to 180s-200s and very difficult to control requiring frequent PRNs. This also limited PT eval as BP roise to max SBP 220mmHg on exertion. On renal ultrasound, right kidney was smaller than left suggesting possible renal artery stenosis so ACEI stopped. Will need o/p follow-up with a renal doppler U/S. We started hydrochlorothiazide on the day of discharge. Patient will need PCP [**Name9 (PRE) 702**] for his HTN. . # ENDO: T2DM. Hold po DM meds. HbA1c 6.5%. Patient was treated with HISS in house and restarted on home DM medications on discharge. . # RENAL: Mild Cr elevation which is iproving 1.5->1.3. Improved to 1.2. Bilateral renal "masses" present on OSH CT-CAP whcih were likely cysts. Renal U/S showed multiple bilateral renal cysts withoutr solid component and R kidney smaller than L suggesting possible renal artery stenosis. Will need o/p follow-up with a renal doppler U/S. . # ID: 2x seizures and left hemisphere lesions as above.LP was significant for 26 WBC (10 L, 16 MONOs), 2 RBCs with normal protein and glucose (opening pressure not reported). The pt then received Decadon 10 mg, acyclovir, CTX, amp, and vanco. No growth on CSF culture. HSV PCR negative. Abx and antivirals were stopped. Afebrile and initial encephalopathy cleared. . # Right arm swollen with small blisters. Right arm swollen and slightly hotter than left. This was felt related to dependent edema and IVs post ICU stay. Improved. . . FEN: Regular/thin liquids. Replete lytes PRN. . # Code status: Full code # Contacts: son [**Name (NI) **] [**Telephone/Fax (1) 89085**] (wants to be there for extubation), mother of [**Name (NI) **] ([**Doctor First Name **]) [**Telephone/Fax (1) 89086**], sister [**Name (NI) 14880**] [**Telephone/Fax (1) 89087**] Medications on Admission: ASA 81 mg sitagliptin 50 mg daily Venlafaxine 150 mg [**Hospital1 **] Topamax 200 qhs glipizide 5 mg daily metoprolol 25 mg [**Hospital1 **] amlodipine 5 mg daily enlapril 5 mg daily Flomax 0.4 mg qhs vitamin B12 omeprazole 20 mg daily zolpidem 10 mg qhs Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Viitamin B12 Sig: One (1) Tab once a day. 3. Flomax 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO at bedtime. 4. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 5. sitagliptin 50 mg Tablet Sig: One (1) Tablet PO once a day. 6. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*0* 10. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 11. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 13. venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO twice a day. 14. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Primary diagnosis: 1) Seizures likely secondary to left parietal brain lesion 2) Left parietal brain lesion ? subacute arterial/venous infarct vs other cause following head injury . Secondary diagnoses: Difficult to control hypertension ? renal artery stenosis Acute renal failure wich settled Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you during your stay at the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented to an outside hospital following two seizures and had a breathing tube placed as there was concern that you were protecting your airway and you were transferred to the ICU. You had a lumbar puncture (spinal tap) which showed evidence of inflammation and you were briefly treated with antibiotics and antivirals until spinal fluid cultures and viral studies came back negative. You were also treated with anti-seizure medications which were continued and you had no further seizures. You were transferred to the [**Hospital1 18**]. You had head imaging including MRI which showed a lesion on the left side of your brain and it is unclear whether this represents a small stroke which occurred following your fall and induced your seizures. You improved although you had limited recollection of the events which brought you into hospital. You were seen by physical therapy and you were felt to be unsteady. You had high blood pressure and we controlled this by adding back your home medications and increased these. You had a very high blood cholesterol and you were started on a cholesterol lowering medication called simvastatin. Your blood pressure was very difficult to control and this may be due to a narrowing of one of the arteries supplying your kidney. We adjusted your blood pressure medications and your blood pressure improved, however this will need to be monitored by your primary care doctor. You should book a repeat MRI to happen on the day of your neurology appointment or the day before to allow results to be back when you are seen by the neurologist. This is so that we can monitor your brain lesion which we feel is probably a stroke but some uncertainty exists as to whether this another inflammatory process. Medication changes: We STARTED Keppra (levetiracetam) 1000mg twice daily for seizures We INCREASED aspirin to 325mg daily We Increased Norvasc to 10mg daily We Started Hydrocholothiazide 25mg daily We INCREASED metoprolol to 25mg three times daily We STOPPED enalapril because of possible kidney artery narrowing. YOU NEED TO STOP SMOKING! THIS IS THE BEST THING YOU CAN DO FOR YOUR HEALTH. THIS INCLUDES SUBSTANCES OTHER THAN TOBACCO. Followup Instructions: Plaese make an appointment to see your PCP for within 1 week on ([**Telephone/Fax (1) 89088**]. . Please organize a repeat MRI scan for [**2124-8-15**] on the day of your appointent. Please call [**Telephone/Fax (1) 327**] to book this for [**2124-8-15**]. . Department: NEUROLOGY When: TUESDAY [**2124-8-15**] at 4:00 PM With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2574**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2124-7-1**]

[ "V15.52", "600.00", "753.10", "348.30", "357.2", "305.20", "V12.54", "272.4", "250.60", "345.10", "305.1", "403.90", "348.89", "584.9", "585.9" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

16177, 16240

6847, 6847

320, 326

16578, 16578

4707, 4707

19159, 19707

2289, 2341

14962, 16154

16261, 16261

14682, 14939

16761, 18696

5927, 6824

4176, 4688

2356, 2793

16464, 16557

18716, 19136

273, 282

354, 1958

4723, 5278

16280, 16443

5300, 5910

16593, 16737

1980, 2023

2039, 2273

30,298

189,330

47623

Discharge summary

report

Admission Date: [**2109-3-26**] Discharge Date: [**2109-4-3**] Date of Birth: [**2030-1-22**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Verapamil Attending:[**First Name3 (LF) 5893**] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: Intubation Attempt at insertion of a central line PICC line insertion History of Present Illness: 79F COPD, CAD, lung CA, afib on coumadin, transferred initially from [**Hospital1 **] with respiratory distress, failed intubation attempt there c/b lacerated posterior pharynx. Then went to OSH where she was finally intubated. Got lasix for presumed CHF, but dropped pressures. CXR however did not show failure. OSH did not have ICU beds, so transferred to [**Hospital1 18**]. . CBC remarkable for WBC 19 with 5 bands and foley drained frank pus. Placed R fem line in ED for pressors and fluids, now on levo. Applied gelfoam to post pharynx but still some oozing, as INR is supratherapeutic. Getting CTA because of acute nature of SOB. Started CTX/Zosyn/Azithro/flagyl for sepsis in rehab pt, although no specific infiltrate convincing for pna. Past Medical History: Hypertension Coronary Artery disease s/p MI and CABG x 2 Tachybrady syndrome s/p pacemaker placement Atrial Fibrillation Diastolic CHF (EF 60%) COPD - previously on home oxygen but not currently Squamous Cell Lung Cancer - s/p ressection in [**2098**] Small Cell Lung Cancer - s/p chemotherapy and radiation in [**2101**] as well as cranial XRT. Social History: She lives in [**Location 11269**] in an [**Hospital3 **] facility. She has a 50 pack year smoking history but quit many years ago. She is divorced. She occassionally drinks alcohol. Family History: Mother died at age 54 of heart disease. Her father was an alcoholic. She has one sister who died of cancer of the back. Physical Exam: GEN: elderly female intubated Neck: supple CHEST: bilateral decreased BS at bases and crackles CVR: distant Heart sounds, ireg ireg ABD: distended, LLQ tenderness Ext: 3+ edema below knees. Peripheral Vascular: (Right radial pulse: weak), (Left radial pulse: absent), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Pertinent Results: 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. There is mild regional left ventricular systolic dysfunction with basal infero-lateral hypokinesis. There is no ventricular septal defect. The right ventricular cavity is dilated The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal 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. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . . CT neck: 1. Interval resolution of subcutaneous emphysema in the neck. 2. No gas or fluid collection in the neck or mediastinum. 3. Moderate-sized bilateral pleural effusions with related atelectasis, slightly increased on the right. 4. Small ascites. 5. Anasarca. . . Gastrograffin swallow study: 1. Hypopharyngeal tear posteriorly. 2. Silent aspiration. . . MICROBIOLOGY: Urine [**2109-3-26**]: resistant klebsiella, sensitive to meropenam and zosyn Sputum [**2109-3-30**] with stenotrophomonas Brief Hospital Course: Ms [**Known lastname 100616**] was admitted with urosepsis, which was determined to be caused by a very resistant klebsiella, sensitive only to zosyn and meropenam. She required intubation and levophed in the acute management of her septic shock. Her extubation was complicated by her co-morbid congestive heart failure, which required a lasix drip to manage. After extubation, she sustained two episodes of demand ischemia secondary to the hypotension resulting from her diuresis. The hypotension and high doses of lasix were also causing elevations in her creatinine. She failed a speech and swallow evaluation, and was continuing to aspirate. Palliative care was consulted about the overall goals of care. The family felt that she would not get a good quality of life with tube feeds, which the only option for her nutrition. The patient was also expressing desires to discontinue aggressive measures. Her PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was brought into the discussion, and agreed that moving into comfort measures only was the best option. Medications on Admission: 1. Ferrous Gluconate 325 mg daily 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk [**Hospital1 **] 3. Tiotropium Bromide 18 mcg daily 4. Lorazepam 0.5 mg qhs 5. Digoxin 125 mcg every other day 6. Alendronate 70 mg weekly 7. Multivitamin daily 8. Pantoprazole 40 mg daily 9. Ropinirole 1 mg daily 10. Benzonatate 100 mg daily prn 11. Toprol XL 25 mg daily 12. Furosemide 20 mg daily 13. Spironolactone 50 mg daily 14. Warfarin as directed Discharge Medications: Patient deceased Discharge Disposition: Expired Discharge Diagnosis: Patient deceased Discharge Condition: Patient deceased Discharge Instructions: Patient deceased Followup Instructions: Patient deceased

[ "E870.8", "280.9", "496", "038.49", "998.81", "785.52", "286.9", "V45.81", "427.31", "453.40", "V10.11", "428.21", "599.0", "E849.7", "428.0", "414.00", "V58.61", "401.9", "518.81", "874.4", "995.91", "790.4" ]

icd9cm

[ [ [] ] ]

[ "96.72", "93.90", "99.04", "38.93", "38.91", "33.23" ]

icd9pcs

[ [ [] ] ]

5384, 5393

3730, 4856

312, 383

5453, 5471

2340, 3707

5536, 5555

1748, 1871

5343, 5361

5414, 5432

4882, 5320

5495, 5513

1886, 2321

253, 274

411, 1159

1181, 1529

1545, 1732

55,591

152,075

35899

Discharge summary

report

Admission Date: [**2133-2-4**] Discharge Date: [**2133-2-18**] Date of Birth: [**2053-12-8**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Tramadol Hcl / Hydrocodone Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2133-2-4**] - AVR (21mm [**Company 1543**] Mosaic Ultra Porcine Valve) History of Present Illness: This is a female patient with a past medical history of aortic valve disease, followed over the years by Dr. [**Last Name (STitle) 8098**]. She has been stable until recently. She was seen in an office visit on [**2132-12-22**] with complaints of worsening dyspnea on exertion and exercise induced chest pain. According to Dr. [**Last Name (STitle) 8098**]??????s note her most recent echocardiogram revealed an aortic valve area of 0.9 cm2. She was scheduled to undergo knee surgery but has postponed that for the time being. She is now admitted for surgical management of her aortic valve stenosis. In terms of symptoms, she reports a significant reduction in her functional capacity with dyspnea on minimal exertion. She states she has difficulty with minimal tasks. Past Medical History: Hypertension Hyperlipidemia Aortic stenosis Osteoarthritis Pending bilateral knee replacements Colectomy with colostomy and reversible for bowel obstruction Social History: She is a widow with 5 grown children. She does smoke or drink. She is a homemaker. Her son [**Name (NI) **] will bring her his [**Telephone/Fax (1) 81561**] Family History: Her brother recently had a cardiac stent in his 60??????s Physical Exam: 72 SR 18 155/72 GEN: NAD HEENT: Perrl, EOMI, Anicteric sclera, OP benign NECK: Supple, no JVD LUNGS: Clear HEART: RRR, IV/VI systolic murmur ABD: Soft, nontender, nondistended, normoactive bowel sounds EXT: Warm, well perfused, no edema NEURO: Nonfocal Pertinent Results: ECHO [**2133-2-4**] PRE BYPASS No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is small. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a small pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST BYPASS Normal biventricular systolic function. There is a bioprosthesis located in the aortic position. It appears well seated. The leaflets can not be seen. No aortic regurgitation is seen. The maximum pressure gradient across the aortic valve is 47 mm Hg with a mean gradient of 20 mm Hg at a cardiac output of 4.23 l/m. The effective orifice area of the valve is around 1 cm2. The gradients are a little higher and the area a little smaller than is expected for this prosthesis. The rest of the exam is unchanged from the pre-bypass study. The thoracic aorta appears intact. [**2133-2-18**] 04:14AM BLOOD WBC-17.3* RBC-3.20* Hgb-8.9* Hct-27.8* MCV-87 MCH-27.7 MCHC-31.9 RDW-14.7 Plt Ct-541* [**2133-2-17**] 09:25AM BLOOD Neuts-87.7* Lymphs-7.1* Monos-3.2 Eos-1.7 Baso-0.3 [**2133-2-18**] 04:14AM BLOOD Glucose-89 UreaN-49* Creat-0.9 Na-145 K-3.3 Cl-102 HCO3-31 AnGap-15 Brief Hospital Course: Ms. [**Known lastname 81562**] was admitted to the [**Hospital1 18**] on [**2133-2-4**] for surgical management of her aortic valve stenosis. She was taken directly to the operating room where she underwent and aortic valve replacement using a tissue valve. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. On POD#1 she was extubated and noted to be lethargic with left sided weakness. She required re-intubation after 3 hours due to fatigue. She had a short burst of atrial fibrillation, but was hemodynamically stable and did not require intervention. On POD#2 a head CT scan was negative for an acute neurologic event. Neurology was consulted and thought the patient may have had small frontal infarct that was not evident on CT scan. An MRI revealed no acute abnormality. A temporary nasogastric feeding tube was placed for nutrition. Diureses was ongoing to facilitate extubation. She was able to successfully wean and extubated on POD #5. Her neurologic status slowly improved over the ensuing days and her left upper extremity strength improved but did not fully return to baseline. She was evaluated by physical therapy and rehab was recommended. She completed a course of ciprofloxacin for a urinary tract infection. Her beta blockade was stopped for bradycardia. The bradycardia abated after the lopressor was discontinued. By post-operative day fourteen she was ready for discharge to rehab. Medications on Admission: Brimonadine [**Hospital1 **], Clonidine 0.1", Diltiazem 240', Cosopt [**Hospital1 **], Folic Acid 1', HCTZ 12.5', Cellcept [**Pager number **]", Vit C 250', MVI 1', Vit E 1', Prednisone 5', Prednisone NaPhos 1% 1 gtt OD daily Discharge Medications: 1. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution Sig: 1000 (1000) mg PO BID (2 times a day). 4. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). 10. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 11. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 15. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). Discharge Disposition: Extended Care Facility: [**Hospital 38**] rehab Discharge Diagnosis: Aortic stenosis s/p Aortic valve replacement (21mm [**Company **] ultra porcine) HTN Hyperlipidemia Osteoarthritis Macular degeneration Vasculitis Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) 8098**] in 2 weeks. Please follow-up with Dr. [**Last Name (STitle) 20478**] in 3 weeks. Completed by:[**2133-2-18**]

[ "E878.1", "518.81", "447.6", "427.89", "401.9", "E941.3", "272.4", "715.36", "434.11", "997.02", "424.1", "427.31", "041.4", "599.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "35.21", "96.71", "38.93", "39.61", "96.6" ]

icd9pcs

[ [ [] ] ]

7188, 7238

4027, 5500

326, 402

7430, 7437

1925, 4004

8235, 8497

1577, 1636

5776, 7165

7259, 7409

5526, 5753

7461, 8212

1651, 1906

267, 288

430, 1205

1227, 1385

1401, 1561

56,965

121,305

37988+37989

Discharge summary

report+report

Admission Date: [**2166-6-5**] Discharge Date: [**2166-6-7**] Date of Birth: [**2087-1-30**] Sex: M Service: MEDICINE Allergies: Aspirin / Keflex / Neurontin Attending:[**First Name3 (LF) 1115**] Chief Complaint: somnolence Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname **] is a 79yo M with a pmh significant for DMII, CVA, HTN, and several recent admissions/ED visits (most recent [**2166-4-29**]) for altered mental status. At most recent admission found to have UTI and is now presenting with increased confusion. At baseline patient AOx2 and on arrival AOx1 and very lethargic. Therefore, history has been difficult to obtain. Per living facility has had increased confusion over the last few days. His evaluation in the ED is as follows: initial vitals Temp: 96.8 68 151/57 18 100% 4L . Significant concern for infection given his recent presentations. Patient was warm and mildly clamy per ED exam, so rectal temp was checked and found to be 100.6. Thorough infectious work-up negative with, CXR, UA, and CT abd all unremarkable. He was empirically treated with Vancomycin and Atreonam given Cephalosporin allergy. Given 2L NS. They had clinical concern for meningitis given fever and AMS and otherwise negative work-up. Bedside LP unable to be done given significant transverse spinous process collapse on CT (reviewed with Rads). Therefore he would need fluro. Vitals at transfer: 97.8F, HR: 70, RR: 16, BP: 121/91, O2Sat: 98 On arrival to the medical floor patient is somnolent, but awakens to loud voice. Unable to relay history. REVIEW OF SYSTEMS: Unable to obtain Past Medical History: - Type II diabetes mellitus on insulin - CVA in early [**2162**] with residual speech hesitancy, mild L weakness - Hypertension - Chronic venous insufficiency - Discogenic LBP s/p distant spinal surgery x 2 - Obesity - History of alcohol abuse - Dyslipidemia - Left toe ulcer s/p Percutaneous angioplasty of left popliteal artery, tibial-peroneal trunk, and anterior tibital artery Social History: Lives at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Never smoked. Prior heavy alcohol use but none recently. Limited in ambulation, uses a motorized wheelchair due to LBP/leg pain. Family History: Per records, has a twin brother also with diabetes. Physical Exam: ADMISSION EXAM VS - Temp 98.2F, BP 154/59, HR 62, R 20, O2-sat 96% RA GENERAL - Somnolent, arousable HEENT - PERRLA, dry MM NECK - Supple, no thyromegaly, JVP non-elevated HEART - PMI non-displaced, Distant heart sounds RRR LUNGS - basilar crackles, good air movement, resp unlabored ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes or lesions LYMPH - no cervical LAD NEURO - Asterixis, somnolent, not able to cooperate with exam LABS: See below. DISCHARGE EXAM VS - Temp 99F/98.6, BP 153-161/47-54, HR 66-80, R 20, O2-sat 97% RA [**Telephone/Fax (1) 84868**]/1450 + Bmx2 0/700 GENERAL - Awake, arousable, oriented to self, place, states date as [**Last Name (LF) 1017**], [**2166-4-29**]. HEENT - PERRLA, dry MM NECK - Supple, no thyromegaly, JVP non-elevated HEART - PMI non-displaced, Distant heart sounds RRR LUNGS - basilar crackles, good air movement, resp unlabored ABDOMEN - tender to palpation throughout abdomen, no rebound, no guarding, NABS, soft/ND, no masses or HSM EXTREMITIES - WWP, no pitting edema, 2+ peripheral pulses, chronic venous stasis skin changes SKIN - no lesions LYMPH - no cervical LAD NEURO - moving limbs with decreased effort. Tremor noted of RUE, which is absent with concentration and in sleep. Awake, appropriate. Pertinent Results: ADMISSION EXAM [**2166-6-5**] 04:20PM BLOOD WBC-13.6*# RBC-4.80 Hgb-13.1* Hct-40.8 MCV-85 MCH-27.4 MCHC-32.2 RDW-15.0 Plt Ct-229# [**2166-6-5**] 04:20PM BLOOD Neuts-71.2* Lymphs-20.3 Monos-4.8 Eos-3.1 Baso-0.6 [**2166-6-5**] 04:20PM BLOOD Glucose-223* UreaN-27* Creat-1.2 Na-137 K-4.8 Cl-100 HCO3-25 AnGap-17 [**2166-6-5**] 04:20PM BLOOD ALT-12 AST-18 AlkPhos-74 TotBili-0.2 [**2166-6-5**] 04:20PM BLOOD Albumin-4.5 Calcium-9.8 Phos-4.1 Mg-2.2 PERTINENT LABS AND STUDIES [**2166-6-5**] 04:20PM BLOOD VitB12-696 Folate-12.1 [**2166-6-5**] 04:20PM BLOOD TSH-1.5 [**2166-6-5**] 04:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2166-6-6**] 12:42AM BLOOD Type-[**Last Name (un) **] pO2-75* pCO2-45 pH-7.38 calTCO2-28 Base XS-0 Comment-GREEN TOP [**2166-6-6**] 12:42AM BLOOD Lactate-1.1 CT abd [**2166-6-5**]: 1. No acute intra-abdominal process. 2. Cholelithiasis without cholecystitis. 3. Two left adrenal adenomas. 4. Moderate-to-severe atherosclerotic disease involving the aorta and coronary arteries. 5. Enlarged prostate. 6. Bilateral renal cysts and scarring in the left kidney. CT C-spine [**2166-6-5**]: No acute fracture or malalignment. CT Head [**2166-6-5**]: No acute intracranial process or fracture. CXR [**2166-6-5**]: No acute cardiopulmonary process. __________________________________________________________ [**2166-6-6**] 3:15 pm MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Pending): __________________________________________________________ [**2166-6-5**] 4:20 pm SEROLOGY/BLOOD CHEM # 64379S [**6-5**] 4:20PM. RAPID PLASMA REAGIN TEST (Pending): __________________________________________________________ [**2166-6-5**] 4:35 pm BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ [**2166-6-5**] 4:35 pm URINE **FINAL REPORT [**2166-6-6**]** URINE CULTURE (Final [**2166-6-6**]): NO GROWTH. __________________________________________________________ [**2166-6-5**] 4:20 pm BLOOD CULTURE Blood Culture, Routine (Pending): DISCHARGE LABS [**2166-6-7**] 07:30AM BLOOD WBC-10.9 RBC-4.28* Hgb-11.5* Hct-37.1* MCV-87 MCH-26.8* MCHC-30.9* RDW-14.7 Plt Ct-165 [**2166-6-7**] 07:30AM BLOOD Glucose-193* UreaN-21* Creat-1.0 Na-136 K-4.0 Cl-103 HCO3-24 AnGap-13 [**2166-6-7**] 07:30AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9 Brief Hospital Course: 79 year old male with a history of DMII, HTN, CVA, and frequent admissions for AMS in the setting of infection. Now presenting with somnolence, which resolved. # Toxic metabolic encephelopathy: Possibly secondary to infection with a WBC elevation to 13, subsequently trended down. He had a broad work up in the ED, with imaging of his abdomen, neck, brain without acute process. His CXR was read as no acute cardiopulmonary process, but with diffuse consolidation. He was empirically treated with Vancomycin, Zosyn for 2 days (one dose of aztreonam in the ED) for presumed HCAP, despite lack of fevers, cough. Medications which could affect his mental status--trazodone, amitryptiline, tramadol, sertraline--were stopped. At time of discharge, his tramadol and sertraline were restarted, but his trazodone and amitryptiline were not restarted. The patietn's mental status was already improved the morning following admission, and he was at his baseline on the morning of discharge. He was able to clearly state location, name and year. He was not clear on the month or date, but this is his baseline. He was awake and interactive, able to follow directions, and appropriate. It is not clear whether the patient's mental status improved because of antibiotics or because of holding his medications. Because the patient did not have fevers, cough, and his leukocytosis was transient, also because he remained very hemodynamically stable and well-appearing, he was not continued on IV antibiotics as it was felt to be unlikely that the patient had MRSA or pseudomonas pneumonia given his clinical appearance, and he was thus discharged on PO levofloxacin and flagyl, the latter to cover anaerobes, especially as there may have been an aspiration component to his presentation. He will complete 5 more days of abx. He should get repeat CXR in [**4-4**] weeks to confirm resolution of pna. . CHRONIC CARE # HTN: Continued lisinopril and atenolol. # BPH: Continued with finasteride and tamsulosin. # Diabetes: Continued NPH home regimen (10U qam/5U qpm) and HISS # Peripheral Vascular Dz: continued on his Plavix, simvastatin. # Chronic LE Pain: the patient was on amitryptiline, which was held at admission and not restarted on discharge, as this may be contributing to his altered mental status. # Depression: restarted sertraline. We held trazadone as the patient presented with somnolence, and this was not restarted at time of discharge. ISSUES OF TRANSITIONS IN CARE: # CONTACT: Daughter [**Known lastname **],[**First Name3 (LF) **] Phone number: [**Telephone/Fax (1) 84869**] # PENDING STUDIES AT TIME OF DISCHARGE: - blood cultures - RPR - MRSA screening swab # ISSUES TO DISCUSS AT FOLLOW UP: - please repeat CXR in [**4-4**] weeks (mid-end of [**Month (only) 205**]) - consider restarting amitryptiline and trazodone Medications on Admission: 1. Acetaminophen 650 mg PO TID 2. Atenolol 25 mg PO DAILY 3. Calcium Carbonate 500 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Finasteride 5 mg PO DAILY 7. Furosemide 20 mg PO DAILY 8. NPH 10 Units Breakfast; NPH 5 Units Dinner; Insulin SC Sliding Scale using HUM Insulin 9. Lisinopril 15 mg PO DAILY 10. Senna 1 TAB PO BID:PRN constipation 11. Simvastatin 40 mg PO DAILY 12. Tamsulosin 0.4 mg PO HS 13. TraMADOL (Ultram) 50 mg PO TID 14. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 15. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 16. Amitriptyline 25 mg PO HS 17. Fleet Enema 1 Enema PR DAILY:PRN constipation 18. Milk of Magnesia 30 mL PO DAILY:PRN constipation 19. Sertraline 75 mg PO DAILY 20. traZODONE 12.5 mg PO BID:PRN agitation Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO three times a day. 2. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. NPH insulin human recomb 100 unit/mL Suspension Sig: 10U breakfast; 5U dinner units Subcutaneous twice a day: 10U with breakfast; 5U with dinner. Insulin sliding scale with HUM Insulin. 9. lisinopril 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 13. Ultram 50 mg Tablet Sig: One (1) Tablet PO three times a day. 14. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 15. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 16. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal once a day as needed for constipation. 17. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO once a day as needed for constipation. 18. sertraline 25 mg Tablet Sig: Three (3) Tablet PO once a day. 19. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. 20. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: primary diagnosis: health care associated pneumonia type 2 diabetes mellitus Secondary diagnosis: hypertension hyperlipidemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted for somnolence. This improved. You may have had a pneumonia, so you were started on antibiotics. You will continue these antibiotics for 5 more days. Please note the following changes to your medications: - START Levofloxacin for 5 more days - START Flagyl for 5 more days - STOP amitriptyline - STOP trazodone Please continue your other medications as prescribed. Please be sure to see your physicians. Followup Instructions: Department: VASCULAR SURGERY When: MONDAY [**2166-8-25**] at 3:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: VASCULAR SURGERY When: MONDAY [**2166-8-25**] at 2:30 PM With: VASCULAR LAB [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Admission Date: [**2166-6-8**] Discharge Date: [**2166-6-15**] Date of Birth: [**2087-1-30**] Sex: M Service: MEDICINE Allergies: Aspirin / Keflex / Neurontin Attending:[**First Name3 (LF) 1990**] Chief Complaint: Vomit Major Surgical or Invasive Procedure: Percutaneous cholecystostomy History of Present Illness: Mr. [**Known lastname **] is a 79 yo M with a pmh significant for DMII, CVA, HTN, and several recent admissions/ED visits (most recent [**Date range (1) 40693**] and [**Date range (1) 17332**]) for altered mental status who presents with abdominal pain and vomiting. During his most recent admission, there was concern for infection given fevers and altered mental status (baseline is A&Ox2), so patient initially relieved Vancomycin and Atreonam, switched to Vanc/Zosyn for HCAP and ultimately discharged on levo/flagyl for treatment of pneumonia (CXR read as negative but w/ R sided consolidation per discharge summary). He received his first dose of flagyl upon discharge at 11:30AM on [**6-7**]. His amitriptyline and trazodone were also discontinued given his altered mental status. On discharge he had reportedly returned to his baseline. On arrival to the [**Hospital1 1501**] on the afternoon of [**6-7**], he began vomiting per report. Per [**Hospital1 1501**] note, pt felt "lousy" and requested to return to the hospital. He was unable to tolerate POs, and he was brought back to the hospital for re-evaluation. In the ED, initial vitals were: 99.5 88 206/88 22 96% RA. Labs were unchanged from earlier in the day except for a new leukocytosis (10.9 --> 14.9). Pt underwent CT Abd/Pelvis which was unchanged from prior on [**6-5**]. He also had negative CXR and UA. A CT head was done given his hypertensive urgency- this was also negative. During his ED stay he received metoprolol 5 mg IV x1, atenolol 25 mg, hydralazine 10 mg x2, zofran 4 mg IV x2. VS on transfer were: HR 86 RR 22 BP 189/65 O2 sat 95 RA. On arrival to the medical floor patient is vomiting bilious material. He denies abdominal pain, diarrhea, chest pain, palpitations, SOB, coughing, HA, or dysurea. No hematemesis or bloody stools. Past Medical History: - Type II diabetes mellitus on insulin - CVA in early [**2162**] with residual speech hesitancy, mild L weakness - Hypertension - Chronic venous insufficiency - Discogenic LBP s/p distant spinal surgery x 2 - Obesity - History of alcohol abuse - Dyslipidemia - Left toe ulcer s/p Percutaneous angioplasty of left popliteal artery, tibial-peroneal trunk, and anterior tibital artery Social History: Lives at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Never smoked. Prior heavy alcohol use but none recently. Limited in ambulation, uses a motorized wheelchair due to LBP/leg pain. Family History: Per records, has a twin brother also with diabetes. Physical Exam: PHYSICAL EXAM: VS - Temp 98.8F, BP 208/85 (automatic cuff); on manual check by MD 185/96, HR 101, R 18, O2-sat 95% RA GENERAL - awake, alert, sitting up in bed, no acute distress w/ emesis basin in hand HEENT - PERRLA, dry MM NECK - Supple, no JVD HEART - RRR, no m/r/g LUNGS - CTAB anteriorly, posterior exam limited, but appears clear, good air movement, resp unlabored ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, trace edema, no c/c 2+ peripheral pulses SKIN - venous stasis changes NEURO - alert and oriented to person, [**Hospital1 18**], [**Month (only) **]; non focal Pertinent Results: Initial Labs: [**2166-6-7**] 11:05PM BLOOD Lactate-1.1 [**2166-6-7**] 07:30AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9 [**2166-6-7**] 10:50PM BLOOD cTropnT-<0.01 [**2166-6-7**] 07:30AM BLOOD Lipase-14 [**2166-6-7**] 07:30AM BLOOD ALT-11 AST-16 LD(LDH)-166 AlkPhos-61 TotBili-0.3 [**2166-6-7**] 07:30AM BLOOD Glucose-193* UreaN-21* Creat-1.0 Na-136 K-4.0 Cl-103 HCO3-24 AnGap-13 [**2166-6-7**] 07:30AM BLOOD Plt Ct-165 [**2166-6-7**] 10:50PM BLOOD Neuts-83.8* Lymphs-12.1* Monos-3.0 Eos-0.8 Baso-0.3 [**2166-6-7**] 07:30AM BLOOD WBC-10.9 RBC-4.28* Hgb-11.5* Hct-37.1* MCV-87 MCH-26.8* MCHC-30.9* RDW-14.7 Plt Ct-165 CT abdomen. Impression: 1. Stably distended gallbladder containing multiple gallstones, with very mild but new stranding seen around the gallbladder. Cholecystitis cannot be excluded and if indicated HIDA scan could be useful for differentiation. 2. No other acute intra-abdominal abnormality identified. 3. Two small left adrenal adenomas. 4. Extensive atherosclerotic change including the coronary arteries. 5. 2.3cm intermediate density lesion in the interpolar right kidney, not fully evaluated on a single phase examination, might represent a hyperdense cyst but can be further evaluated with ultrasound on a non-emergent basis HIDA scan: IMPRESSION: Non-visualization of the gallbladder even after morphine administration, compatible with acute cholecystitis. . Brief Hospital Course: 79 M with history of DM2, CVA, HTN, admitted for acute cholecystitis sp IR guided perc drainage, hospital course complicated with severe sepsis, biliary source. #Acute cholecystitis/Severe Sepsis: Abdominal CT showed fat stranding around gallbladder. Follow up HIDA scan positive for acute cholecystitis. Surgery and IR were consulted. IR placed perc-drain on [**2166-6-8**]. The follow day, pt developed severe sepsis with biliary source and was transfered to the MICU for close observation and care. He clinicaly improved after a few days and was transfered back to the medical floor. He was given zosyn antibiotics started on [**6-8**] to be completed on [**6-22**], he completed 7 day course of therapy at time of discharge and will resume his antibiotics at his extended care facility. Management of drain: Gallbladder tube: Check gallbladder tube three times a day. -Measure and record output every shift -Do not flush catheter -Every shift check the patency of tube and that the tube and drainage bag are secured to the patient For questions regarding care of catheter call: [**Hospital Ward Name 516**] resident -pager [**Numeric Identifier 84870**]. [**Hospital Ward Name 517**] resident - pager [**Numeric Identifier 21129**]. Telephone [**Telephone/Fax (1) 2756**]. Troubleshooting: If catheter stops draining suddenly: 1) Check that the stopcock is open. 2) Remove dressing carefully and inspect to make sure that there is no kink in the catheter. 3) inspect to be sure that there is no debris blocking the catheter. If there is, then firmly flush 5 cc of sterile saline into the catheter. GEN Change the dressing daily. Cleanse skin with 1/2 strength hydrogen peroxide. Rinse with saline moistened q-tip. Apply a DSD #Hypertension: Patient is known to have baseline in 150s, but the day of presentation his BP range 170-200s. He was briefly given labetalol 100mg PO and hydralazine 25mg for management in the short term. However, BP quickly returned to baseline later that day. # Diabetes- type 2: Pt was placed on insulin gtt in the MICU for better control of glucose. [**Last Name (un) **] was consulted. Pt eventualy switched back to home NPH. #[**Last Name (un) **]: Cr peaked to 2.2 and trended down to 1.6. [**Last Name (un) **] likely pre-renal in setting of sepsis. Resolved with fluids. Transitional Issues: -follow up with surgery to discuss elective cholecystectomy -has gallbladder tube in place Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Acetaminophen 650 mg PO TID 2. Atenolol 25 mg PO DAILY 3. Calcium Carbonate 500 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Finasteride 5 mg PO DAILY 7. Furosemide 20 mg PO DAILY 8. Lisinopril 15 mg PO DAILY 9. Senna 1 TAB PO BID:PRN constipation 10. Simvastatin 40 mg PO DAILY 11. Tamsulosin 0.4 mg PO HS 12. Fleet Enema 1 Enema PR DAILY:PRN constipation 13. Milk of Magnesia 30 mL PO DAILY:PRN constipation 14. Sertraline 75 mg PO DAILY 15. NPH 10 Units Breakfast NPH 5 Units Lunch Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Finasteride 5 mg PO DAILY 3. Lisinopril 15 mg PO DAILY 4. Simvastatin 40 mg PO DAILY 5. Calcium Carbonate 500 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Furosemide 20 mg PO DAILY 8. Milk of Magnesia 30 mL PO DAILY:PRN constipation 9. Senna 1 TAB PO BID:PRN constipation 10. Sertraline 75 mg PO DAILY 11. Tamsulosin 0.4 mg PO HS 12. Piperacillin-Tazobactam 4.5 g IV Q8H Duration: 3 Days Take until Tuesday [**2166-6-22**] 13. NPH 10 Units Breakfast NPH 5 Units Dinner Insulin SC Sliding Scale using HUM Insulin 14. Metoprolol Succinate XL 25 mg PO DAILY 15. Outpatient Lab Work Please check CBC, LFT, Chem7 (while on zosyn) Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: Acute cholecystitis Severe sepsis Hypertensive urgency Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You came to the hospital with abdominal pain, vomitting, and an elevated white blood cell count. You were found to have acute gallbladder inflammation ("cholecystitis") and you were treated with anti-nausea medicine, antibiotics, and fluids through your veins. A tube was also placed into your gallbladder to treat your gallbladder. You will need to keep this tube in your gallbladder for at least 4 weeks. You should follow-up with the surgeons or interventional radiologists to have this removed after [**2166-7-8**]. Your tube may continue to have fluid leaking from it. If there is frank, gross bleeding from the tube, please seek medical attention. If there is more than 400 mL of fluid from the tube in a single day, you should also seek medical attention. While you were in the hospital, you developed a very high blood pressure. We treated you with blood pressure medications, and this returned to [**Location 213**]. We made changes to your blood pressure medications (see below). While you were in the hospital, you also developed a severe infection (from the gallbladder) and went to the ICU for one day. You should receive antibiotics through the PICC line that was placed until Tuesday. MEDICATIONS CHANGES: -STOP taking Atenolol 25 mg PO DAILY -Instead, start taking metoprolol succinate (long-acting) 25 mg DAILY. -We HELD your furosemide 20 mg PO daily. You may resume this as soon as you return to eating a normal amount of food. Your primary care doctor can help you decide when to resume this. -Your plavix medication (medication for clogged vessels) was held after the gallbladder tube was placed. We encourage you to resume this medication when the tube stops draining bloody bile OR after your gallbladder infection has improved. -You will receive Piperacillin-Tazobactam 4.5 g IV every 8 hours through [**2166-6-22**] to complete the treatment for your gallbladder infection. We recommend you see the surgeons in a few weeks to also discuss the possibility of removing the gallbladder at some point in the months ahead. Followup Instructions: You will need to meet with the surgeons to discuss possible future elective removal of your gallbladder. An appointment has been arranged for thursday, [**6-26**], 2:45PM, Dr [**Last Name (STitle) **]. [**Hospital Unit Name 3269**] [**Location (un) 470**], [**Hospital Unit Name **]. [**Last Name (NamePattern1) 439**], [**Location (un) 86**] MA. [**Telephone/Fax (1) 84871**]. Department: VASCULAR SURGERY When: MONDAY [**2166-8-25**] at 2:30 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: MONDAY [**2166-8-25**] at 3:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "715.90", "724.2", "278.00", "438.19", "574.00", "348.31", "729.5", "459.81", "867.0", "272.4", "600.00", "599.70", "486", "584.9", "288.60", "250.02", "294.20", "285.9", "443.9", "311", "V58.67", "E879.8", "276.2", "788.30", "995.92", "584.5", "728.87", "438.89", "038.9" ]

icd9cm

[ [ [] ] ]

[ "38.97", "51.01" ]

icd9pcs

[ [ [] ] ]

21797, 21919

17971, 20286

13351, 13381

22018, 22018

16558, 17948

24266, 25194

15875, 15928

21110, 21774

21940, 21997

20425, 21087

22196, 24243

15958, 16539

8840, 8966

5823, 6111

20307, 20399

12284, 12484

1646, 1665

13306, 13313

13409, 15226

11799, 11829

11719, 11778

22033, 22172

15248, 15632

15648, 15859

70,017

110,801

39026

Discharge summary

report

Admission Date: [**2181-1-1**] Discharge Date: [**2181-1-5**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: upper GI bleed Major Surgical or Invasive Procedure: Endoscopy History of Present Illness: 89 year old woman with past medical history significant for chronic anemia, lung cancer s/p RFA, recent UTI treated at [**Hospital3 5365**] and discharged to rehab [**12-28**], presenting with upper GI bleed. . Patient has been having nausea since last Saturday, and per history it is unclear if she has been having blood in her vomitus since then. Patient however was noted to have coffee ground emesis on the day of admission and she was sent from rehab back to [**Hospital3 5365**] for evaluation. Per report, she was going to be admitted but due to lack of telemetry beds she was transferred to [**Hospital1 18**] for further management. . In the ED, vital signs were initially: 97.3 86 132/66 18 97, Patient received 1L NS and underwent NG lavage with positive coffee grounds. Per report, she initially had a well formed stool that was guaiac negative, however during her evaluation has a large, loose guaiac positive stool and associated hypotension down to 70's systolic. Patient was type and crossed x 4 units PRBC, GI consult was obtained and patient was admitted for further management. Past Medical History: Chronic anemia Lung ca s/p RFA Spinal stenosis s/p Small bowel obstruction -- Per daughter in setting of [**Name (NI) 28303**] overuse (does not like to go the bathroom) s/p hysterectomy 80's s/p cholecystectomy hx of UTIs ([**1-25**] in the last year) Social History: Very hard of hearing, Lives with daughter, uses [**Name2 (NI) **] for ambulation Family History: NC Physical Exam: VS: 96.9, 178/60, 49, 18, 100% 3L NC GEN: The patient is in no distress and appears comfortable SKIN: No rashes or skin changes noted HEENT: No JVD, neck supple, No lymphadenopathy in cervical, posterior, or supraclavicular chains noted. CHEST: Lungs are clear with occasional rhonchi at right base CARDIAC: irregular, bradycardic, soft S1 S2, no murmurs, rubs, or gallops. ABDOMEN: No apparent scars. Non-distended, and soft without tenderness EXTREMITIES: no peripheral edema, warm without cyanosis NEUROLOGIC: alert, oriented to name/year/location. CN II-XII grossly intact. BUE 4+/5, and BLE 4+/5 both proximally and distally. No pronator drift. Reflexes were symmetric. Pertinent Results: LABS ON ADMISSION: [**2181-1-1**] 07:30PM BLOOD WBC-9.3 RBC-3.57* Hgb-10.9* Hct-33.3* MCV-93 MCH-30.6 MCHC-32.8 RDW-14.5 Plt Ct-272 [**2181-1-1**] 07:30PM BLOOD Neuts-88.7* Lymphs-8.2* Monos-3.1 Eos-0 Baso-0.1 [**2181-1-1**] 07:30PM BLOOD PT-10.9 PTT-19.5* INR(PT)-0.9 [**2181-1-1**] 07:30PM BLOOD Glucose-160* UreaN-60* Creat-1.4* Na-148* K-4.2 Cl-105 HCO3-32 AnGap-15 [**2181-1-1**] 07:30PM BLOOD CK(CPK)-41 [**2181-1-1**] 07:30PM BLOOD cTropnT-<0.01 [**2181-1-1**] 07:30PM BLOOD Calcium-9.8 Phos-5.0* Mg-2.7* [**2181-1-3**] 03:41AM BLOOD TSH-0.59 [**2181-1-2**] 12:48AM BLOOD Lactate-1.6 . LABS ON DISCHARGE: [**2181-1-5**] 07:00AM BLOOD WBC-7.6 RBC-3.51* Hgb-10.9* Hct-32.8* MCV-93 MCH-31.0 MCHC-33.1 RDW-14.5 Plt Ct-233 [**2181-1-5**] 07:00AM BLOOD Plt Ct-233 [**2181-1-5**] 07:00AM BLOOD Glucose-87 UreaN-29* Creat-1.1 Na-141 K-4.0 Cl-105 HCO3-29 AnGap-11 [**2181-1-5**] 07:00AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.9 . Endoscopy: Large hiatal hernia Granularity and nodularity in the antrum compatible with gastritis (biopsy taken). No blood was seen in the stomach or intestine. Abnormal esophageal motility consistent with presbyesophagus . Upper GI Final Read: FINDINGS: The study was limited due to the inability of the patient to be in a standing position. Thin liquid barium was administered to the patient in RPO and LPO positions and images were obtained. The images demonstrate a small axial hiatal hernia with the GE junction positioned above the diaphragm. Also seen is a large paraesophageal hernia, with the entire stomach including the proximal portion of the antrum, positioned above the diaphragm. The distal portion of the antrum exits below the diaphragm. Stomach empties normally and there is no evidence of gastric outlet obstruction. IMPRESSION: Large mixed hiatal hernia with nearly the entire stomach positioned above the diaphragm. Brief Hospital Course: 89 year old woman with past history of lung cancer s/p RFA, recurrent UTI's, presenting from rehab with upper GI bleeding. . # UPPER GI BLEED: Unclear etiology, however in light of vomiting worrisome for esophageal tear (boorhave's). Differential diagnosis included peptic ulcer disease, variceal bleed (although no history of esophageal varices), gastritis, avm, etc. Patient was given 2 units of pRBC, started on IV PPI. Scoped by GI with EGD showing gastritis, no active bleeding/ulcers/or tears, and small axial hiatal hernia and a large para esophageal hernia. Source of bleeding felt to be gastritis. Patient's H. pylori serology also returned positive. The UGIB had resolved on discharge, as evidenced by stable Hct and vital signs for over 24 hours. She had no further episodes of bloody emesis or melena. On discharge, patient will continue [**Hospital1 **] PPI and will be treated with triple therapy for H pylori with PPI [**Hospital1 **], amoxicillin, clarithromycin. . # SINUS BRADYCARDIA WITH PAUSES: on 12 lead EKG, appears to be sinus bradycardia with PVCs. Also has some 1st degree block as well as pauses < 2 seconds. Likey has underlying sick sinus. DDx also included elevated vagal activity, infiltrative diseases, collagen vascular diseases, carotid sinus hypersensitivity. She does not appear to be on any medications which may be contributing. Electrolytes have been within normal limits and TSH was normal. Of note, option for PPM was discussed with patient and HCP [**Name (NI) **], as documented in [**Name (NI) **] note. Both understand the risks and benefits, and PPM was strongly opposed and would not be in line with patient's wishes. . # HIATAL HERNIA: small axial hiatal hernia and a large para esophageal hernia noted on EGD. Patient does have mild symptoms of reflux, without regurgitation; however, patient and HCP [**Name (NI) **] felt that these symptoms were mild and did not warrant surgical intervention. . # ACUTE ON CHRONIC RENAL FAILURE: resolved and back to baseline on discharge. Patients baseline creatinine 1.1 after obtaining OSH records. In setting of GI Bleeding most likely pre-renal azotemia. Nephrotoxins were avoided. Urine was negative for eosinophil smear. After GIB resolved and after volume resuscitation, BUN and Cr were at baseline. Discharge Cr 1.1 . # HX of UTI: Per D/C Summary culture with Citrobacter sensitive to cipro. Denies urinary sx currently. Urine culture on [**2181-1-2**] was negative. . # HYPERTENSION: Initially held BP meds due to prior GI bleed and hypotension. Resumed on low dose lisinopril and amlodine on discharge. These may be titrated as needed at rehab facility. . # Dispo: discharge to rehab facility, follow-up appt with PCP Medications on Admission: Bisacodyl Lidocaine patch Colace 100mg PO BID Omeprazole 20mg PO daily Cipro 250mg PO BID Prinivil 30mg PO BID Norvasc 10mg PO daily Compazine 25mg PO BID PRN 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:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day for 10 days. Disp:*40 Tablet(s)* Refills:*0* 8. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] Continuing Care Center - [**Hospital1 392**] Discharge Diagnosis: 1) upper GI bleed 2) Gastritis 3) acute blood loss anemia 4) Hiatal hernia Discharge Condition: Mental status: Alert and oriented to self and date, with intermittent confusion as to location and reason for hospitalization. Ambulatory status: with [**Hospital1 **] Discharge Instructions: It was a pleasure taking care of you at the [**Hospital1 771**]. You were transferred here from [**Hospital1 **] after vomiting blood. You received a blood transfusion to replace the blood you had lost, and pantoprazole to decrease acid production in your stomach. You had an endoscopy that showed gastritis, which was thought to be the source of your bleeding. Your bleeding has now stopped and your blood counts have stabilized. You should continue to take pantoprazole 40 mg twice a day by mouth. . NEW MEDICATIONS/MEDICATION CHANGES: - START Pantoprazole 40 mg by mouth, twice a day - START amoxicillin 1 gram by mouth twice daily for only 10 days - START clarithromycin 500 mg twice daily for only 10 days . In addition, your endoscopy showed a hiatal hernia, which you have had before, and for which you had previously declined surgery. . Please seek medical attention for any renewed vomiting, dark stools, blood in your stools, difficulty eating, or any other concerning symptoms. Followup Instructions: Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], within 1 week. His phone number is [**Telephone/Fax (1) 86541**]. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2181-1-5**]

[ "553.3", "276.0", "535.51", "285.9", "403.90", "V10.11", "427.89", "584.9", "585.9" ]

icd9cm

[ [ [] ] ]

[ "45.16" ]

icd9pcs

[ [ [] ] ]

8148, 8289

4400, 7116

274, 285

8408, 8408

2517, 2522

9615, 9982

1803, 1807

7325, 8125

8310, 8387

7142, 7302

8602, 9120

1822, 2498

9140, 9592

220, 236

3129, 4377

313, 1412

2536, 3110

8423, 8578

1434, 1689

1705, 1787

28,460

132,836

33126

Discharge summary

report

Admission Date: [**2134-12-30**] Discharge Date: [**2135-1-12**] Date of Birth: [**2085-12-17**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins / Zestril Attending:[**First Name3 (LF) 7141**] Chief Complaint: likely ovarian carcinoma shortness of breath Major Surgical or Invasive Procedure: Exploratory laparotomy, drainage of ascites, bilateral salpingo-oophorectomy, subtotal abdominal hysterectomy, infragastric omentectomy, suboptimal tumor debulking. History of Present Illness: The patient is a 49-year-old G4, P4, sent by Dr. [**First Name8 (NamePattern2) 7422**] [**Last Name (NamePattern1) **] for a consultation regarding probable ovarian carcinoma. She was recently admitted to Caritas [**Hospital3 **] with shortness of breath, increasing abdominal distention, and diarrhea. She had a CT of the torso on [**2134-12-17**]. This revealed a large left pleural effusion. There was a shrunken liver. There was a large amount of free peritoneal fluid. There was diffuse thickening of the transverse mesocolon suggestive of omental caking. There was no retroperitoneal abnormality. There was a right adnexal mass. She underwent left pleurocentesis with drainage of 1500 cc of fluid. She also underwent paracentesis with drainage of 5 liters of fluid. The cytology from the paracentesis subsequently revealed malignant cells consistent with ovarian origin. A CA-125 was elevated at 505. The patient has had recent unintentional weight loss of up to 50 pounds despite the increasing abdominal girth. She reports intermittent fever. She has had frequent urination. She has had some dizziness but denies any syncopal episodes. She has had no headaches. Past Medical History: PAST MEDICAL HISTORY: Significant for diabetes, sleep apnea, bipolar disease, borderline personality disorder, arthritis, short-term memory loss, history of ethanol abuse with question liver disease, history of acute diverticulitis [**11/2133**], which was treated with antibiotics alone. PAST SURGICAL HISTORY: Arthroscopies, surgery for deviated septum. OB HISTORY: Vaginal delivery x4. GYN HISTORY: Last Pap smear was [**11/2134**] and the results are pending. Last mammogram was [**8-/2134**] and revealed fibrocystic disease. The patient also had a colonoscopy recently, which revealed evidence of diverticulosis, but no malignancy. Social History: The patient has smoked for 27 years, an unspecified amount. She does not currently drink but has a long history of ethanol abuse. She is disabled. Family History: Significant for a brother with [**Name2 (NI) 499**] cancer and four paternal cousins who have had breast cancer at young ages (one of these cousins tested positive for a [**Name (NI) **] mutation), mother with melanoma, a paternal uncle with melanoma, and a maternal aunt with breast cancer. Physical Exam: GENERAL: Well-developed, but clearly short of breath even at rest. HEENT: Skin and sclerae were anicteric. LYMPHATICS: Lymph node survey was negative. LUNGS: Revealed no breath sounds in the left lung field. The right-sided breath sounds were normal. Heart was somewhat distant but without gallops or murmurs. BREASTS: Without masses. ABDOMEN: Severely distended with obvious ascites. There were no palpable masses. EXTREMITIES: Without edema. PELVIC: The external genitalia were normal. The speculum examination was quite limited due to the patient's body habitus and abdominal distention. The cervix cannot be visualized. The vaginal walls appeared smooth. Bimanual and rectovaginal examination was severely limited by the above. There were no palpable pelvic masses. The cervix was normal to palpation. Pertinent Results: [**2134-12-30**] 11:40PM ASCITES AMYLASE-87 [**2134-12-30**] 11:40PM ASCITES WBC-540* RBC-4850* POLYS-67* LYMPHS-26* MONOS-7* [**2134-12-30**] 09:12PM LACTATE-1.5 [**2134-12-30**] 05:33PM ALT(SGPT)-11 AST(SGOT)-21 CK(CPK)-31 ALK PHOS-115 AMYLASE-60 TOT BILI-0.5 [**2134-12-30**] 05:33PM LIPASE-22 [**2134-12-30**] 05:33PM CK-MB-NotDone cTropnT-<0.01 [**2134-12-30**] 05:33PM ALBUMIN-3.5 [**2134-12-30**] 05:33PM PT-13.5* PTT-26.2 INR(PT)-1.2* [**2134-12-30**] 03:49PM GLUCOSE-80 UREA N-7 CREAT-0.9 SODIUM-137 POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-19* ANION GAP-21* [**2134-12-30**] 03:49PM WBC-22.5* RBC-5.22 HGB-11.3* HCT-37.6 MCV-72* MCH-21.7* MCHC-30.1* RDW-17.3* [**2134-12-30**] 03:49PM NEUTS-82.5* LYMPHS-11.9* MONOS-3.7 EOS-1.7 BASOS-0.4 CTA CHEST W&W/O C&RECON [**2134-12-30**] CHEST: No filling defect is noted within the main pulmonary artery and its branches to suggest pulmonary embolism. However evaluation of the subsegmental braches is limited due to atelectasis. The heart has normal appearance. No pericardial effusion is noted. No pathologically enlarged central lymphadenopathy including mediastinal, hilar, or axillary lymph nodes are visualized. Moderate to severe left malignant pleural effusion is noted. Thyroid contains a nodule in the right lobe. The lung windows demonstrate complete collapse of the left lower lobe and the inferior part of the lingula. The right lung is clear with no focal consolidation, pulmonary nodule or parenchymal opacification. Minor atelectatic changes are noted at the right lung base. The visualized portion of the upper abdomen demonstrates normal appearance of the liver, spleen, and the left adrenal gland appears normal. Moderate amount of ascites is noted within the abdomen. Incidental note is also made of omental caking within the anterior abdomen. BONE WINDOWS: The bone windows do not demonstrate any concerning lytic or sclerotic lesions. Multilevel degenerative changes of the thoracic spine is visualized. IMPRESSION: 1. No pulmonary embolism. Evaluation of the subsegmental branches of the left lower lung is limited due to lung collapse. 2. Large malignant left pleural effusion and complete collapse of the left lower lobe and the inferior portion of the lingula. 3. Moderate ascites and omental caking. [**12-30**] ECG Sinus rhythm. Low precordial voltage. No previous tracing available for comparison. [**12-31**] Cell block from pleural effusion. POSITIVE FOR MALIGNANT CELLS, consistent with adenocarcinoma. [**12-31**] CXR There has been evacuation of the left-sided pleural effusion with residual atelectasis at the left base. No pneumothorax is seen. The right lung is clear. IMPRESSION: No pneumothorax following left thoracentesis. Brief Hospital Course: 49 yo G14P4-0-10-4 was admitted [**2134-12-30**] with shortness of breath with ascites and pleural effusions secondary to ovarian cancer. She received thoracentesis and paracentesis status post admission with symptomatic improvement. She was taken to the operating room on [**2135-1-4**] where she underwent exploratory laparotomy, drainage of ascites, bilateral salpingo-oophorectomy, subtotal abdominal hysterectomy, infragastric omentectomy and suboptimal tumor debulking. Intraoperative Course. Her intraoperative course was uncomplicated. Intraoperative findings were significant for [**1-30**] liters of straw-colored ascites, intraperitoneal carcinomatosis, studding with innumerable tumors measuring up to a centimeter, most prominently involving the right hemidiaphragm, the paracolic gutters, the small bowel and its mesentery, and the cul-de-sac, normal liver, no palpable retroperitoneal adenopathy, bulky disease involving the entire omentum extensively involving the transverse [**Month/Day (3) 499**] and mesocolon, bulky disease involving both ovaries with right ovary measuring about 8 cm and the left ovary about 4 cm, surface disease of uterus, bladder and peritoneum, uninvolved rectum. At the conclusion of the debulking, the largest residual tumor was 1.5 cm, and there was diffuse intraperitoneal carcinomatosis. Please see the dictated operative report for full details. The pt was transferred to the [**Hospital Unit Name 153**] postoperatively for closer monitoring. Postoperative Course. - Neurologic. The pt's pain was well controlled on a dilaudid pca. This was transitioned to oral medications when the pt was tolerating a regular diet. - Cardiovascular. The pt received aggressive intraoperative fluid hydration given drainage of ascites and predicted fluid shifts. Her blood pressure remained stable postoperatively. Home hypertensive regimen was restarted. - Heme. The Hct drifted from 26.9 postoperatively to a low of 23.4. No evidence of hemorrhage was present. The decreased Hct was determined to be from fluid shifts. The pt was transfused 2 units pRBCs on postoperative day #5. Her Hct remained stable at 28.5 for the duration of the hospitalization. - Respiratory. The pt self-extubated on postoperative day #1. She continued to saturate in the mid 90's on 2L oxygen via nasal canula. She desated to low 90s on room air. On postoperative day #2 a chest xray showed a large left peural effusion, mild to moderate R pleural effusion. She was weaned off oxygen and was discharged on room air. - Gastrointestinal. The pt developed nausea and vomitting on postoperative day #3. This resolved with diet restriction. She was then advanced to a regular diet without difficulty. Her appetite remained low throughout the hospitalization. She received a hepatology consult prior to surgery to rule out alcohol induced chronic liver disease. - Endocrinology. The pt received an insulin sliding scale and regular glucose testing for her type 2 diabetes. She was restarted on home regimen of glargine 10 units q day postoperatively. - Genitourinary. Urine output was low on postoperative day #0. FeNa was consistent with intravascular depletion. Fluid resuscitation was continued and urine output became adequate on postoperative day #1. Creatinine became mildly elevated to 1.3 on postoperative day #1, but rapidly returned to [**Location 213**]. - Infectious disease. There was concern for possible SBP preoperatively given leukocytosis on admission. Ceftriaxone was started empirically. The peritoneal, urine and blood cultures returned negative. Antibiotics were therefore discontinued. She had one loose stool postoperatively with a negative c difficle toxin. She otherwise remained afebrile and asymptomatic postoperatively. - Psychiatry. Pt was continued on home regimen for her bipolar disorder. She remained appropriate throughout hospitalization. She was followed by social work as an inpt. - Prophylaxis. The pt was given subcutaneous heparin, pneumatic boots, and protonix. The pt was discharged on hospital day #13 and postoperative day #8 in stable condition and performing all activities of daily living. Medications on Admission: Aspirin 81 mg daily Simvastatin 20 mg daily Atenolol 50 mg daily Insulin glargine 10 units qhs Aripiprazole 5 mg [**Hospital1 **] Lithium 300 mg [**Hospital1 **] Quetiapine 75 mg qhs Clonazepam 1 mg [**Hospital1 **] prn Benztropine 0.5 mg [**Hospital1 **] IC Diphenoxylate Pantoprazole 40 mg [**Hospital1 **] Fish oil Varenicycline 1 mg [**Hospital1 **] Discharge Medications: 1. Acetaminophen 160 mg/5 mL Solution Sig: [**12-29**] PO Q6H (every 6 hours) as needed. 2. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 7. Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 9. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Benztropine 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO Q AM (). 13. Lithium Carbonate 300 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)). Discharge Disposition: Home Discharge Diagnosis: ovarian cancer pulmonary effusions ascites postoperative anemia postoperative nausea/vomiting Discharge Condition: stable Discharge Instructions: Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 5162**], chills, chest pain, shortness of breath, increased abdominal pain, incision drainage or discharge, leg pain/swelling, heavy vaginal bleeding, lightheadedness/dizziness, palpitations, any concerns. No driving while taking narcotics. Nothing in the vagina for 6 weeks. No swimming or hot tubs for 6 weeks. No heavy lifting for 6 weeks (more than a jug of milk). Followup Instructions: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7613**], MD Phone:[**Telephone/Fax (1) 7614**] Date/Time:[**2135-2-10**] 11:30 Please call Dr[**Name (NI) 2989**] office at [**Telephone/Fax (1) 7614**] to schedule a staple removal appt for this week. Appt with Dr [**Last Name (STitle) 2244**] [**2135-1-24**] at 9:30am. [**Hospital Ward Name 23**] [**Location (un) **]. ([**Telephone/Fax (1) 77004**] Completed by:[**2135-4-1**]

[ "E878.6", "327.23", "E849.7", "296.80", "V16.3", "276.2", "V16.8", "301.83", "560.1", "276.50", "199.0", "458.29", "197.2", "V16.0", "716.90", "997.4", "305.03", "V15.82", "183.0", "250.00", "518.81", "584.9", "305.63" ]

icd9cm

[ [ [] ] ]

[ "65.61", "68.39", "54.4", "99.04", "34.91", "54.91" ]

icd9pcs

[ [ [] ] ]

12183, 12189

6503, 10690

342, 509

12327, 12336

3725, 6480

12830, 13277

2574, 2867

11094, 12160

12210, 12306

10716, 11071

12360, 12807

2060, 2393

2882, 3706

258, 304

537, 1723

1768, 2036

2409, 2558

6,829

108,428

11048

Discharge summary

report

Admission Date: [**2109-8-23**] Discharge Date: [**2109-9-5**] Date of Birth: [**2036-9-15**] Sex: F Service: CARDIOTHORACIC SURGERY ADMITTING DIAGNOSIS: Shortness of breath DISCHARGE DIAGNOSIS: Sternal wound infection/mediastinitis HISTORY OF PRESENT ILLNESS: This is a 72-year-old female Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] on [**2109-8-5**] who was transferred from [**Hospital6 3872**]. She was admitted there for hypercarbic respiratory failure and intubated secondary to CO2 retention when given oxygen at the outside hospital. She was subsequently sent to their Intensive Care Unit and extubated, at which point she was found to have an infection of her sternotomy wound. She was placed on vancomycin Proteus sensitive to the vancomycin. She was also in mild renal failure during her hospitalization which was resolving upon transfer. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft x4 2. Hypertension 3. Chronic obstructive pulmonary disease 4. Status post knee replacement 5. Aortic stenosis 6. Hiatal hernia 7. Depression 8. Status post cholecystectomy 9. Status post appendectomy 10. Status post carpal tunnel release surgery ALLERGIES: She had no known drug allergies. ADMISSION MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Zantac 150 mg p.o. b.i.d. 3. Colace 100 mg p.o. b.i.d. 4. Lasix 20 mg p.o. b.i.d. 5. K-Dur 20 milliequivalents p.o. b.i.d. 6. Lopressor 100 mg p.o. b.i.d. 7. Atrovent and albuterol metered dose inhaler 2 puffs 4x per day SOCIAL HISTORY: Significant for ex-smoker who stopped seven years ago. She had a 60 pack year history of smoking. PHYSICAL EXAM ON ADMISSION: VITAL SIGNS: She was afebrile with a pulse in the high 90s and a blood pressure in the high 180s/90s. She was saturating 96% on 2 liters nasal cannula. HEART: She was in regular rate and rhythm. CHEST: Crackles bilaterally halfway up the lung fields and she had a dressing placed over her sternotomy with purulent exudate on the inferior portion. ADMISSION LABS: White count of 6.9, hematocrit of 25.4. BUN and creatinine of 40/0.8. Gram stain of the wound demonstrated gram positive cocci in pairs, chains and clusters. Given these findings, the patient was continued on his vancomycin 1 gm intravenous q 12 hours and ciprofloxacin 500 mg b.i.d. was added for gram negative coverage. Cardiothoracic surgery was consulted to come and evaluate the patient. HOSPITAL COURSE: After consultation with cardiac surgery, the patient was taken to the Operating Room on [**8-25**] where a radical sternal debridement and open packing of the wound were performed for a sternal wound infection with associated sternal osteomyelitis. This was performed by Dr. [**Last Name (STitle) **], assisted by Dr. [**Last Name (STitle) 11743**]. An infectious disease consult was also requested which also recommended continuing of the vancomycin, ciprofloxacin as it appeared to be adequate coverage for the patient's infections. The cultures obtained from the sternal swab in the Emergency Room had demonstrated coagulase positive Staphylococcus aureus, probable Enterococcus and Proteus. The patient remained in the Intensive Care Unit and a plastic surgery consult was requested for possible flap closure of his sternum. The plastic surgeons recommended flap closure of the wound and the patient was taken to the Operating Room once again on [**8-29**] where an omental flap closure of his sternal wound was performed by Dr. [**First Name (STitle) **], assisted by Dr. [**Last Name (STitle) **]. Postoperatively, the patient was continued on his vancomycin and ciprofloxacin and was doing well, transferred to the floor. The patient's creatinine was noted, however, to double on postoperative day #2, climbing from 0.7 to 1.4 and peaking over the next couple days at 2. Given the development of acute renal failure, the patient's antibiotics were changed to renal doses. The patient's urine sediment was examined and did not demonstrate any evidence ATN. The FENa was not less than 1% and there was no evidence of acute interstitial nephritis at the time. Over the next couple of days, the renal failure began to resolve with a decrease in the creatinine to 1.9 and then 1.8 respectively. The patient was making good urine and remained afebrile with stable vital signs. Given the fact that her sternotomy was healing very well with no erythema, edema, induration or drainage and the abdominal incision that was used for a flap was well healed with any erythema, edema, induration or drainage and that the patient had a PICC line placed and was capable of having intravenous antibiotics at a rehabilitation facility, it was felt that she was stable for transfer. She was transferred on a regular diet. DISCHARGE MEDICATIONS; 1. Colace 100 mg p.o. b.i.d. 2. Zantac 150 mg p.o. b.i.d. 3. Aspirin 81 mg p.o. q.d. 4. Heparin subcutaneous 5000 units subcutaneous b.i.d. 5. Albuterol/Atrovent metered dose inhaler 4 puffs q4h 6. Zestril 10 mg p.o. q.d. 7. Vitamin C 500 mg p.o. b.i.d. 8. Zinc sulfate 220 mg p.o. q.d. 9. Lopressor 75 mg p.o. b.i.d. 10. Zoloft 50 mg p.o. q.d. 11. Vancomycin 1 gm intravenous q 24 hours for 32 days 12. Ciprofloxacin 500 mg p.o. q.d. for 30 days 13. Percocet 1 to 2 p.o. q 4 to 6 hours prn with a request that vancomycin peak and trough levels be checked after the first dose given at the rehabilitation center. DISCHARGE DIAGNOSES: 1. Sternal wound infection with sternal osteomyelitis, status post operative debridement with flap closure 2. Coronary artery disease, status post coronary artery bypass grafting x4 in [**2109-7-10**] 3. Hypertension 4. Chronic obstructive pulmonary disease 5. Aortic stenosis DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-641 Dictated By:[**Name8 (MD) 4720**] MEDQUIST36 D: [**2109-9-5**] 09:13 T: [**2109-9-5**] 10:10 JOB#: [**Job Number 35719**]

[ "285.9", "584.9", "496", "568.0", "V45.81", "519.2", "730.08", "611.1", "998.83" ]

icd9cm

[ [ [] ] ]

[ "86.74", "54.59", "77.61", "83.82", "86.22", "38.93" ]

icd9pcs

[ [ [] ] ]

5505, 6011

218, 257

2515, 5484

1327, 1586

286, 910

2100, 2497

1731, 2083

175, 196

932, 1304

1603, 1717

25,553

164,133

3889+3890+3891+55520

Discharge summary

report+report+report+addendum

Admission Date: [**2146-5-30**] Discharge Date: [**2146-6-3**] Date of Birth: [**2063-5-28**] Sex: F Service: MEDICINE Allergies: Codeine / Lasix Attending:[**First Name3 (LF) 2745**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None. History of Present Illness: HPI: Please refer to nightfloat note. In brief, Ms. [**Known lastname 12129**] is an 83 year-old patient with a known history of COPD, asthma, and hypertension admitted for multiple COPD flares this year. She presents now with two days of cough and greatly exacerbated shortness of breath. She reports that her symptoms began roughly two weeks ago, when she developed rhinorrhea. At this time however, she felt that her asthma/COPD was at baseline. Despite Claritin and Mucinex, her runny nose continued and she began to develop a progressive worsening of her chronic SOB. Ms. [**Known lastname 12129**] noted an acute change two days prior to admission, when she could no longer walk to the bathroom without stopping to catch her breath and developed a new cough. Note that during the course of her illness, the patient never developed any fevers or chills. Patient did report developing white sputum and said that she had trouble sleeping flat, but she has had 3 pillow orthopnea for years. No PND. Otherwise no chest pressure, pain, palpitations, lightheadedness, syncope or pleuritic chest pain. No nausea, vomiting, diarrhea, or constipation. On [**5-29**] - the day of admission - the patient reported airway narrowing reminiscent of her previous asthma flares and unresponsive to her nebulizer treatment. At this point in time she called the paramedics and was admitted to the [**Hospital1 18**] ED. . In [**Hospital1 18**] ED, patient's vital signs were T=97.9, P=96, BP=209/79, RR=26, and O2 Sat of 100% RA. CXR performed and showed no pulmonary edema. Patient's SOB improved with nebulizers. She improved with nebs. She received combivent, prednisone 60mg, mag, azithro 500mg, asa 325mg, nitro paste x1inch. Her repeat BP was 193/60 and 98% on 2.5LNC. At this point she was transfered up to the floor, where she continues to remain comfortable. . ROS otherwise negative in detail except for foreign body sensation in right eye. Patient attributes this to her trigeminal neuralgia but does grade the pain as [**10-14**]. Notably no headaches, visual changes, as might be expected with hypertension. Past Medical History: 1. Asthma/COPD - Recently admitted for a flare on [**2146-3-29**] and treated with nebulizers, steroids, and a course of azithromycin. Last seen by Dr. [**Last Name (STitle) 1632**] in Pulmonology in [**Month (only) 547**], when he thought she was deconditioned from her time in the hospital although adequately medicated. Recommended a Cardiology consult at this time for what he believed to be significant diastolic dysfunction secondary to long-standing hypertension. 2. Paralyzed left hemidiaphragm s/p pericardial window procedure 3. Severe hypertension with diastolic dysfunction - Per PCP notes typically controlled in the 160's unless patient experiences an asthma flare when it shoots to 170's-180's. Notably systolic pressures were in the 130's during her last hospital admission, presumably the reason why her HCTZ and enalapril doses were halved. Patient is poorly compliant and most recently has not been taking her antihypertensives due to her ill son-in-law, unable to pick up her meds from the pharmacy. 4. Hyperlipidemia 5. Chronic renal insufficiency (creatinine around 1.4). 6. Polymyalgia rheumatica. 7. Osteoporosis. 8. Trigeminal neuralgia - reportedly seen by Optometry [**2146-4-26**] and referred to Dr. [**Last Name (STitle) **] of [**Last Name (STitle) 878**]. 9. Iron-deficient anemia 10. Gastritis Social History: Ms. [**Known lastname 12129**] is a widow of many years and a mother of three. She lives in the bottom unit of a shared home with her daughter and son-in-law, who provide her with a large amount of care and support. Although Ms. B is able to complete most of her ADL's, she relies on her daughter for shopping and cooking. While she doesn't specifically say it, her increasing dependence on her children has taken a bit of its toll on her. This may be partially responsible for her decreased med compliance - the patient relies on others to go to CVS to pick up her meds. Her daughter had the flu prior to Ms. [**Known lastname 12129**]' hospitalization, and because of this, she was unable to pick up her medications on time. Additionally, it sounds as if the patient doesn't leave her house very often. She comments on how she doesn't like to walk outside or to sit on her porch. Ms. [**Known lastname 12129**] would rather watch television, socializing with friends infrequently. Family History: Diabetes mellitus in siblings and children. No bleeding or clotting disorders. Mom with ?MI Physical Exam: VS- T:98.7/98.7 P:85(85-107) BP:158/92(158-210)/(72-100) RR:18 O2 Sat: 95% on 3L GEN- Patient sits with three pillows behind her, puffing on her nebulizers. NAD. SKIN- Color good. Nails without clubbing or cyanosis. HEENT- NCAT. Sclera anicteric and conjunctiva clear. EOMI intact. Pupils equal and reactive to light and accomodation. Unable to appreciate optic disk on undilated exam as there did appear to be some posterior cataracts. OP clear. MMM. NECK- No lymphadenopathy or thyromegaly. PULM- Increased AP diameter with some notable kyphosis. Diminished breath sounds in left lower lung field. Crackles heard diffusely through upper and lower lung fields, R>L however. No wheezes or rhonchi. CV- Displaced PMI not appreciated. RRR. Normal S1 and S2 without rubs or murmurs. ABD- Positive bowel sounds. Non-obese or distended. Soft. Non-tender to light or deep palpation. No abnormal masses or organomegaly. EXT- Bilateral non-pitting edema, left leg greater than right leg. DP pulses palpable bilaterally. NEURO- CN II-XII intact. Notably deltoids 4+ strength bilaterally but otherwise strength was [**5-9**]. No signs of impairment to cold or light touch. Biceps/Triceps/BR/Petellar/Achilles reflexes all [**3-9**] bilaterally Pertinent Results: Admission labs: [**Age over 90 **]|100|25 ----------<137 4.6|35|1.6 estGFR: 31/37 (click for details) CK: 88 MB: Notdone 10.2 7.3><300 30.0 N:56.5 L:27.1 M:5.4 E:10.2 Bas:0.9 CK: 88 MB: Notdone Trop-T: 0.07 -> CK: 88 MB: Notdone Trop-T: 0.06 CXR [**5-30**]: Stable radiograph with multiple priors with no acute pulmonary process noted. Again seen is a stably elevated left hemidiaphragm, atheromatous disease of the aorta, and an enlarged cardiac silhouette. ECG [**6-1**]: Sinus rhythm. Left ventricular hypertrophy with associated ST-T wave changes. Compared to the previous tracing there is no significant change. Brief Hospital Course: ASSESSMENT/PLAN: 83 year-old woman with a known history of COPD, asthma, and hypertension admitted for multiple COPD flares this year. She presents after two days of cough and greatly exacerbated SOB/sensations of airway narrowing in the setting of hypertensive urgency. 1) Dyspnea: Multi-factorial likley with component of asthma exacerbation probably with recent viral URI given sputum change and wheezing, but also given elevated blood pressure and diastolic heart failure that contributes. She was treated with home inhalers and nebs(Albuterol .083% Q4h, Ipratropium .02% Q4h, Cromolyn 800mcg 2 puffs Q6h, Budesonide .25mg/2ml Q4h, guaifenesin 600mg [**Hospital1 **]), prednisone taper (40mg daily for 3 days then taper to 30mg), azithromycin for 5 day course. Also we attempted to improve her diastolic dysfunction and blood pressure as outlined below. On discharge she was breathing comfortably, satting 96% on RA at rest. 2) Diastolic Heart Failure: Initially decompensated with hypertensive urgency. She would benefit from improved BP and HR control as her blood pressure is [**Last Name (un) **] labile (SBP 120-220 in house) and HR 80-100, sinus. She was given 2 doses over 2 days of ehtacrynic acid for mild diuresis to improve her respiratory status. To improve afterload reduction her enalapril was increased to 20mg daily. Her thiazide was stopped to off-set any decrease in blood pressure this change might cause. She has never had nodal [**Doctor Last Name 360**] for rate control and after discussion with her PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and review of cost of medications (as she has difficulty paying for her meds) she was started on diltiazem 30mg qid. She initially tolerated this well but the second day of it felt dizzy, lightheaded, weak and unwell. Her blood pressure at this time was systolic 140's but just prior to getting the medications it had been 200. She was not orthostatic by BP or HR with this. Despite this her enalapril dose was decreased back to 10mg daily and she was discharged with follow-up [**2146-6-8**] with [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3817**] who works with Dr. [**Last Name (STitle) **]. Transportation was also arranged for this appointment. 3) Hypertension: Patient's BP's according to PCP typically are running at 150-160's systolic when well-controlled. These numbers can peak to the 190's or higher during an acute asthma exacerbation, and attempts to lower pressures below 160 have resulted in lightheadedness, fatigue, and dizziness. She had missed one of her clonidine patches and probably her enalpril prior to admit to explain her elevated BP on arrival, but her blood pressure was quite labile in house as well (120-220). Her clonidine and nifedipine were continued with no dose adjustment. The enalapril with increased then decreased as above. She was started on diltiazem and was discharged on 30mg tid. Her hydrochlorothiazide was discontinued. 4) Trigeminal Neuralgia: She complained of right eye pain the same as it was when evaluated by optometry, Dr. [**Last Name (STitle) 699**], [**4-12**], who felt this was trigeminal neuralgia as previously diagnosed. He has been recommending a pain clinic evaluation for this since [**2144**] but Ms. [**Known lastname 12129**] has never had this. She has been taking her carbamazepine 1-2 tabs daily prn with no relief. She was increased to 300mg [**Hospital1 **] with some improvement. A follow-up appointment was made in pain clinic [**6-13**] and transportation was arranged. 5) Hyperlipidemia: Normally controlled at home on statin (Atorvastatin 10 mg PO Daily), but we held this given risk of rhabdo in the setting of Azithromycin. 6)Osteoporosis: She was restarted fosamax as she had not refilled her prescription. Also she was continued on vitamin D 400 [**Hospital1 **] and calcium carbonate 500mg po tid. 7)Iron Deficiency Anemia: Hemoglobin usually running [**9-14**] and hematocrit running 29-31. Current hemoglobin and hematocrit at baseline. Continued on Ferrous Sulfate 325mg PO Daily. Medications on Admission: Hydrochlorothiazide 12.5 mg Daily - not taking immediately prior to admission as ran out of medication. On 25mg according to OMR but 12.5mg after last hospital discharge for unspecified reason. Clonidine 0.1 mg/24 hr Patch Weekly Transdermal QWED Clonidine 0.3 mg/24 hr Patch Weekly Transdermal QWED Nifedipine 180 mg Tablet Sustained Release DAILY Enalapril Maleate 10 mg PO DAILY - not taking immediately prior to admission as ran out of medication. On 20mg according to OMR but decreased to 10mg after last hospital discharge for unspecified reason. Prednisone 5 mg Daily - patient reports not taking at home. Appears to be some confusion over this. Dr.[**Name (NI) 17376**] note indicates that she should have been continuing with 5mg daily until her next appointment, but patient reports that she already completed her required course. Cromolyn 800 mcg/Actuation Two (2) Puff Inhalation Q6H Albuterol sulfate 2.5mg/3ml (.083%) Neb Q6H Ipratropium 0.5 mg/2.5 ml (.02%) Neb Q6H Budesonide .25 mg/2 ml Neb Q6H - Patient reports not taking this with regularity. Combivent MDI and Flovent when out of house Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day) Oxygen 3L at night Aspirin 325 mg DAILY. Atorvastatin 10 mg PO DAILY Cholecalciferol 400u Two (2) Tablet PO DAILY Omeprazole OTC 20 mg PO Daily. Docusate Sodium One Hundred (100) mg PO BID (2 times a day). Senna 8.6 mg PO BID Ferrous Sulfate 325 mg DAILY Carbamazepine 100 mg [**Hospital1 **] Fosamax 70mg Qwk Tolterodine 2 mg QHS Discharge Medications: 1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 3. Cromolyn 800 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 4. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nifedipine 90 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*5* 9. Detrol LA 2 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO at bedtime. 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 12. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 13. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 15. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QWED (every Wednesday). Disp:*4 Tablet(s)* Refills:*2* 16. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 17. Budesonide 0.25 mg/2 mL Suspension for Nebulization Sig: One (1) neb Inhalation every six (6) hours. 18. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day for 30 doses: please take 3 tablets daily for 2 days then reduce to 2 tablets daily for 3 days, then 1 tablet daily through [**2146-6-16**] when you see Dr. [**Last Name (STitle) 575**]. . Disp:*30 Tablet(s)* Refills:*0* 19. Carbamazepine 100 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO BID (2 times a day). Disp:*180 Tablet, Chewable(s)* Refills:*2* 20. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 21. Oxygen 3L NC oxygen when sleeping and 2L NC oxygen with ambulation only. 22. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*5* 23. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 17377**] home health care Discharge Diagnosis: Primary: Asthma exacerbation, hypertensive urgency, diastolic heart failure with mild exacerbation, trigeminal neuralgia. Secondary: Chronic kidney disease, osteoporosis, gastritis, anxiety. Discharge Condition: Stable on her home dose of oxygen, stable blood pressure. Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Please notify your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], or return to the Emergency Department if you experience fevers, chills, cough, shortness of breath, chest pain or pressure, dizziness, lightheadedness, or any symptoms that concern you. Followup Instructions: Please follow-up with Nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3817**] on Wednesday [**2146-6-8**] at 10:00 am. Please call [**Telephone/Fax (1) 250**] if questions or you need to move this appointment. Please follow-up with Dr. [**First Name (STitle) 13368**] [**Last Name (NamePattern4) 13369**], MD [**First Name (Titles) **] [**Last Name (Titles) 878**] on Monday [**2146-6-13**] at 10:40pm. Please call [**Telephone/Fax (1) 1652**] if questions. Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on Monday [**2146-7-11**] at 8:20am. Please call [**Telephone/Fax (1) 250**] if questions regarding this appointment. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**] of Pulmonology, on [**2146-6-16**] at 9:45am. Please call [**Telephone/Fax (1) 612**] if questions regarding this appointment. Admission Date: [**2146-6-3**] Discharge Date: [**2146-6-8**] Date of Birth: [**2063-5-28**] Sex: F Service: MEDICINE Allergies: Codeine / Lasix Attending:[**First Name3 (LF) 30**] Chief Complaint: Respiratory Distress. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known firstname 2894**] [**Known lastname 12129**] is an 83F asthma/COPD who returns with shortness of breath after being discharged today. She was originally admitted with 3d of worsening shortness of breath and wheezing and was treated for COPD exacerbation after an URI ([**Date range (1) 16805**]). She had been started on a course of steroids and completed course of azithromycin. She arrived home at 4PM and at approximately 630 she developed shortness of breath while sitting on the couch and told her daughter to call the ambulance. She felt dizzy at the time. She had no associated chest pain, diaphoresis, nausea. She denies fevers, chills, palpitations, abdominal pain. She states that she was concerned about leaving the hospital today because she was started on a new antihypertensive. She says she does not do well with new medications and was worried about how it would affect her. She took Diltiazem 30mg this morning and reports weakness and fatigue beginning this morning. It continued throughout the day but did not necessarily worsen while at home. She continues to feel weak. She did not take any medications at home. In the ED, the patient's vital signs were T 97.2, BP 240/140, RR 26, O2 sat 100% on CPAP. EMS gave the patient SL NTG and brought her in on Bipap. CXR was unchanged from previous. CPAP was stopped on arrival to [**Hospital1 18**] and patient was quickly weaned to 2L NC 95-100% oxygenation. An aspirin was given in the ED, but no nebulizers as patient was back at baseline. She is being admitted for monitoring of dyspnea. On arrival to the floor the patient says her breathing is close to her baseline. Past Medical History: 1. Severe bronchitic asthma - followed by Dr. [**Last Name (STitle) 575**] 2. Hypertension - poorly controlled on multiple antihypertensive agents with goal SBP 160 given dizziness/lightheadedness, ARF in the past with more aggressive regimens 3. Chronic Renal Insufficiency w/ baseline Cr 1.5-2.0 4. Polymyalgia rheumatica 5. Hyperlipidemia 6. Osteoporosis 7. Gastritis 8. Paretic left diaphragm status post pericardial window procedure 9. Trigeminal neuralgia 10. Iron-deficiency anemia 11. status post appendectomy Family History: Diabetes mellitus in siblings and children. No bleeding or clotting disorders. Mom with ?MI Physical Exam: Vitals: 184/82, 91, 18, 99% on 2L General: Elderly female in NAD HEENT: PERRL, EOMI, OP clear Neck: no LAD, supple, JVP of 6cm Heart: RRR no m/r/g Lungs: Diffuse expiratory wheezes, rales left base Abd: +BS, NTND, soft Ext: 1+ edema bilaterally Neuro: CN 2-12 intact, 5/5 strength, sensation intact to light touch Psych: appropriate Skin: no rashes Pertinent Results: Admission labs: [**Age over 90 **]|95|58 ---------<157 5.4|33|2.0 K: Hemolyzed, Slightly -->repeat 4.9 CK: 51 MB: Notdone Trop-T: 0.05-->MB: NotDone Trop-T: 0.08 Ca: 10.3 Mg: 2.0 P: 4.2 proBNP: 5535 CXR portable [**6-3**]: No acute cardiopulmonary disease. CXR portable [**6-6**]: Faint right lower lobe opacity more prominent than prior study may reflect atelectasis or pneumonia. There is no evidence of pulmonary edema. ECG [**6-3**]: Sinus rhythm. Left ventricular hypertrophy with secondary ST-T wave changes. Compared to the previous tracing of [**2146-5-31**] there is no significant diagnostic change. Brief Hospital Course: Impression: 83 yo woman with asthma, hypertension, and diastolic dysfunction who presents with sudden onset shortness of breath at home hours after discharge from hospital. 1 Shortness of breath: This was thought largely related to anxiety of being discharged, with possible contribution of hypertensive urgency given presenting vital signs and rapidity of improvement initially. No evidence of worsening asthma exacerbation. She was thought to have increased rales on exam with possible increased pulm edema [**6-6**] though cxr did not support this. She benefit from diruesis and would definitely benfit from improved control of HR and BP for diastolic dysfunction as her labile BP/HR and dyspnea appear strongly corelated but she does not tolerate medication to improve either parameter due to 'dizziness' or vaguely feeling unwell after these medications. She was continued on her prednisone taper, her albuterol, ipratropium, and budesonide via nebulizer, and her inhaled cromolyn. 2 Asthma exacerbation: She was continued with treatment for recent asthma exacerbation with prednisone taper, home nebs: ipratropium, albuterol, budesonide, cromolyn, and supplemental home level of oxygen (3L NC when sleeping, 2L NC with ambulation). 3 Leukocytosis: Given complaint of urinary frequency and incontinence concerning for UTI but UA and culture were negative. She remained afebrile and WBC trended down. 4 Elevated troponin: Noted on admission, trended down. EKG unchanged. This was thought demand in the setting of severe hypertension and will be slow to clear given renal failure. She was continued on aspirin, no bblocker given COPD, statin, enalapril. 5 Hypertensive urgency: No focal neurological findings. Based on [**Name (NI) **], pt baseline BP 170-190 (with goal of treatment in the past being SBP 160). She states diltiazem makes her weak so was switched to verapamil and BP quite labile. Otherwise she was continued on enalipril, clonidine, nifedipine, and the verapamil. 6 Diastolic heart failure, decompensated: This was thought contributing to shortness of breath as above. She would benefit from rate control/afterload reduction if she tolerates it. [**Month (only) 116**] also benefit from a bit of diuresis but has not tolerated this in the past and would favor HR/BP control. 7 Gastritis: Continued on ppi. 8 Osteoporosis: Continued on vitamin D, fosamax Qwk, and calcium. 9 Chronic Kidney Disease: Creatinine at baseline in house, she was continued on enalapril. 10 Trigeminal Neuralgia: Not bothersome to her on this admit. She was continued on Carbamazepine 300 mg [**Hospital1 **]. 11 Urinary dysfunction: She was continued on Tolterodine. 12 Code: full. Medications on Admission: 1. Albuterol Sulfate Neb q6H 2. Ipratropium Bromide neb q6H 3. Cromolyn 800 mcg/2 puff q6H 4. Quinine Sulfate 324 mg HS 5. Aspirin 325 mg Tablet Daily 6. Nifedipine 180 mg Tablet Sustained Release DAILY 7. Cholecalciferol (Vitamin D3) 400 unit PO BID 8. Omeprazole 20 mg Capsule DAILY 9. Detrol LA 2 mg Capsule, Sust. Release DAILY 10. Ferrous Sulfate 325 mg DAILY 11. Guaifenesin 600 mg Tablet [**Hospital1 **] 12. Clonidine 0.1 mg/24 hr Patch Weekly qMON 13. Clonidine 0.3 mg/24 hr Patch Weekly qMON 14. Calcium Carbonate 500 mg Tablet,PO TID 15. Alendronate 70 mg Tablet QWED 16 Albuterol 90 mcg/Actuation Aerosol 1-2 puffs PRN wheezine 17. Budesonide 0.25 mg/2 mL q6H 18. Prednisone 30mg two days, 20mg 3 days, 10mg daily 19. Carbamazepine 300 mg Tablet [**Hospital1 **] 20. Atorvastatin 10 mg Tablet DAILY 21. Enalapril Maleate 10 mg Tablet daily 22. Diltiazem HCl 30 mg Tablet TID Discharge Medications: 1. Cromolyn 800 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours): for breathing. Disp:*1 inhaler* Refills:*2* 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours): for your breathing. Disp:*120 amps* Refills:*2* 3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). Disp:*120 amps* Refills:*2* 4. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at bedtime): for muscle cramps. Disp:*30 Capsule(s)* Refills:*2* 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): to protect your heart. Disp:*30 Tablet(s)* Refills:*2* 6. Nifedipine 90 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily): for your blood pressure. Disp:*60 Tablet Sustained Release(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): for acid reflux. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily): to protect your bones. Disp:*30 Tablet(s)* Refills:*2* 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily): for your anemia. Disp:*30 Tablet(s)* Refills:*2* 10. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWEDNESDAY: for your blood pressure; use in addition to your 0.3 mg patch. Disp:*4 Patches* Refills:*2* 11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. Disp:*1 inhaler* Refills:*2* 12. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day: take one daily until your appointment with Dr. [**Last Name (STitle) 575**] [**2146-6-16**]. Disp:*30 Tablet(s)* Refills:*2* 13. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for cholesterol. Disp:*30 Tablet(s)* Refills:*2* 14. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for your blood pressure. Disp:*30 Tablet(s)* Refills:*2* 15. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QWED (every Wednesday): to protect your bones. Disp:*4 Tablet(s)* Refills:*2* 16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day): to protect your bones. Disp:*90 Tablet, Chewable(s)* Refills:*2* 17. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWEDNESDAY: for your blood pressure; please use in addition to your 0.1 mg patch. Disp:*4 Patches* Refills:*2* 18. Detrol LA 2 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO at bedtime: for your bladder. Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 19. Carbamazepine 100 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO BID (2 times a day): for neuralgia. Disp:*180 Tablet, Chewable(s)* Refills:*2* 20. Budesonide 0.25 mg/2 mL Suspension for Nebulization Sig: One (1) nebulizer Inhalation every six (6) hours: for your breathing. Disp:*120 amps* Refills:*2* 21. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO bid (): for clearing mucous. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 22. Home Oxygen Please use 3L NC oxygen when sleeping and 2L NC when ambulating. 23. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): for your blood pressure. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 17377**] Homecare Discharge Diagnosis: Primary: Anxiety, Asthma exacerbation, hypertensive urgency, chronic diastolic heart failure with mild acute exacerbation, trigeminal neuralgia. . Secondary: Chronic kidney disease IV, osteoporosis, gastritis, anxiety. Discharge Condition: Stable on her home dose of oxygen, stable blood pressure. Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Please notify your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], or return to the Emergency Department if you experience fevers, chills, cough, shortness of breath, chest pain or pressure, dizziness, lightheadedness, or any symptoms that concern you. . We have stopped your diltiazem and started a new medication called verapamil. We are also tapering your prednisone. Please take all medications as prescribed. Followup Instructions: Please follow-up with Dr. [**First Name (STitle) 13368**] [**Last Name (NamePattern4) 13369**], MD [**First Name (Titles) **] [**Last Name (Titles) 878**] on Monday [**2146-6-13**] at 10:40pm. Please call [**Telephone/Fax (1) 1652**] if questions. Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on Monday [**2146-7-11**] at 8:20am. Please call [**Telephone/Fax (1) 250**] if questions regarding this appointment. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**] of Pulmonology, on [**2146-6-16**] at 9:25am. Please call [**Telephone/Fax (1) 612**] if questions regarding this appointment. Admission Date: [**2146-6-9**] Discharge Date: [**2146-6-22**] Date of Birth: [**2063-5-28**] Sex: F Service: MEDICINE Allergies: Codeine / Lasix / Diltiazem / Ativan Attending:[**First Name3 (LF) 613**] Chief Complaint: respiratory failure bradycardia Major Surgical or Invasive Procedure: Endotracheal Intubation, extubation Bronchoscopy, with Y-stent placement History of Present Illness: This is an 83 yo female with a past medical history of COPD, HTN, CHF who p/w resp distress from home. She was discharged yesterday from the hospital during which she was treated for hypertensive urgency in the setting of dyspnea and anxiety. She responded promptly to SL nitroglycerin and BiPap and experienced no further dyspnea and was discharged to home on [**6-8**]. Her medications were adjusted during this admission to continue nifedipine, but to exchange diltiazem for verapamil, and per the patient's daughter, she obtained several doses of verapamil until she could fill the new prescriptions (she was NOT sent home with these doses, which was confirmed with the [**Hospital Ward Name **] 2 nursing staff). The patient arrived home from the hospital after 6pm and received 3 medications she had at home, it is unclear if the diltiazem was one of these medications. She then became acutely distressed today and called EMS. Upon EMS arrival, she was found to be hypertensive to 200/40 and bradycardic. She was intubated for resp distress in the field and was given atropine for HR in 30s (unclear if for hypotension). . Upon reaching ED- SBP in 90s and she was satting well on the vent. She was found to be in a new junctional rythm on EKG in 30's 40's. In the ED, she received glucagon, versed, levoflox, solumedrol, calcium and received fluid for an elevated lactate. A CXR revealed interstitial edema. [**Hospital Unit Name 196**] was consulted but did not feel that her respiratory failure was CHF related. UA neg. She received an additional dose of atropine for HR in the 20's prior to transfer to the MICU. She is admitted to the MICU for further work up and management. Past Medical History: 1. Asthma/COPD - Recently admitted for a flare on [**2146-3-29**] and treated with nebulizers, steroids, and a course of azithromycin. Last seen by Dr. [**Last Name (STitle) 1632**] in Pulmonology in [**Month (only) 547**], when he thought she was deconditioned from her time in the hospital although adequately medicated. Recommended a Cardiology consult at this time for what he believed to be significant diastolic dysfunction secondary to long-standing hypertension. 2. Paralyzed left hemidiaphragm s/p pericardial window procedure 3. Severe hypertension with diastolic dysfunction - Per PCP notes typically controlled in the 160's unless patient experiences an asthma flare when it shoots to 170's-180's. Notably systolic pressures were in the 130's during her last hospital admission, presumably the reason why her HCTZ and enalapril doses were halved. Patient is poorly compliant and most recently has not been taking her antihypertensives due to her ill son-in-law, unable to pick up her meds from the pharmacy. 4. Hyperlipidemia 5. Chronic renal insufficiency (creatinine around 1.4). 6. Polymyalgia rheumatica. 7. Osteoporosis. 8. Trigeminal neuralgia - reportedly seen by Optometry [**2146-4-26**] and referred to Dr. [**Last Name (STitle) **] of [**Last Name (STitle) 878**]. 9. Iron-deficient anemia 10. Gastritis Social History: Ms. [**Known lastname 12129**] is a widow of many years and a mother of three. She lives in the bottom unit of a shared home with her daughter and son-in-law, who provide her with a large amount of care and support. Although Ms. B is able to complete most of her ADL's, she relies on her daughter for shopping and cooking. While she doesn't specifically say it, her increasing dependence on her children has taken a bit of its toll on her. This may be partially responsible for her decreased med compliance - the patient relies on others to go to CVS to pick up her meds. Her daughter had the flu prior to Ms. [**Known lastname 12129**]' hospitalization, and because of this, she was unable to pick up her medications on time. Additionally, it sounds as if the patient doesn't leave her house very often. She comments on how she doesn't like to walk outside or to sit on her porch. Ms. [**Known lastname 12129**] would rather watch television, socializing with friends infrequently. Family History: Diabetes mellitus in siblings and children. No bleeding or clotting disorders. Mom with ?MI Physical Exam: VS: T 96.8 R BP 114/47 HR 40 R 14 Sat 100% on A/C 400x14 FiO2 0.4 Peep 5 GEN: NAD, comfortable on vent HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection, anicteric, OP clear, MM dry, Neck supple, no LAD, no JVD. CV: Bradycardic, distant heart sounds, no m/r/g PULM: CTAB, no w/r/r, decrease breath sounds at left base ABD: soft, NT, ND, + BS. Ecchymoses over abdomen EXT: cool, dry, dopplerable pulses at DP, palpable at popliteal. NEURO: sedated. Not responding to pain at this time. Spontaneous movements, moving ext x 4. CNII-XII in tact. SKIN: Cool and dry. No rash. Pertinent Results: ADMISSION LABS: [**2146-6-8**] 07:45AM WBC-9.9 RBC-3.17* HGB-9.3* HCT-29.0* MCV-92 MCH-29.2 MCHC-31.9 RDW-15.0 [**2146-6-8**] 07:45AM PLT COUNT-332 [**2146-6-8**] 07:45AM GLUCOSE-102 UREA N-60* CREAT-1.9* SODIUM-137 POTASSIUM-5.1 CHLORIDE-96 TOTAL CO2-35* ANION GAP-11 [**2146-6-8**] 07:45AM CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-2.2 [**2146-6-9**] 04:59AM TYPE-ART RATES-/16 TIDAL VOL-450 PO2-486* PCO2-50* PH-7.35 TOTAL CO2-29 BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED [**2146-6-9**] 07:58AM LACTATE-2.6* [**2146-6-9**] 06:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2146-6-9**] 06:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG . DISCHARGE LABS: [**2146-6-22**] 07:05AM BLOOD WBC-7.7 RBC-2.69* Hgb-8.0* Hct-24.9* MCV-93 MCH-29.9 MCHC-32.3 RDW-15.1 Plt Ct-301 [**2146-6-22**] 07:05AM BLOOD Plt Ct-301 [**2146-6-22**] 07:05AM BLOOD Glucose-104 UreaN-40* Creat-1.7* Na-135 K-4.1 Cl-95* HCO3-31 AnGap-13 . [**6-9**] CXR: 1. Endotracheal tube malpositioned in the right mainstem bronchus. The tube should be pulled back at least 2.5 cm for more optimal placement. 2. Interstitial edema and right basilar atelectasis. 3. Large ovoid mass at the left lung base obscuring the diaphragm. Diagnostic considerations include a lung mass, fluid-filled hiatal hernia or possible Bochdalek hernia. Further evaluation with PA and lateral chest radiograph is recommended when the patient's condition allows. . EKG: Underlying rhythm appears to be atrial fibrillation or slow junctional bradycardia, although there appear to be at least two sinus beats. Left ventricular hypertrophy. Non-specific lateral ST-T wave changes could be due to left ventricular hypertrophy. Ventricular premature beat. Compared to tracing #2 atrial fibrillation and ventricular premature beat are new. [**2146-6-19**] CXR: Mild failure probably present, persistent elevation of the left hemidiaphragm. . [**2146-6-21**] Video Swallow: No aspiration or penetration identified. Brief Hospital Course: 83F with asthma, hypertension, and diastolic dysfunction who presented with sudden onset shortness of breath at home hours after discharge from hospital found to be in a junctional bradycardia and hypertensive. . # Respiratory Failure: Secondary to acute exacerbation of COPD/asthma as well as acute on chronic diastolic CHF. The patient was intubated in the field for respiratory distress. She has a long history of COPD exacerbations and acute diastolic heart failure associated with refractory hypertension. Chest film upon admit showed mild interstitial edema, and an elevated left hemidiaphragm, consistent with her history of hemidiaphragmatic paralysis. Any insult to her respiratory status is obviously not tolerated well, given this neuromuscular deficit and underlying obstructive disease. The patient was found to be bradycardic, hypertensive and in respiratory distress, most likely because increased diastolic filling times were not sufficient to maintain adequate forward flow with subsequent adrenergic response. She was still on a prednisone taper from her recent admission. There was no evidence of pulmonary infection. Her presentation was not consistent with ARDS and her initial ABG on the ventilator shows mild compensated hypercapnea without hypoxia. . Her nodal agents were held, and she was treated with a nitro gtt for her HTN, as well as nebs and stress dose steroids, and she was extubated later on the first day of her hospital course. Blood pressure medications, including clonidine, enalapril, and nifedipine were titrated. She was transferred to the floor, where she initially did well. However, she then became agitated and was given ativan. Later that evening she was noted to be more somnolent and was again found to be hypercarbic. She was transferred back to the ICU and started on BiPAP. She was diuresed with diuril with some improvement in her respiratory status (but developed hyponatremia, see below). Bronchoscopy on [**2146-6-17**] confirmed tracheobronchomalacia, which had been suspected, and a Y stent was placed. She was ultimately extubated for the final time on [**6-18**] and has done well. Additional diuresis with lasix resulted in further improvement in respiratory function. Pt is being discharged on a slow prednisone taper, and she should continue on prednisone 10mg until her pulmonary followup appointment on [**7-14**] with Dr. [**Last Name (STitle) 575**]. She should also continue on her usual nebs and inhalers, and on guaifenesin for stent maintenance. . # Junctional Bradycardia: The patient was initially in a junctional rhythm without antegrade or retrograde P waves, implying no AV nodal conduction. The most likely etiology of this rhythm was recieving her doses of verapamil during the day in the hospital and then taking verapamil and a dose of her diltiazem in error after arriving at home (a medication she was supposed to stop). She received atropine x 2 (once in the field and once in the ED). It was thought to be unusual, however, for CCB toxicity to result in HTN. She received the appropriate treatment for CCB toxicity regardless, including calcium gluconate and glucagon in the ED. All nodal agents were held and this rhythm resolved. The patient has been in sinus rhythm, and is being discharged off all nodal agents (no CCB or BB). . # Hypertensive urgency: Patient has long history of refractory hypertension and was initially 200 systolic when EMS arrived. Based on [**Name (NI) **], pt baseline BP 170-190 (with goal of treatment in the past being SBP 160). BP has been overall improved, but remains labile. She is off CCB now given prior junctional bradycardia. Currently she has had stable but suboptimally controlled BP on clonidine patches, ACE inhibitor, and nifedipine. . # Diastolic heart failure, acute on chronic: CHF was felt to be contributing to her has mild interstitial edema and ultimately her respiratory failure on her 2nd ICU course. She improved with diuril diuresis, but developed hyponatremia. Later she tolerated lasix diuresis well and she is currently again well-compensated in terms of her CHF. She is on an ACE-inhibitor. . # Hyponatremia: Likely this was due to diuresis with Diuril. Initially Tegretol was also suspected, as this can also cause hyponatremia. However, since hyponatremia corrected when diuril was stopped, and since pt had been on Tegretol for some time prior for trigeminal neuralgia, Tegretol was resumed prior to discharge. . # Leukocytosis: Mild leukocytosis on admission, with pt on steroids. No other evidence of active infection found. Leukocytosis resolved prior to discharge. . # Elevated troponin: Mild troponin elevated which has been chronic over the last several months and the last several admissions. CKs have been flat. Likely related to CHF and renal failure. No evidence of ACS. Continued aspirin, statin, ACE. No BB (both due to COPD and with junctional rhythm as described above). . # Anemia: Known iron deficiency. Hct stable near her baseline (trended down slightly over the course of the hospitalization, likely due to acute illness and blood draws). Continued iron supplement. . # Gastritis: Continue PPI, uptitrated to [**Hospital1 **]. . # Osteoporosis: Continued vitD, fosamax Qwk, calcium. . # CKD: Creatinine has been stable at her baseline of 1.7. . # Trigeminal Neuralgia: Initially held Tegretol given concern for hyponatremia (see above), but this was resumed prior to discharge. . # Urinary dysfunction: Continue detrol. . # Ear discomfort: No evidence of infection on exam, but dry, hard cerumen present in canal. Suggested Debrox drops for a few days to soften, and irrigation can be attempted at that point if cerumen is still present. . # FEN: After extubation, pt passed a swallow evaluation, including video swallow. She is to be on a soft diet with thin liquids. Nutriton consult also recommended Ensure pudding TID. Medications on Admission: 1. Albuterol Sulfate Neb q6H 2. Ipratropium Bromide neb q6H 3. Cromolyn 800 mcg/2 puff q6H 4. Quinine Sulfate 324 mg HS 5. Aspirin 325 mg Tablet Daily 6. Nifedipine 180 mg Tablet Sustained Release DAILY 7. Cholecalciferol (Vitamin D3) 400 unit PO BID 8. Omeprazole 20 mg Capsule DAILY 9. Detrol LA 2 mg Capsule, Sust. Release DAILY 10. Ferrous Sulfate 325 mg DAILY 11. Guaifenesin 600 mg Tablet [**Hospital1 **] 12. Clonidine 0.1 mg/24 hr Patch Weekly qMON 13. Clonidine 0.3 mg/24 hr Patch Weekly qMON 14. Calcium Carbonate 500 mg Tablet,PO TID 15. Alendronate 70 mg Tablet QWED 16 Albuterol 90 mcg/Actuation Aerosol 1-2 puffs PRN wheezine 17. Budesonide 0.25 mg/2 mL q6H 18. Prednisone 30mg two days, 20mg 3 days, 10mg daily 19. Carbamazepine 300 mg Tablet [**Hospital1 **] 20. Atorvastatin 10 mg Tablet DAILY 21. Enalapril Maleate 10 mg Tablet daily 22. Diltiazem HCl 30 mg Tablet TID stopped and switched to Verapamil TID on [**6-6**]. Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nifedipine 90 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Detrol LA 2 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO at bedtime. 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Carbamazepine 100 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMONDAY: with 0.3mg patch for 0.4mg total. 10. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMONDAY: with 0.1mg patch for 0.4mg total. 11. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every Thursday). 12. Cromolyn 800 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 15. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-5**] Sprays Nasal QID (4 times a day) as needed for nasal congestion. 17. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day): for stent maintenance. 19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 20. Lidocaine HCl 1 % (10 mg/mL) Solution Sig: One (1) neb Injection Q1-2H () as needed for cough/pain: lidocaine nebs. 21. Budesonide 0.25 mg/2 mL Suspension for Nebulization Sig: One (1) neb Inhalation q6h (). 22. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb treatmeent Inhalation Q6H (every 6 hours). 23. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 24. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. 25. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 26. Prednisone 5 mg Tablet Sig: TAPER Tablet PO once a day: 20mg daily for 3 more days, then 15mg daily for 5 days, then 10mg daily ongoing until pulmonary appointment with Dr. [**Last Name (STitle) 575**] on [**2146-7-14**]. 27. Enalapril Maleate 20 mg Tablet Sig: One (1) Tablet PO once a day. 28. Debrox 6.5 % Drops Sig: 5-10 drops Otic twice a day for 4 days: to ears. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary diagnoses: hypoxia secondary to COPD/asthma, tracheobronchomalacia junctional bradycardia secondary to calcium-channel blocker toxicity hypertensive urgency . Secondary diagnoses: chronic kidney disease trigeminal neuralgia iron deficiency anemia. Discharge Condition: stable Discharge Instructions: You were admitted because you were found to have a low heart rate and an elevated blood pressure. This may have been related to the blood pressure pills that you were taking at that time. You also had respiratory distress which has improved. Several of your medications have been changed. You should take only the medications currently prescribed, and discard any of your old medications that you still have. Specifically, the following changes have been made: -Hydrochlorothiazide was STOPPED on your last hospitalization. You should not take this medication. -Verapamil has been STOPPED. You should also not take diltiazem any longer (this was stopped on your last admission). -Dose of enalapril was increased for your blood pressure. -Prednisone taper as instructed on medication sheet, with prednisone 10mg daily to be continued until pulmonary appointment with Dr. [**Last Name (STitle) 575**]. -Guaifenesin for maintenance of your tracheal stent. Please keep all followup appointments. Please call your doctor if you develop fever/chills, shortness of breath, chest pain, increased swelling of the legs or any other concerning symptoms. Followup Instructions: You have the following appointment already scheduled with Dr. [**Last Name (STitle) **]: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14839**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2146-7-11**] 8:20 We have also rescheduled the following pulmonary appointment for you with Dr. [**Last Name (STitle) 575**]. You should arrive at 10:00am for this appointment: Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2146-7-14**] 10:10 Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2146-7-14**] 10:30 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Name: [**Known lastname 2441**],[**Known firstname 2770**] Unit No: [**Numeric Identifier 2771**] Admission Date: [**2146-6-3**] Discharge Date: [**2146-6-8**] Date of Birth: [**2063-5-28**] Sex: F Service: MEDICINE Allergies: Codeine / Lasix Attending:[**First Name3 (LF) 175**] Addendum: Please disregard the HPI in this discharge summary, entered in error, the appropriate HPI is below: Ms. [**Known firstname **] [**Known lastname **] is an 83F asthma/COPD who returns with shortness of breath after being discharged today. She was originally admitted with 3d of worsening shortness of breath and wheezing and was treated for COPD exacerbation after an URI ([**Date range (1) 2772**]). She had been started on a course of steroids and completed course of azithromycin. She arrived home at 4PM and at approximately 630 she developed shortness of breath while sitting on the couch and told her daughter to call the ambulance. She felt dizzy at the time. She had no associated chest pain, diaphoresis, nausea. She denies fevers, chills, palpitations, abdominal pain. She states that she was concerned about leaving the hospital today because she was started on a new antihypertensive. She says she does not do well with new medications and was worried about how it would affect her. She took Diltiazem 30mg this morning and reports weakness and fatigue beginning this morning. It continued throughout the day but did not necessarily worsen while at home. She continues to feel weak. She did not take any medications at home. In the ED, the patient's vital signs were T 97.2, BP 240/140, RR 26, O2 sat 100% on CPAP. EMS gave the patient SL NTG and brought her in on Bipap. CXR was unchanged from previous. CPAP was stopped on arrival to [**Hospital1 8**] and patient was quickly weaned to 2L NC 95-100% oxygenation. An aspirin was given in the ED, but no nebulizers as patient was back at baseline. She is being admitted for monitoring of dyspnea. On arrival to the floor the patient says her breathing is close to her baseline. Discharge Disposition: Home With Service Facility: [**Hospital 2773**] Homecare [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 181**] MD [**MD Number(1) 182**] Completed by:[**2146-6-13**]

[ "403.90", "725", "733.00", "465.9", "272.4", "493.22", "585.9", "280.9", "V15.81", "350.1", "428.31", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.05", "93.90", "96.71" ]

icd9pcs

[ [ [] ] ]

50761, 50977

36482, 42400

29522, 29596

46615, 46624

34406, 34406

47821, 50738

33701, 33794

43390, 46226

46336, 46503

42426, 43367

46648, 47798

35166, 36459

33809, 34387

46524, 46594

29451, 29484

29624, 31312

34422, 35150

31334, 32685

32701, 33685

47,757

146,207

54795

Discharge summary

report

Admission Date: [**2119-5-30**] Discharge Date: [**2119-7-2**] Date of Birth: [**2100-12-27**] Sex: M Service: MEDICINE Allergies: penicillin G / ceftriaxone / phenytoin / meropenem Attending:[**First Name3 (LF) 2291**] Chief Complaint: seizure Major Surgical or Invasive Procedure: [**2119-5-31**]: Burr hole and abscess aspiration [**2119-6-21**] Left craniotomy drainage of brain abscess [**2119-6-28**] Re-Do Left craniotomy drainage of brain abscess History of Present Illness: 18 y/o M in good health first presented to OSH [**5-27**] following first seizure. Pt had generalized seizure, was brought to OSH where CT head was in itially interpreted as normal, and patient started on PO dilantin. Plan for outpatient MRI. The patient had no neurologic deficits, constitutional symptoms, or other findings at that time, per report. He returned home, and had progressively worsening headaches over the past 2 days. Earlier today, the patient had 2 generalized seizures and was taken again to an OSH where CT head with IV contrast demonstrated a 2.5 cm ring enhancing mass in the left temparoparietal lobe. The patient had a temperature of 101.9 at the OSH and was administered IV CTX/Vanco/Flagyl. Upon arrival to [**Hospital1 18**], the patient is awake and responsive, interviewed in Spanish. He describes headaches, but otherwise denies any recent problems. [**Name (NI) **] his mother, he usually speaks and undedrstands some english, but has been unable to do so over the past 3 days. Past Medical History: denies. No history of pediatric infections, recurrent infections. Social History: Immigrated from [**Country 13622**] Republic. Lives with family. No recent travel. Does not use illicit substances, does not inject drugs. Family History: non-contributory Physical Exam: ADMISSION: T: 99.4 BP: 130/64 HR:90 R:18 O2Sat:100/2L-NC Awake and alert Cooperative with exam Names [**1-10**] objects in Spanish Makes paraphasic errors and neologisms Poor repetition Pupils equally round and reactive to light Extraocular movements intact bil without abnormal nystagmus Facial strength and sensation intact and symmetric Hearing intact to voice Palatal elevation symmetrical Sternocleidomastoid and trapezius normal bilaterally Tongue midline without fasciculations Normal bulk and tone bilaterally No abnormal movements, tremors Strength full power [**5-13**] throughout No pronator drift Sensation intact to light touch x 4 ext Toes downgoing bilaterally Non-dysmetric on finger-nose-finger PHYSICAL EXAM UPON DISCHARGE: Afebrile, BP 100s/60s, HR 80s, satting 99%ra General: Alert, conversant. Skin: peeling skin on arms and legs. No erythema or drainage at PICC site. HEENT: Line of staples on left occiput. No erythema or discharge surrounding staples. No facial edema. Sclera anicteric, conjunctiva clear. Neck: supple, JVP not elevated, no LAD Lungs: CTAB, no wheezes, rales, rhonchi CV: RRR, normal S1 + S2, no m/r/g Abdomen: soft, NT, ND, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused (brisk cap refill), 2+ pulses, no clubbing, cyanosis or edema. No lesions on palms or soles. Neuro:CN 2-12 intact, sensation throughout, [**5-13**] stregnth throughout. Can walk on heels and toes. Pertinent Results: [**2119-5-30**]: CXR- IMPRESSION: Normal chest. [**2119-5-31**]: MRI Brain- Limited planning study. Peripherally T1 hyperintense lesion in the left temporo-parietal lobe with surrounding perilesional edema causing mass effect on the ocipital [**Doctor Last Name 534**] of left lateral ventricle. This has significantly increased in size since the prior CT dated [**2119-5-27**]. The differentials for this includes infection (abscess), inflammatory lesion or tumefactive multiple sclerosis or subacute hematoma. Given the short term increase compared to the CT Head study of [**2119-5-27**], neoplastic etiology is less likely; however, lymphoma related lesion if the pt. is immunosuppressed cannot be completely excluded. Correlate with complete MR imaging an labs. [**5-31**] CT Head: Immediately status post left parietal burr hole and aspiration of the ring-enhancing lesion with associated vasogenic edema in the left parietal lobe, apparently representing known abscess (according to the given history). There is a small amount of intralesional gas and blood, post-procedure [**6-1**] ECHO: IMPRESSION: No valvular vegetations or abscesses appreciated. [**6-1**] Panorex: There is no evidence of gross decay or dental infection. His 3rd molars appear to be impacted and may require removal in the future. [**2119-6-16**] HEAD CT IMPRESSION: Interval increase in the size of a left rim-enhancing brain lesion measuring 1.9 x 3.7 x 3.5 cm. [**2119-6-16**] RUE U/S IMPRESSION: No DVT. [**2119-6-17**] RUQ U/S IMPRESSION: normal abdominal ultrasound. No intra- or extra-hepatic bile duct dilation. [**2119-6-18**] MRI HEAD W/ CONTRAST CONCLUSION: Continued enlargement of the abscess, now with contact with the ventricle and at least subependymal enhancement. [**2119-6-21**] HEAD CT IMPRESSION: Expected post-surgical changes, immediately after left parietal craniotomy for evacuation of an intracranial abscess. Pneumocephalus and small intraparenchymal blood at the resection site with surrounding edema are noted. [**2119-6-23**] CXR IMPRESSION: No acute chest abnormality. [**2119-6-27**] HEAD MRI IMPRESSION: 1. Overall evidence of progression with interval thickening of the abscess cavity, extension of adjacent FLAIR signal and new involvement of the left occipital [**Doctor Last Name 534**] subependyma. 2. No new parenchymal abscesses identified. [**2119-6-29**] HEAD CT IMPRESSION: Expected postoperative changes immediately after left parietal craniotomy for evacuation of intracranial abscess with pneumocephalus, vasogenic edema, and small amount of intraparenchymal blood. [**2119-6-12**] PERIPHERAL FLOW CYTOMETRY INTERPRETATION: Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by B-cell lymphoma are not seen in specimen. Correlation with clinical findings and morphology is recommended. ABSCESS CULTURES [**2119-5-31**] 1:05 pm ABSCESS INTERCRANIAL. **FINAL REPORT [**2119-6-8**]** GRAM STAIN (Final [**2119-5-31**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND SINGLY. WOUND CULTURE (Final [**2119-6-8**]): STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. MODERATE GROWTH. Sensitivity testing performed by Sensititre. CLINDAMYCIN MIC <= 0.12 MCG/ML. CEFTRIAXONE SENSITIVITY REQUESTED BY [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**] [**9-/3768**] [**2119-6-6**]. SENSITIVE TO CEFTRIAXONE MIC = 0.125MCG/ML, Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML ________________________________________________________ STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP | CLINDAMYCIN----------- S ERYTHROMYCIN----------<=0.25 S PENICILLIN G----------<=0.06 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2119-6-4**]): NO ANAEROBES ISOLATED. [**2119-6-21**] 2:00 pm SWAB ABSCESS. **FINAL REPORT [**2119-6-27**]** GRAM STAIN (Final [**2119-6-21**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2119-6-23**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2119-6-27**]): NO GROWTH. [**2119-6-28**] 10:25 pm SWAB Site: BRAIN LEFT BRAIN ABSCESS DEEP. GRAM STAIN (Final [**2119-6-29**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2119-6-30**]): NO GROWTH. ANAEROBIC CULTURE: ___________________________________________ [**2119-6-28**] 10:15 pm SWAB Site: BRAIN LEFT ACCESS POINT. GRAM STAIN (Final [**2119-6-29**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2119-6-30**]): NO GROWTH. ANAEROBIC CULTURE: ___________________________________________ [**2119-6-28**] 10:30 pm SWAB Site: BRAIN LEFT BRAIN ABSCESS 2ND FOCUS. GRAM STAIN (Final [**2119-6-29**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE: ______________________________________________ ANAEROBIC CULTURE: __________________________________________ [**2119-5-31**] 7:35 am Blood (Toxo) TOXOPLASMA IgG ANTIBODY (Final [**2119-6-2**]): POSITIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. 29 IU/ML. Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml. TOXOPLASMA IgM ANTIBODY (Final [**2119-6-2**]): NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. [**2119-5-31**] 07:20PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test - NEG [**2119-5-31**] 07:42PM URINE HISTOPLASMA ANTIGEN-Test [**2119-5-31**] 07:20PM BLOOD CYSTICERCOSIS ANTIBODY-Test - NEG [**2119-5-31**] 07:20PM BLOOD B-GLUCAN-Test - NEG [**2119-6-2**] 10:55AM BLOOD HIV Ab- NEGATIVE [**2119-6-10**] 05:17AM BLOOD CD5-DONE CD23-DONE CD45-DONE HLA-DR[**Last Name (STitle) 7735**] [**Name (STitle) 7736**]7-DONE Kappa-DONE CD2-DONE CD7-DONE CD10-DONE CD19-DONE CD20-DONE Lambda-DONE [**2119-6-14**] 06:40AM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND MICROBIOLOGY - BLOOD CULTURES [**2119-6-23**] 9:00 pm BLOOD CULTURE X 2: NO GROWTH [**2119-6-22**] 12:39 pm BLOOD CULTURE X 2: NO GROWTH [**2119-6-18**] 10:00 am BLOOD CULTURE X 2: NO GROWTH [**2119-6-17**] 3:26 am BLOOD CULTURE X 2: NO GROWTH [**2119-6-16**] 8:14 pm BLOOD CULTURE X 2: NO GROWTH [**2119-6-15**] 9:02 am BLOOD CULTURE X 2: NO GROWTH [**2119-6-9**] 8:44 pm BLOOD CULTURE X 2: NO GROWTH [**2119-6-8**] 4:48 am BLOOD CULTURE X 2: NO GROWTH [**2119-6-4**] 9:36 pm BLOOD CULTURE X 2: NO GROWTH [**2119-5-31**] 7:35 am BLOOD CULTURE X 2: NO GROWTH [**2119-5-30**] 11:30 pm BLOOD CULTUREX 2: NO GROWTH LFTs [**2119-5-30**] 11:30PM BLOOD ALT-22 AST-26 AlkPhos-103 TotBili-0.3 [**2119-5-31**] 01:43AM BLOOD ALT-21 AST-27 AlkPhos-108 TotBili-0.3 [**2119-6-5**] 11:29AM BLOOD ALT-33 AST-25 AlkPhos-93 Amylase-54 TotBili-0.1 [**2119-6-8**] 04:48AM BLOOD ALT-89* AST-90* AlkPhos-82 TotBili-0.1 [**2119-6-9**] 04:57AM BLOOD ALT-126* AST-123* [**2119-6-10**] 05:17AM BLOOD ALT-144* AST-122* LD(LDH)-381* [**2119-6-11**] 05:21AM BLOOD ALT-158* AST-109* [**2119-6-12**] 05:34AM BLOOD ALT-179* AST-82* [**2119-6-13**] 05:49AM BLOOD ALT-173* AST-70* AlkPhos-112 TotBili-0.3 [**2119-6-14**] 06:39AM BLOOD ALT-173* AST-55* AlkPhos-116 TotBili-0.4 [**2119-6-15**] 06:07AM BLOOD ALT-117* AST-29 AlkPhos-105 TotBili-0.4 [**2119-6-16**] 05:44AM BLOOD ALT-125* AST-40 [**2119-6-17**] 03:27AM BLOOD ALT-249* AST-136* LD(LDH)-494* CK(CPK)-36* AlkPhos-89 TotBili-0.3 [**2119-6-19**] 05:53AM BLOOD ALT-185* AST-30 [**2119-6-20**] 05:00AM BLOOD WBC-12.4* RBC-3.99* Hgb-11.8* Hct-36.0* MCV-90 MCH-29.5 MCHC-32.7 RDW-13.1 Plt Ct-317 [**2119-6-21**] 05:47AM BLOOD ALT-229* AST-72* AlkPhos-104 [**2119-6-22**] 04:57AM BLOOD ALT-240* AST-56* AlkPhos-117 TotBili-0.3 [**2119-6-23**] 08:16AM BLOOD ALT-175* AST-47* AlkPhos-111 TotBili-0.5 [**2119-6-25**] 04:04AM BLOOD ALT-123* AST-33 AlkPhos-104 TotBili-0.4 [**2119-6-26**] 02:13AM BLOOD ALT-113* AST-31 AlkPhos-106 TotBili-0.3 [**2119-6-27**] 05:34AM BLOOD ALT-106* AST-33 AlkPhos-104 TotBili-0.4 URINALYSIS [**2119-6-24**] 04:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2119-6-23**] 08:58PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR [**2119-6-18**] 06:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2119-6-16**] 04:34PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2119-6-4**] 09:37PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR Brief Hospital Course: 18yo M with no PMH admitted for seizures, fever and AMS, found to have brain abscess, cultures positive for S. anginosus s/p I&Dx3; treatment course complicated by multiple drug allergies, and red man syndrome in setting of vancomycin infusion. # Brain Abscess: Pt initialy given vancomycin/ceftriaxone/flagyl for broad coverage and on [**2119-5-31**], the pt unerwent Burr hole and aspiration without complication. Pt given dilantin and keppra for seizure prophylaxis initialy. Brain abscess grew out strep anginosus. Pt had thorough workup to investigate etiology: panorex of teeth, TTE, TEE and CT A+P. CT A+P showed cecal thickening and typhlitis, possibly the original source of infection, although pt denied every having GI symptoms. After patient's initial post-op course, he developed daily fevers up to 103 ultimately attributed to antibiotic drug reaction. See below for antibiotic course. After a trial of several antibiotics, it was felt that he had a beta-lactam allergy and he was ultimately switched to vancomycin and flagyl which he ultimately tolerated well. Pt had repeat head imaging (head CT [**6-16**], head MRI [**2119-6-18**]) which demonstrated enlargement of the abscess. The patient was then taken for a second I&D ([**2119-6-21**]), via mini craniotomy. The patient tolerated this procedure well, and returned to the Medicine floor that day. Post-operative neurologic exam was within normal limits. Of note, abscess cultures were negative (including fungi and anaerobes). Repeat imaging on [**6-27**] with MRI suggested possible extension of the abscess again. The patient underwent third I&D on [**2119-6-28**]. No pus or abscess was found during this procedure (washings were negative) and his prior MRI findings were likely attributed to post-op changes rather then progressing abscess infection. Pt remained neurologically intact. #SURGICAL INTERVENTIONS FOR ABSCESS The pt underwent mutiple I&Ds for S. anginosus brain abscess: [**2119-5-31**], [**2119-6-21**], [**2119-6-28**]. Pt is due to get staples removed early [**2119-7-9**] (10 days since most recent I+D). # PHARMACOLOGIC TREATMENT OF ABSCESS/Red Man Syndrome/B-Lactam allergy: The pt was treated with numerous antimicrobial agents. Treatment course was complicated by drug-induced rashes and fevers. Pt was placed on empiric antibiotic therapy with vanc/ceftriaxone/flagyl until speciation was determined. Pt was then switched to Penicillin G. Due to rash, Penicillin was discontinued and he was then switched to ceftriaxone/flagyl. Patient's rash worsened and he had daily high fevers 103, and he was then switched to meropenem. Rash temporarily abated, but returned worse than before (morbilliform from head to toe, also with fevers). Meropenem was discontinued and pt was placed on vancomycin/flagyl. During his initial vancomycin infusion ([**2119-6-16**]), pt developed characteristic 'Red man Syndrome' with cehst pain, pruritis, redness, agitation during the infusion. The patient was transferred to the MICU for further observation and his vancomycin infusion rate was slowed down. He was initialy given solumedrol during his vanco infusions and that was then stopped as his clinical picture and rash improved. He was maintained on vancomycin (slow infusion over 3 hrs) and flagyl for the remainder of his hospital course and tolerated this well. The patient was discharged on vancomycin and flagyl, four week course from the date of third I&D ([**7-1**]- [**2119-7-26**]). Pt will continued to get weekly CBC with diff, BUN, Cr, Vanco trough, and close follow up with ID and neurosurgery. # VANCOMYCIN INFUSION REACTION: During patient's vancomycin infusion ([**2119-6-16**]), the patient became acutely agitated, tachypneic, and complained of worsened pruritus and sudden-onset chest pain with redness throughout body. The patient was diagnosed with "red man syndrome." The patient was transferred to the MICU for supervision of further infusions. Infusion rate was slowed (over 3hours). He was initialy "pre-treated" with diphenhydramine and methylprednisolone prior to vanco infusion, to further reduce rash and pruritus. Methylprednisolone was eventually discontinued and patient tolerated vancomycin slow infusions without difficulty. # TRANSAMINITIS: The patient had intermittently elevated LFTs. Transaminitis was likely due to drug reaction (phenytoin vs beta-lactams). RUQ u/s and abdominal CT demonstrated no abnormalities, and bilirubins were normal. LFTs trended down and stabalized while on vancomycin and flagyl. # EOSINOPHILIA: the patient had a eosinophilia, coincident with rash and transaminitis. Eosinophilia was attributed to drug allergy. Work up was negative for helminth infection, etc. # SEIZURE PROPHYLAXIS: The pt had an apparent seizure after his first I&D. He was placed on phenytoin and levacetiram for seizure prophylaxis. Due to concerns that phenytoin was contributing to his rash, fevers, and transaminitis, phenytoin was discontinued later in the hospital course. The patient was maintained on levacetiram throughout. He will follow up with neurosurgery to determine when he can stop this medication. # GENERAL INFECTIOUS WORK-UP: The patient underwent a thorough infectious work-up, including Panorex XRay, dental consult, TTE, TEE with bubble study, AbdCT, serial blood cultures, and assays. Abdominal CT with contrast was notable for typhlitis and prominent mesenteric, periaortic, inguinal and femoral lymph nodes. Testicular exam was normal. Flow cytometry was negative for a lymphoma/leukemia. True etiology of his strep anginosus brain abscess was unclear. [**Name2 (NI) **] CT A+P showed typhlitis, pt denied every having abdominal symptoms. Transitional Issues: -Needs staples removed [**2119-7-9**] -Will require 4 weeks of antibiotics as of [**7-1**]- [**2119-7-26**]. Pt will get weekly OPAT labs sent to [**Hospital **] clinic. -Currently on keppra 750mg [**Hospital1 **] for seizure prophylaxis. -Has allergy to B-lactams: morbilliform rash, LFTs, fevers Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain, headache or T > 38.3 Do not exceed 4g/day 2. LeVETiracetam 750 mg PO BID RX *levetiracetam 750 mg 1 Tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*2 3. Vancomycin 1250 mg IV Q 8H INFUSE OVER 3 HOURS 4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *Flagyl 500 mg 1 Tablet(s) by mouth three times a day Disp #*30 Tablet Refills:*4 RX *metronidazole 500 mg 1 Tablet(s) by mouth q 8 hrs Disp #*90 Tablet Refills:*1 5. Sarna Lotion 1 Appl TP [**Hospital1 **] RX *Sarna Anti-Itch 0.5 %-0.5 % apply liberally to areas of rash and peeling skin twice a day Disp #*600 Milliliter Refills:*1 6. Heparin Flush PICC line maintenance and Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent. Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 7. Outpatient Lab Work Check once a week: CBC with diff, BUN, Cr, Vanco-trough. Fax to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 17715**]. 8. Vancomycin Vancomycin 1250 mg IV Q 8H. INFUSE OVER 3 HOURS. Disp: 4 week's supply. Premedicate with benadryl 25mg PO. 9. DiphenhydrAMINE 50 mg PO Q8H Give prior to vancomycin dose HOLD FOR SEDATION RR < 12 Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Intracranial abscess hyperexia tonic clonic seizures beta lactam allergy "red man syndrome" Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 111991**], Thank you for the privilege of participating in your care. You were admitted to the [**Hospital1 69**] because you were found to have an infection in your brain (an "abscess"). We still do not know where this infection came from. We do not know why you developed this infection in your brain. We performed a very thorough workup to investigate where this infection might have come from. A CT scan of your abdomen showed a possible inflammation or infection which might have been the original source of infection. The imaging of the teeth, chest, heart, rest of your body is all reassuring. The brain abscess required treatment with surgery and antibiotics. After your first surgery, imaging showed that the infection could be getting bigger. For this reason, you had to have two more surgeries. The most recent surgery was reassuring that the infection appears to be gone at this time. Laboratory cultures from the first surgery showed infection with bacteria. Cultures from the second and third operation did not grow any bacteria, indicating that the antibiotics were treating the infection well. Also, the Neurosurgeons did not see any infection during the third surgery. This is strong evidence that the infection is disappearing. During your hospitalization, you had a very itchy rash, and many high fevers. The rash and fevers were most likely caused by the antibiotics you took after your first surgery. These antibiotics that you seem to have an adverse reaction to are: penicillin, ceftriaxone and meropenem. You are currently on vancomycin and flagyl antibiotics that are fighting the infection. You are tolerating these medications well. You will need to continue the vancomycin and flagyl for a total 4 week course since your last surgery. Thus, you should take it through [**7-26**]. The infectious disease doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 111992**] [**Name5 (PTitle) **] when to stop these medications. When you leave the hospital, it is very important that you continue to take ALL antibiotics as prescribed. If you do not take all your medicines, it is possible that the infection could come back. A nurse will come to your home to help you with the medications. It is also important to take the medication Keppra, 1 pill twice a day. This medication will prevent seizures. You should continue this medication until the neurosurgeons tell you that you can stop. It will likely be for several months. Please schedule an appointment with your primary care doctor, Dr. [**Last Name (STitle) **]. Also, please go to the appointments scheduled with the Neurosurgery and Infectious Disease teams. It is very important that you go to these appointments. Your doctors [**Name5 (PTitle) 9004**] to be sure that you continue to recover well. You will also have more imaging of your head, to be sure that the infection is getting smaller. Here are some instructions from the Neurosurgery team: - your sutures should stay clean and dry until they are removed. - do not wash your head where the wound is until [**7-8**]. (10 days after surgery) At that point you can then wash your hair. ?????? Have a friend or family member check the wound for signs of infection such as redness or drainage daily. ?????? Exercise should be limited to walking; no lifting >10lbs, straining, or excessive bending. ?????? DO NOT take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. until follow up. ?????? Do not drive until your follow up appointment. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 4676**] to schedule an appointment with one of the Physician Assistant in [**7-18**] days from the time of surgery for staple removal ([**7-9**] you will be due to have the sutures removed). ??????You will need a CT of the brain with contrast in the future. You have an appointment scheduled on [**7-19**] per the neurosurgeons. [**Telephone/Fax (1) 1669**] is the office phone number for the neurosurgeons. Please see appointment time and date below. ?????? You need to follow up with Infectious Disease on [**7-5**] with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] and Dr. [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) **]. You need the following labs sent weekly to them: CBC with diff, BUN, Cr, Vanco trough, fax to: Dr [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1419**]. The Visiting nurses will be notified to do this for you. Department: INFECTIOUS DISEASE When: WEDNESDAY [**2119-7-5**] at 11:30 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: RADIOLOGY When: WEDNESDAY [**2119-7-19**] at 9:15 AM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: WEDNESDAY [**2119-7-19**] at 10:45 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**2119-7-21**], 8:30am Infectious Disease Office [**Hospital **] Medical Building, [**Last Name (NamePattern1) 439**], Basement [**Telephone/Fax (1) 457**] [**2119-8-17**] 8:00am with Dr [**Last Name (STitle) 1206**]. Neurologist. [**Hospital Ward Name 23**] Building clinical center, [**Location (un) **].

[ "520.6", "995.27", "041.02", "348.5", "693.0", "780.39", "785.6", "431", "348.89", "285.9", "288.3", "324.0", "E930.8", "288.50", "458.9" ]

icd9cm

[ [ [] ] ]

[ "02.12", "38.93", "00.39", "88.72", "01.39" ]

icd9pcs

[ [ [] ] ]

19585, 19668

12260, 17955

319, 493

19804, 19804

3308, 4090

23520, 25685

1804, 1822

18332, 19562

19689, 19783

18302, 18308

19955, 23497

1837, 2561

17976, 18276

272, 281

2591, 3289

521, 1538

4099, 12237

19819, 19931

1560, 1628

1644, 1788

53,556

162,204

40515

Discharge summary

report

Admission Date: [**2155-5-27**] Discharge Date: [**2155-6-17**] Date of Birth: [**2085-9-15**] Sex: F Service: SURGERY Allergies: morphine Attending:[**First Name3 (LF) 2836**] Chief Complaint: Jaundice, abdominal pain Major Surgical or Invasive Procedure: [**2155-5-27**]: ERCP [**2155-5-29**]: IR- guided biliary drain placement [**2155-6-3**]: Endoscopic ultrasound with biopsy [**2155-6-9**]: Open cholecystectomy, gastrojejunostomy and hepaticojejunostomy History of Present Illness: 69 yo F w/ family history of pancreatic cancer presents with chronic mid abdominal cramps for several months since esophageal hernia repair in [**2154-8-21**], not made worse or better with food or bowel movements, and non-radiating. She's had 35lb weight loss since then, decreased appetite, and alternating constipation/diarrhea. About 9 days ago, she developed icterus and jaundice and was referred to [**Hospital 7168**] hospital. Labs revealed obstructive cholangiopathy (TBili 15.1), and mild hypovolemic hyponatremia (S-Na 128->132). Outside hosptial Abdominal CT [**2155-5-25**] showed marked Biliary Dilation of CBD and PD as well as hypodensities in the tail and head of the pancreas, and no obvious liver mets. An ERCP was attempted at outside hospital and was unsuccessful. She was referred to [**Hospital1 18**] for reattempt. This was done today, but was unsuccessful after small sphincterotomy. The General Surgery was consulted for possible surgical resection. Past Medical History: - Hypertension - Diabetes Type 2: (Dx'd 6 wks ago) - Coronary Artery Disease - Hyperlipidemia - Hypothyroidism - H/O Pancreatitis - s/p Hysterectomy & USO - s/p L knee surgery - s/p R eye surgery - Mild anxiety disorder Social History: Divorced. Lives with boyfriend. Former 30 pk*yr history of smoking, quit 20yr ago. Rare ETOH (1 drink every other week). Three children involved in her life -- all named as HCP (one lives in [**Name (NI) **]). Family History: Father - CAD (died 50s) Mother - DM, CAD, CVA Had NINE siblings: Pancreatic CA - brother Breast CA - sister, niece [**Name (NI) **] CA - brother CAD - brother, sister Physical Exam: Admission Exam: Jaundiced, in NAD. Pain = "[**4-29**]" Afeb, 159/80, 69, 16 99% RA (+) Icterus, OP clear, (+) temporal/fascial wasting, no [**Doctor First Name **] Lungs: CTA bilaterally Cor: RRR no audible MRG Abd: soft, non-tender, no R/G, no palpable masses or HSM Ext: no edema, clubbing, cyanosis Skin: Jaundiced Neuro: A & O x three, nl speech/cognition Lymph: no palpable LN On Discharge: VS: 98.4, 90, 130/66, 20, 97% RA Gen: AAO x 3, NAD CV: RRR, no m/r/g Lungs; Diminished throughout Abd: Bilateral subcostal incision open to air with stri strips and c/d/i Extr: Warm, no c/c/e Pertinent Results: [**2155-5-26**] CBC: WBC 4.7, HGB 11.5, HCT 33.7, PLT 233, INR 1.1 [**2155-5-27**] Chem 7: Na 132, K 3.5, Cl 100, HCO3 26, BUN 6, Cr 0.6, Glu 155 [**2155-5-27**] Other labs: Ca 8.4, TBili 15.1, DBili 9.5, AST 89, ALT 100, TP 5.6, Albumin 2.2, AlkPhos 305, Lip 20 [**2155-6-13**] 04:02AM BLOOD WBC-6.7 RBC-2.60* Hgb-8.5* Hct-24.9* MCV-96 MCH-32.8* MCHC-34.2 RDW-18.5* Plt Ct-265 [**2155-6-16**] 04:23AM BLOOD Glucose-131* UreaN-16 Creat-0.3* Na-132* K-4.0 Cl-102 HCO3-23 AnGap-11 [**2155-6-15**] 04:51AM BLOOD TotBili-5.0* DirBili-3.4* IndBili-1.6 [**2155-5-27**] ERCP: Impression: Limited exam of the esophagus showed hiatus hernia. Limited exam of the stomach was normal. Dudoenum was deformed due to involvement with tumor. Ampulla and duodenum were involved with tumor. Cannulation of the biliary duct was unsuccessful with a sphincterotome using a free-hand technique. Contrast medium was injected and partial oacification of pancreatic duct was achieved. A small precut was performed to facilitate biliary access,however this was unsuccessful [**2155-6-3**] EUS: IMPRESSION: Mass #1: A 45mm X 30 mm 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. FNA of the mass was performed and aspirate was sent for cytology. Mass #2: The was a second 26mm x 26mm mass noted in the body of the pancreas. This mass likely represents a second tumor deposit and may involve the splenic vein. Vessels [Venous structures]: Due to the distorted anatomy, the portal vein could not be fully assessed. Vessels [Arterial]: The celiac artery take-off from the Aorta was imaged. This did not appear to be invaded by the mass. The superior mesenteric artery take-off from the Aorta was imaged. This did not appear to be invaded by the mass. The superior mesenteric artery was partially imaged from the second/third part of the duodenum. The mass did not appear to invade the visualized superior mesenteric artery. Pancreatic parenchyma: The pancreas appeared to be mostly replaced by the tumors. The parenchyma showed marked atrophy. The remainder of the EUS exam was limited due to the inability to enter the second/third duodenum. Additionally, due to the patient's fluctuating oxygen saturations throughout the procedure, examination time was limited and attention was focused to sampling the pancreatic head lesion. [**2155-5-27**] ABD CT: IMPRESSION: 1. 2.6-cm heterogeneously enhancing pancreatic head mass concerning for pancreatic adenocarcinoma with resultant massive dilatation of the CBD, distention of the gallbladder, and intrahepatic biliary ductal dilatation. 2. Abnormal heterogeneous enhancement of a 2.8-cm portion of the pancreatic body, concerning for multifocal involvement vs. area of pancreatitis with resultant splenic venous thrombosis and collateral formation. 3. Primary tumor abuts SMV with approximately 25% involvement. Remainder of the vasculature appears free of tumors aside from the gastroepiploic artery. 4. Conventional hepatic and vascular anatomy with the exception of duplicated right renal arteries. [**2155-6-5**] CT CHEST: IMPRESSION: 1. Small non-hemorrhagic bilateral pleural effusions with bibasilar atelectasis, left greater than right. 2. Left upper lobe residual consolidative abnormality may be resolving pneumonia or hemorrhage. 3. No strong evidence of metastasis. A 4-mm right middle lobe nodule is indeterminate. Cytology Report PANCREATIC HEAD MASS Procedure Date of [**2155-6-3**] REPORT APPROVED DATE: [**2155-6-5**] SPECIMEN RECEIVED: [**2155-6-4**] [**-1/2048**] PANCREATIC HEAD MASS SPECIMEN DESCRIPTION: Received in cytolyt Prepared 1 ThinPrep slide CLINICAL DATA: 70 yo with 2.6 cm heterogeneously enhancing pancreatic head mass. There was a second mass at the panc body concerning for a second tumor deposit. ERCP not successful on [**2155-5-27**] due to mass involvement of duodenum and ampulla. PTBD placed by IR but not able to traverse stricture or obtain cytology. PREVIOUS SPECIMENS: [**2155-6-3**] [**-1/2027**] COMMON BILE DUCT BRUSHINGS REPORT TO: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 1982**] DIAGNOSIS: EUS, Pancreatic head mass: POSITIVE FOR MALIGNANT CELLS, consistent with adenocarcinoma. Brief Hospital Course: 69 year old woman who presented with obstructive jaundice due to a tumor involving the pancreas and duodenum. Ms. [**Known lastname 88723**] presented with jaundice and elevated total bilirubin. Imaging showed a mass at the head of the pancreas. Patient underwent several attempts at ERCP prior to arrival. On [**5-29**] she underwent placement of an external drain with some improvement in her liver function tests and bilirubin. On [**6-2**] and [**6-4**] she went back to the IR suite for internalization of her drain, though both attempts were unsuccessful due to being unable to pass the pancreatic blockage. There was a high suspicion for malignancy. Different samples were sent to evaluate this. IR sent brushing from [**6-2**] and biopsy of CBD and an EUS with biopsy was performed on [**6-3**]. She will need follow-up with Oncology, Dr. [**Last Name (STitle) 1852**], as the cytology from the EUS was consistent with pancreatic adenocarcinoma. Shortly after the placement of the external biliary drain on [**5-29**], she became hypotensive and hypoxic. She was placed on neo synephrine and a non-rebreathe in the PACU. She was fluid resuscitated. Her initial lactate was 7.1. She was then transferred to the ICU. Her pressors were switched to Levophed. She was initially covered with gentamicin, vancomycin, and Zosyn. Her biliary and blood cultures grew out E. coli. Out of concern for ESBL, her antibiotics were changed to meropenem and she was continued on this (she had severe sepsis). She developed thrombocytopenia. The etiology of this was likely multifactorial. Her SQ heparin was stopped. Platelets began to improve, although so did her sepsis. A HIT Ab was sent and returned negative. Her home antihypertensives were initially held while her blood pressures were low. The patient was stabilized in the ICU and was transferred back on the floor in stable condition. On [**2155-6-9**], the patient was transferred to pancreatico-biliary service for elective surgical resection. On [**6-9**], she underwent hepatojejunostomy, gastrojejunostomy and open cholecystectomy, which went well without complication (reader referred to the Operative Note for details). In the PACU, the patient desaturated, she was re-intubated and transferred in ICU. In ICU the patient was stabilized, extubated on POD # 1 and transferred on the floor. The patient arrived on the floor NPO with NGT, on IV fluids, TPN and antibiotics (Meropenem), with a foley catheter, and Dilaudid PCA for pain control. The patient was hemodynamically stable. Neuro: The patient received Dilaudid PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Cardiac echocardiogram ([**2155-5-30**]) revealed normal LEVF > 55%. Pulmonary: The patient was re intubated post operatively [**1-22**] thick secretions and hypoxemia. She was extubated on POD # 1, and remained stable from pulmonary stand point until discharge. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was started TPN on HD # 12, and continued on until HD # 21 (POD # 7). Post-operatively, the patient was made NPO/NGT with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. TPN was discontinued on POD # 7, the patient able to tolerate regular diet prior discharge. ID: The patient underwent two weeks course of Meropenem for E-coli bacteremia. Surveillance blood cultures were negative. The patient's white blood count and fever curves were closely watched for signs of infection. Wound was evaluated daily and no signs or symptoms of infection were noticed. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. When on regular diet, the patient was restarted on her oral Glyburide. The patient was recommended to follow up with her Primary Care after discharge to continue monitoring her blood sugar level. Hematology: The patient developed thrombocytopenia with platelets of 83 on HD # 5, a HIT Ab was sent and returned negative. Platelets level improved and was WNL prior discharge. The patient was transfused with 2 units of plasma [**1-22**] increased INR (1.9). Prophylaxis: The venodyne boots were used during this stay; patient 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 with bystander assist, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Atenolol 50mg daily Diltiazem LA 300mg daily Omeprazole 40mg daily Quinapril 20mg daily Rifaximin 550mg [**Hospital1 **] Pravastatin 20mg daily Levothyroxine 125mcg daily Reglan 10mg TID Vitamin D 400IU daily Polyethylene Glycol 1 pk [**Hospital1 **] Senna 2 tabs qhs prn constipation Additional home meds on hold now: Glyburide 10mg [**Hospital1 **] ASA 325mg daily Omega 3FA daily Xanax prn anxiety Probiotics 1 tab daily Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 4. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 10. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 11. diltiazem HCl 300 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 12. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. 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* 14. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 15. One Touch Ultra System Kit Kit Sig: One (1) kit Miscellaneous qam. Disp:*1 kit* Refills:*0* 16. lancets Misc Sig: One (1) lancet Miscellaneous qam. Disp:*1 box* Refills:*2* 17. test strip Sig: One (1) strip qam. Disp:*1 box* Refills:*2* 18. Alcohol Pads Pads, Medicated Sig: One (1) pad Topical qam. Disp:*1 box* Refills:*0* Discharge Disposition: Home With Service Facility: Community VNA, [**Location (un) 8545**] Discharge Diagnosis: Pancreatic adenocarcinoma Biliary obstruction E coli septicemia Thrombocytopenia Bilateral pleural effusions Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-29**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 8770**] Date/Time:[**2155-6-25**] 3:00 Provider: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3751**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2155-6-25**] 3:00 [**Hospital Ward Name 23**] 9, [**Hospital Ward Name **] . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 2998**] Date/Time:[**2155-7-2**] 12:45 [**Hospital1 **] [**Location (un) 620**], [**Street Address(2) 3001**], [**Location (un) 620**], [**Numeric Identifier 3002**] . Please follow up with Dr. [**Last Name (STitle) 88724**] (PCP) in [**12-22**] weeks after discharge. Call [**0-0-**] Dr.[**Name (NI) 88725**] office to schedule a follow up appointment. Completed by:[**2155-6-17**]

[ "285.9", "E928.8", "780.52", "511.9", "786.09", "995.92", "564.09", "250.00", "287.5", "794.31", "E849.9", "276.1", "401.9", "038.42", "157.8", "414.01", "790.92", "244.9", "553.3", "785.52" ]

icd9cm

[ [ [] ] ]

[ "99.15", "51.22", "52.11", "51.14", "51.37", "51.98", "38.97", "44.39", "51.85" ]

icd9pcs

[ [ [] ] ]

14481, 14551

7189, 12202

293, 499

14704, 14704

2790, 2952

15962, 16825

1996, 2165

12678, 14458

14572, 14683

12228, 12655

14855, 15434

15449, 15939

2180, 2563

2577, 2771

229, 255

527, 1507

14719, 14831

1529, 1751

1767, 1980

2964, 7166

54,325

137,302

53633

Discharge summary

report

Admission Date: [**2122-4-21**] Discharge Date: [**2122-4-29**] Date of Birth: [**2056-4-20**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 34120**] Chief Complaint: nausea, vomiting, fatigue, abdominal distention Major Surgical or Invasive Procedure: Paracentesis [**2122-4-22**] Central line placement [**2122-4-21**] PICC line placement [**2122-4-24**] History of Present Illness: This is a 65 year-old Female with a PMH significant for poorly differentiated metastatic adenocarcinoma of unknown primary with neuroendocrine features (diagnosed in [**12/2120**] s/p 4-cycles of chemotherapy with most recent administration of cisplatin and etoposide on [**2122-4-15**]; recent PET-CT imaging showing overall disease progression), vitamin B12 deficiency, hypertension, hyperlipidemia, rosacea and reflux esophagitis who presents with several days of fatigue in the setting of nausea, emesis and poor PO intake. . Again, the patient has had three sets of cycled chemotherapy and recently started her third cycle of cisplatin and etoposide (on [**2122-4-13**]) with her last dosing on [**2122-4-15**]. On the day of her third dose she had noted some constipation, abdominal distention and fatigue with decreased sleep and took stool softeners with some avail. Her weight was also noted to up 5-lbs from baseline (weight from [**2122-3-19**] 62.1 kg, [**2122-4-9**] 66.0 kg). On [**2122-4-17**], she had developed some nausea with non-bloody, non-bilious, food particulate emesis and loose, non-bloody stools despite her prior constipation concerns. She discussed these findings with her Oncologist, but had no abdominal pain or fevers; her PO intake had tapered. On [**2122-4-21**], she spoke with the on-call provider from [**Name9 (PRE) 2287**] who instructed her to present to the [**Hospital1 18**] ED given that her PO intake had been poor, her fatigue had worsened to the point of her being bedbound and her nausea with emesis had persisted. She also noted some urinary frequency and urgency. She has had no recent sick contacts, upper respiratory or cough symptoms. No neck pain or meningismus; no photophobia. . Of note, she also underwent therapeutic paracentesis on [**2122-4-10**] with removal of 4 liters of serosanguinous ascites which showed negative cytology. This was performed given on-going worsening abdominal distention and ascites with a significant decrease in PO intake. Since her therapeutic tap she has noted no increase in intra-abdominal distention or abdominal pain. . On arrival to the [**Hospital1 18**] ED, initial VS 99.5 103 112/45 16 99% RA. Her laboratory studies were notable for WBC 0.1 (36% neutrophils, ANC 36), HCT 23.6%, PLT 132. Serum chemistry revealed sodium 132, potassium 2.7, BUN 40, creatinine 1.5 (baseline 0.8). INR 1.0. Lactate 1.8. Troponin < 0.01. LFTs: AST 45, ALT 30, AP 307, T-bili 0.8, Alb 2.6. A CXR showed no evidence of consolidation. in the ED she received 4L normal saline with minimal UOP. She received Cefepime 2 grams IV x 1 for neutropenic fever concerns. She received Magnesium sulfate 2 grams IV x 1 and Potassium chloride 40 mEq PO, 10 mEq IV x 1 and Zofran 4 mg IV x 1 and Acetaminophen 1000 mg PO x 1. Of note, at 15:00 she developed fever to 102.9 with rigors and tachycardia to the 130s. A right IJ central venous catheter was placed and pulled back 2-cm to position in the ED. Prior to transfer, VS 98.3 107 106/67. . On arrival to the [**Hospital Unit Name 153**], she feels improved since arrival to the ED. She denies worsening abdominal discomfort, but has had minimal urine output. . ROS: Denies headaches or vision changes. No cough or upper respiratory symptoms. Denies chest pain, dizziness or lightheadedness; no palpitations. Denies shortness of breath. No nausea or vomiting, denies abdominal pain. No dysuria or hematuria. Denies muscle weakness, myalgias or neurologic complaints. Past Medical History: ONCOLOGIC HISTORY: Presented with abdominal distention, early satiety and anemia in 10/[**2120**]. EGD ([**2120-12-20**]) demonstrated gastritis that was H.pylori positive. CT imaging in [**12/2120**] revealed inumerable liver metastases and omentum cake with marked ascites and small left adrenal mass. Cytology was positive for malignant cells. Biopsy of a liver lesion noted poorly differentiated carcinoma with neuroendocrine features (strongly positive for CK7, TTF-1, synpatophysin and focal positivity for chromogranin and [**Last Name (un) **]-31, but CK-20, CDX-2, S100 negative. The immunohistochemical profile fit lung carcinoma, but CT chest imaging revealed multiple small pulmonary nodules without dominant lung mass. In [**1-/2121**] she had large volume paracentesis and underwent initiation of chemotherapy ([**2121-1-15**]) - Carboplatin AUC 5 and Paclitaxol (therapy from [**2121-1-15**] to [**2121-5-1**] for 4-cycles) - Carboplatin and Doxil (for widespread recurrence, [**2121-9-4**] to [**2121-11-6**] for 3-cycles) - Gemcitabine and Docetaxol (for disease progression, [**2121-12-4**] to [**2122-4-2**] for 6-cycles) - Cisplatin and Etoposide (began cycling on [**2122-4-13**], last dosing [**2122-4-15**]) . PAST MEDICAL & SURGICAL HISTORY: 1. Poorly differentiated metastatic adenocarcinoma of unknown primary 2. Hypertension 3. Hypercholesterolemia 4. Rosacea 5. Neuropathy (from chemotherapy) 6. Reflux esophagitis, GERD (EGD negative in [**2115**] showing gastritis) Social History: The patient is never married. She worked as a free-[**Doctor First Name **] financial writer out of her home in [**Location (un) 16174**], MA. She is close with her sister, [**Name (NI) 5969**] (lives in [**Location 5110**], MA). Never smoker. Rare and only ocassional alcohol use. Denies recreational substance use. Lives with her sister and relies on her for ADL needs. Family History: Mother died of leukemia. Father died of heart failure. [**Doctor First Name 5969**] is healthy but had a hysterectomy for endometriosis. No family history of breast or ovarian cancer. Physical Exam: ADMISSION EXAM: VITALS: 98.6 96/54 99 16 98% 3L NC GENERAL: Appears in no acute distress. Interactive, but overall lethargic but arousable. Appears older than stated age. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes dry without plaques or exudates. NECK: supple without lymphadenopathy. JVD not elevated. CVS: Sinus tachycardic with normal rhythm, without murmurs, rubs or gallops. S1 and S2 normal. RESP: Decreased breath sounds at bases bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. Stable inspiratory effort. ABD: soft, diffusely minimally tender, moderately distended, with hypoactive bowel sounds. No peritoneal signs. Marked fluid wave. Non-tense. EXTR: no cyanosis, clubbing; 2+ peripheral pulses; bilateral pitting edema to the thighs with some pre-sacral edema NEURO: CN II-XII intact throughout. Alert and oriented x 3. Strength 4/5 bilaterally limited by cooperation, sensation grossly intact. Gait deferred. RECTAL: deferred given neutropenia . DISCHARGE EXAM: VS- Tm/c 97.6 BO 106/56 HR 104 RR 16 O2 98% RA I/O- 1080/2050 Gen- pale, cachectic female in NAD HEENT- sclera anicteric, PERRL, EOMI, moist mucous membranes without erythema, exudate or lesions Neck- no palpable lymphadenopathy CV- RRR, normal S1/S2, no m/r/g Pulm- CTA, decreased breath sounds at bilateral bases, no wheezes, ronchi or rales Abd- +BS, soft, nontender, +tympany, no heptosplenomegaly palpable, no rebound/guarding Ext- WWP, 2+ edema to knees bilaterally, 2+ DP/PT pulses Neuro- A+Ox 3, CN intact, strength 5/5 bilaterally in upper and lower extremities Access- Site of prior R IJ c/d/i, PICC site c/d/i Pertinent Results: Lab Results on Admission: WBC-0.1*# RBC-2.54*# Hgb-8.3*# Hct-23.6*# MCV-93 MCH-32.6* MCHC-35.0 RDW-16.6* Plt Ct-132*# Neuts-36* Bands-0 Lymphs-64* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] Plt Smr-LOW Plt Ct-132*# PT-11.1 PTT-22.7* INR(PT)-1.0 Fibrino-507*# FDP-10-40* Glucose-130* UreaN-40* Creat-1.5* Na-132* K-2.7* Cl-88* HCO3-29 AnGap-18 ALT-30 AST-45* AlkPhos-307* TotBili-0.8 LD(LDH)-842* Lipase-17 cTropnT-<0.01 Albumin-2.6* Calcium-8.4 Phos-3.4 Mg-1.6 Hapto-335* [**2122-4-21**] 11:39AM BLOOD Lactate-1.8 [**2122-4-21**] 08:19PM BLOOD Lactate-0.8 [**2122-4-21**] 08:19PM BLOOD O2 Sat-78 [**2122-4-21**] 08:19PM BLOOD freeCa-1.02* URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009 Blood-NEG Nitrite-NEG Protein-30 Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0 UreaN-510 Creat-43 Na-27 K-37 Cl-56 Osmolal-381 . Labs on discharge: WBC-15.3* RBC-3.03* Hgb-8.8* Hct-28.3* MCV-93 MCH-29.2 MCHC-31.2 RDW-16.8* Plt Ct-88*# Neuts-72* Bands-2 Lymphs-9* Monos-11 Eos-0 Baso-1 Atyps-2* Metas-0 Myelos-1* Promyel-2* Glucose-90 UreaN-17 Creat-1.0 Na-135 K-3.0* Cl-99 HCO3-29 AnGap-10 Calcium-7.8* Phos-2.9 Mg-1.5* . . MICROBIOLOGY: [**4-21**] Blood Culture, Routine (Preliminary): KLEBSIELLA OXYTOCA. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA OXYTOCA | AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [**2122-4-22**]): GRAM NEGATIVE ROD(S) [**4-21**] Blood Culture STREPTOCOCCUS INFANTARIUS SSP. COLI (STREPTOCOCCUS BOVIS). CLINDAMYCIN MIC <= 0.12 MCG/ML. ESCHERICHIA COLI. FINAL SENSITIVITIES. KLEBSIELLA OXYTOCA. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS | ESCHERICHIA COLI | | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- <=0.25 S CLINDAMYCIN----------- S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- <=0.25 S PENICILLIN G----------<=0.06 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ <=1 S Aerobic Bottle Gram Stain (Final [**2122-4-22**]): GRAM POSITIVE COCCI IN PAIRS AND IN SHORT CHAINS. GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [**2122-4-22**]): GRAM NEGATIVE ROD(S). [**4-21**] Urine culture- no growth [**4-22**] Blood culture- no growth [**4-23**] Blood culture- no growth . IMAGING: . [**2122-4-6**] FDG TUMOR IMAGING (PET-CT) - Significant progression of disease burden since the examination from [**2122-1-28**] with worsening peritoneal carcinomatosis, ascites, liver metastases, and pulmonary nodules. Mild worsening of right hydroureteronephrosis. . [**2122-4-10**] PARACENTESIS DIAG/THERA - Uncomplicated ultrasound-guided therapeutic and diagnostic paracentesis, with removal of 4.0 liters of serosanguinous ascites. Ascites fluid with negative cytology. . [**2122-4-21**] CHEST (PA & LAT) - The lungs are clear. Cardiac silhouette is within normal limits. Osseous and soft tissue structures are unremarkable. Right central line with tip projecting over the mid-superior vena cava. . [**2122-4-21**] CT ABD & PELVIS W/O CON - Large ascites with layering dependent hematocrit level consistent with hemoperitoneum. The source of bleeding is not identified on this examination, though the patient is known to have intraperitoneal metastatic disease. Findings again consistent with known widely metastatic carcinoma of unknown origin, with probable interval progression of liver masses, and redemonstration of adnexal mass, multiple omental masses, and peritoneal implants consistent with metastatic disease. Bilateral hydronephrosis and proximal hydroureter to the level of the pelvis. Delineation is limited on this non-contrast examination, but the fibroid uterus and pelvic metastatic deposits may be contributing to progressive ureteral dilation. . [**2122-4-22**] 2D-ECHO - The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . [**2122-4-23**] PORTABLE ABDOMEN ?????? No evidence of free air. Gas-distended but not dilated transverse colon noted. Several air-fluid levels noted in the colon. . Brief Hospital Course: 65yo F with a PMH significant for poorly differentiated metastatic adenocarcinoma of unknown primary with neuroendocrine features s/p cisplatin/etoposide on [**2122-4-15**] presenting with febrile neutropenia. . # SEVERE POLYMICROBIAL SEPSIS, FEBRILE NEUTROPENIA - Presented with nausea, emesis and neutropenic fevers. Patient initially stabilized in the ICU given septic shock. She was broadly covered, then narrowed to vancomycin/ceftriaxone once cultures grew pansensitive klebsiella and streptococcus. Source of GNR, GPC bacteremia appeared to be biliary or intra-abdominal given her peritoneal carcinomatosis and implants resulting in probable bacterial translocation and seeding. A 2D-Echo was negative for valvular vegetations. Vancomycin was discontinued once counts recovered and patient was discharged to rehab with plan to continue IV ceftriaxone for total of 14 days antibiotic therapy (ending [**2122-5-5**]). . # ASCITES- Patient has known chronic ascites. She had increased abdominal girth after aggressive fluid resuscitation in ICU for early goal directed therapy. She had no evidence of SBP. She underwent therapeutic ultrasound guided paracentesis on [**4-23**] and [**4-29**] with improvement in shortness of breath and abdominal distension. . # ACUTE RENAL INSUFFICIENCY, METABOLIC DERANGEMENTS - Patient presented with acute elevation in creatinine to 1.5 with BUN 40 in the setting of septic shock. Following volume resuscitation, patient's creatinine returned to baseline (0.8-1.1) and remained there for the rest of hospitalization. . # LEUKOPENIA, ACUTE ON CHRONIC NORMOCYTIC ANEMIA, THROMBOCYTOPENIA - Patient required PRBC and platelet transfusions during admission secondary to myelosuppressive therapy. Patient received neupogen injections daily until neutropenia resolved. . # POORLY DIFFERENTIATED METASTATIC ADENOCARCINOMA OF UNKNOWN PRIMARY - Notable for neuroendocrine features. Currently on cycle 3 of carboplatin etoposide given [**4-15**]. Followed by Dr. [**First Name (STitle) 2405**]. . # CHEMOTHERAPY-INDUCED NEUROPATHY - Secondary to Taxol therapy with notable improvement on Gabapentin. She has also been maintained on Vitamin B6 therapy. Her Gabapentin was continued at 600 mg daily (patient reports taking it only once a day). Her pyridoxime was initially held, but restarted once she was transferred to the floor. . # HYPERTENSION - Presented with hypotension in the setting of presumed infection, neutropenic fever. Not currently on anti-hypertensive agents per her outpatient records. Blood pressure well controlled throughout admission. . # TRANSITIONAL ISSUES - - ceftriaxone to be continued through [**2122-5-5**] (PICC can be removed thereafter) *** if patient discharged from rehab prior, PICC can be removed and patient can be sent home on oral levofloxacin to be continued through [**2122-5-5**]*** - will follow-up with Dr. [**First Name (STitle) 2405**] regarding further chemotherapy - discharged on once daily lasix given volume overload secondary to aggressive ICU volume resuscitation and chronic ascites Medications on Admission: 1. Omeprazole 20 mg EC PO daily 2. Cholecalciferol-vitamin D3 1000 units PO daily (not always taking) 3. Gabapentin 600 mg PO daily 4. Pyridoxine 50 mg PO daily (not always taking) Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. gabapentin 600 mg Tablet Sig: One (1) Tablet PO once a day. 4. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 5. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 7 days: ending [**2122-5-5**]. Discharge Disposition: Extended Care Facility: [**Hospital1 19286**] Discharge Diagnosis: Primary diagnosis: # Febrile neutropenia (fever with low blood counts) # Bacteremia Secondary diagnosis: # Metastatic adenocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you during your recent admission to [**Hospital1 18**]! You were admitted with an infection in your bloodstream. You were placed on IV antibiotics and initially watched in the intensive care unit. You improved on antibiotics, and will continue these antibiotics for a total of 2 weeks. Your blood counts improved with time and an injection that stimulated your bone marrow. You required several transfusions of blood. You were given a diuretic, lasix, to help get excess fluid off of your legs. In addition, you had a procedure to take fluid out of your abdomen. The physical therapists felt that you were too weak to return home, and would benefit from a short stay at rehab to help you get stronger. The following changes have been made to your medication regimen: - START lasix by mouth once a day - START ceftriaxone (an antibiotic) through [**2122-5-5**]- If you are discharged from rehab prior to [**5-5**], you can just take an oral antibiotic (levaquin) through the above date. Followup Instructions: Monday [**2122-5-4**] @ 10:00 AM Follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2405**] at [**Location (un) **] [**Location (un) 2274**]

[ "E933.1", "785.52", "266.2", "276.8", "284.11", "199.1", "272.4", "285.9", "401.9", "789.59", "197.7", "288.00", "287.5", "584.9", "197.6", "995.92", "357.7", "038.9" ]

icd9cm

[ [ [] ] ]

[ "54.91", "38.93" ]

icd9pcs

[ [ [] ] ]

17526, 17574

13663, 16740

354, 460

17752, 17752

7782, 7794

18988, 19174

5897, 6082

16972, 17503

17595, 17595

16766, 16949

17935, 18965

6097, 7124

9175, 13640

7140, 7763

266, 316

8830, 9131

488, 3973

17701, 17731

17614, 17680

7808, 8811

17767, 17911

3995, 5492

5508, 5881

1,271

110,426

46443

Discharge summary

report

Admission Date: [**2160-1-28**] Discharge Date: [**2160-1-29**] Date of Birth: Sex: F Service: General Cardiology NOTE: This dictation will cover the period from the point that the patient was admitted to the point that the patient was transferred to the Intensive Care Unit. Hence, it will serve as a dictation from [**2160-1-28**] to [**2160-1-29**]. The rest will be dictated by the Medical Intensive Care Unit house staff. CHIEF COMPLAINT: The patient's chief complaint is chest pain and shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old female with a history of coronary artery disease, status post coronary artery bypass graft (saphenous vein graft to left anterior descending artery, saphenous vein graft to diagonal, and second obtuse marginal to posterior descending artery) in [**2152**], with a history of an abnormal MIBI studies times two, status post abnormal MIBI in [**2159-9-3**] with moderate reversible defect at the apex, septum, inferolateral wall. She deferred catheterization on last admission in the setting of flat enzymes and positive MIBI. The patient now presents with shortness of breath that awoke her this morning which has progressively worsened through the morning. The patient has no chest pain. No fevers. No chills. No nausea. No vomiting. No abdominal pain. No dysuria. No melena. No swelling in the lower extremities. At 6:45 a.m., she developed 8/10 chest pain which decreased to [**6-12**] with three sublingual nitroglycerin and then [**3-12**] status post 2 mg of morphine sulfate. She was started on nitroglycerin drip in the Emergency Room. She was guaiac-negative. She was started on a heparin drip. The patient was then chest pain free. She states that otherwise she has not had chest pain or shortness of breath since her last admission. She states that she is able to do all of her activities of daily living without difficulty. On [**2159-9-24**], the patient had a Persantine MIBI with a moderate reversible perfusion defect in the apex, septum, inferolateral walls, and an ejection fraction at that time of 59%. She had apical hypokinesis new since MIBI in [**2157-9-3**]. An echocardiogram in [**2158-11-3**] revealed an ejection fraction of 60%, nonobstructive focal hypertrophy of the basal septum. No aortic stenosis. No aortic regurgitation. Trivial mitral regurgitation. There was 1+ tricuspid regurgitation. PAST MEDICAL HISTORY: (Otherwise, the patient's past medical history is significant for) 1. Coronary artery disease; status post coronary artery bypass graft with saphenous vein graft to left anterior descending artery, saphenous vein graft to diagonal, and second obtuse marginal to posterior descending artery in [**2142**] with a recent abnormal stress MIBI (as mentioned above). The patient is status post four catheterizations. 2. History of emphysema. 3. History of hypertension. 4. History of hyperlipidemia. 5. History of type 2 diabetes. 6. Status post corneal transplant. 7. History of diverticulosis. 8. Status post appendectomy. 9. Status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. 10. Status post right lung lobe puncture in the setting of catheterization (per patient). MEDICATIONS ON ADMISSION: 1. Tylenol 325-mg tablets one tablet by mouth at hour of sleep. 2. Isosorbide mononitrate 90 mg by mouth once per day. 3. Aspirin 325 mg by mouth once per day. 4. Lipitor 10 mg by mouth once per day. 5. Docusate 100 mg by mouth twice per day. 6. Metformin 500 mg by mouth twice per day. 7. Protonix 40 mg by mouth once per day. 8. Valium 5 mg by mouth as needed. 9. Ranitidine 150 mg by mouth twice per day. 10. Albuterol as needed. 11. Nasacort. 12. Plavix 75 mg by mouth once per day. ALLERGIES: The patient's allergies are to SULFA. FAMILY HISTORY: The patient's family history is significant for diabetes, coronary artery disease, and myocardial infarction in father. SOCIAL HISTORY: Her social history is significant for the fact that she lives alone in [**Location (un) **] housing. She is divorced. She does all of her activities of daily living. No ethanol. No tobacco. CODE STATUS: She is a full code. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed her temperature was 96.3 degrees Fahrenheit, her heart rate was 57, her blood pressure was 110/48, her respiratory rate was 20, and her oxygen saturation was 97% on room air. Generally, a very pleasant female in no acute distress. She was alert and oriented times three. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. The extraocular movements were intact. The oropharynx was clear. The mucous membranes were moist. The neck was supple with no jugular venous distention. There was no lymphadenopathy. Cardiovascular examination revealed a regular rhythm, bradycardic. No murmurs, rubs, or gallops were noted. The lung examination revealed there were bilateral bibasilar crackles. No wheezes or rales. Otherwise, the lungs were clear. The abdomen was flat, soft, nontender, and nondistended. Guaiac-negative. There were good bowel sounds. Extremity examination revealed the extremities were clear of any clubbing, cyanosis, or edema. There were 2+ dorsalis pedis pulses. Bilaterally, the patient groin was free of any bruits. Neurologic examination revealed cranial nerves II through XII were intact. Strength was [**5-7**] and symmetric. The toes were downgoing. The skin was clean, dry, and intact. There were no lesions or rashes were noted. PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's admission laboratory data included a white blood cell count of 4.8, her hematocrit was 40.5, and her platelet count was 91 (baseline 82 to 150). Differential revealed neutrophils of 61 and lymphocytes of 26. Sodium was 138, potassium was 4.3, chloride was 100, bicarbonate was 30, blood urea nitrogen was 26, creatinine was 1, and her blood glucose was 156. Her calcium was 9, her magnesium was 1, and her phosphate was 4. Creatine kinase was 44. Troponin was less than 0.01. RADIOLOGY/IMAGING FINDINGS: A chest x-ray was significant for mild tortuosity. The lungs were clear. Chronic scarring of the right lung base. Scoliosis, status post median sternotomy. Electrocardiogram revealed a right bundle-branch block. There was a sinus rhythm. There were ST depressions in V4 through V6. There was a normal axis. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The [**Hospital 228**] hospital course by issue/system was as follows. 1. CHEST PAIN ISSUES: The patient's first set of cardiac enzymes were negative. She was continued on nitroglycerin as well as heparin drip. The plan was that the patient would be ruled out for a myocardial infarction. Initially, the patient was resistant to have cardiac catheterization. Hence, it was decided that the patient would be medically managed. The patient did rule out for a myocardial infarction. On day two of admission, the patient agreed to a cardiac catheterization which revealed the following. Left ventriculography revealed no mitral regurgitation with an left ventricular ejection fraction of 55%. Coronary angiography revealed a right-dominant system. The left main coronary artery with mild diffuse disease. The left circumflex with serial 70% stenosis before grafted obtuse marginal. The right coronary artery to mid PL filled by left-to-right collaterals. The saphenous vein graft diagonal to obtuse marginal was patent with 70% focal stenosis in obtuse marginal limb. The saphenous vein graft to left anterior descending artery had a 3-mm X 13-mm cypher stent delivered to obtuse marginal. Status post procedure, the patient was maintained on Integrilin. Status post procedure, the patient was noted to be hypotensive to 96/57. The patient underwent a computed tomography scan to rule out a retroperitoneal bleed due to a 6-point hematocrit drop from 40 to 33. This computed tomography scan revealed no retroperitoneal bleed. However, the patient became agitated again and became hypotensive to 90/60 and then dropped to 70/50. The patient was transiently placed on a dopamine drip. A second femoral line was placed. The patient was taken to the Medical Intensive Care Unit. 2. CORONARY ARTERY DISEASE ISSUES: While on the Cardiology floor, the patient was continued on aspirin, atenolol, Lipitor, as well as a nitroglycerin drip. 3. GASTROINTESTINAL ISSUES: The patient was on a bowel regimen and proton pump inhibitor. 4. EMPHYSEMA ISSUES: The patient was on albuterol and Atrovent. 5. ANXIETY ISSUES: The patient was on Valium at hour of sleep as needed. 6. DIABETES ISSUES: For diabetes, her metformin was held and she was continued on a regular insulin sliding-scale and four times per day fingerstick blood glucose checks. The patient was nothing by mouth while she ruled out and was on intravenous fluids. 7. CODE STATUS ISSUES: Her code status was full. NOTE: For the rest of the [**Hospital 228**] hospital course by system, please refer to the Medical Intensive Care Unit discharge note. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**MD Number(1) 5226**] Dictated By:[**Last Name (NamePattern1) 5843**] MEDQUIST36 D: [**2160-2-28**] 15:50 T: [**2160-3-1**] 07:09 JOB#: [**Job Number 98661**]

[ "998.11", "428.0", "V45.81", "401.9", "250.00", "414.01", "411.1", "492.8", "287.5" ]

icd9cm

[ [ [] ] ]

[ "96.04", "88.53", "99.04", "96.71", "36.01", "36.07", "99.05", "38.91", "88.55", "37.22", "99.20" ]

icd9pcs

[ [ [] ] ]

3909, 4030

3331, 3891

6580, 9498

477, 547

576, 2470

2493, 3304

4047, 6546

59,834

163,758

10080

Discharge summary

report

Admission Date: [**2200-5-16**] Discharge Date: [**2200-5-17**] Date of Birth: [**2171-7-14**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Headache, hypotension, fever Major Surgical or Invasive Procedure: Lumbar puncture in ED History of Present Illness: 28 year old woman with history of ruptured hemorrhagic ovarian cyst ([**2192**]) who presents with acute onset headache, fevers/chills. The patient states she was in her usual state of health until ~11:15 this morning when she developed a sudden headache with associated neck stiffness and subjective fevers/chills. The patient called [**Hospital3 **] Clinic who said an urgent care appointment could be made available. As the patient continued to feel ill, she presented to the ED instead. The patient had no other associated symptoms (cough, congestion, SOB, chest pain, palpitations, dysuria, abdominal pain etc). She denies recent sick contacts although she works at an apartment complex with many elderly residents. She got her influenza vaccine last winter. The patient states she should be starting her menstrual period today and has experienced some spotting but no frank cycle/flow yet. She is sexually active and does not use barrier protection as she is in a monogamous relationship. She has not had symptoms or thoughts concerning for sexually transmitted disease. . In the ED, the patient's initial VS were: Pain [**6-29**], T103.4, HR121, BP129/100, 98% on RA. The patient had a lumbar puncture that was unremarkable. Received empirically Ceftriaxone 2grams afterwards. The patient's urinalysis and CXR were also unremarkable. Labs were notable for slightly elevated WBC at 11.1 with no bands, left shift, elevated TBili (unchanged from priors) and normal lactate. After three liters of fluids, the patient's blood pressures drifted down to 90s/50s with a repeat lactate that bumped to 3.2. The patient was empirically given Vanc/Flagyl and another 1L normal saline with improvement in her BP. She also received Benadryl 50mg IV X1 for "total body itching" that subsequently resolved; ?red man syndrome or other reaction to Vancomycin infusion. On transfer, VS: T99.1, HR89, BP99/50, RR18, 100% on RA. . ROS: Night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, BRBPR, melena, dysuria, hematuria, vaginal discharge. Past Medical History: * Left ovarian cyst: Hemorrhagic rupture w/ hemoperitoneum requiring several transfusions, open cystectomy ([**4-/2193**]) * Aspiration: Oral contrast w/ hypoxia ([**4-/2193**]) * Dysmenorrhea * Seasonal allergies * Elevated TBili: Indirect>direct, normal ultrasound, ?[**Doctor Last Name **] ([**8-/2191**]) Social History: The patient works as a Leasing Consultant at an apartment community. Denies tobacco, alcohol and illicit drugs. Family History: Grandmother and grandfather with hypertension, diabetes. Otherwise no family history of immunocompromise, sudden cardiac death, malignancies. Physical Exam: VS: Temp: 99.1 BP: 107/64 HR: 92 --> 69 RR: 14 O2sat 99% on RA GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no nuchal rigidity RESP: CTA b/l with good air movement throughout, no wheezing/rhonchi/rales CV: RR, S1 and S2 wnl, no murmurs/gallops/rubs ABD: Nontender, nondistended, +BS, soft EXT: No cyanosis/ecchymosis/edema SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. Strength and sensation grossly intact Pertinent Results: CSF - Protein 22, Glucose 63, WBC 2, RBC 0, Lymphs 88, Mono 12 . Lactate: 2.0 --> 3.2 . Chem 7 137 100 10 107 AGap=13 3.5 28 0.7 . LFTs ALT: 13 AP: 36 Tbili: 3.1 AST: 20 Lip: 32 . CBC 91 11.1 > 12.6 < 250 36.3 N:93.8 L:3.9 M:1.5 E:0.6 Bas:0.2 . MICRO: Urinalysis - Small blood, neg nitrites/leuks, few bacteria, <1 White, 5 epis CSF gram stain - negative, culture pending BCx X2 pending . EKG: Not done . Imaging: CXR - There is no focal consolidation, pleural effusion, or pneumothorax. Heart and mediastinal contours are unremarkable. Note is made of calcified granulomas in the right lung, which appear similar compared to prior. IMPRESSION: No evidence for pneumonia. Brief Hospital Course: 28 year old woman with history of ruptured hemorrhagic ovarian cyst ([**2192**]) who presents with acute onset headache, fevers/chills. . # Hypotension: Initially not hypotensive in the ED. Given Benadryl for total body pruritis so ?sedation in the setting of high fever/dehydration causing hypotension. It appears, however, that the Benadryl was given after the patient was already having issues with hypotension. Given fevers, tachycardia, elevated lactate and mild leukocytosis, the patient meets SIRS criteria. The patient did not require more IVF overnight while in the ICU. Blood, urine and CSF cultures were monitored and no growth to date on discharge. . # Fevers/chills/headache: Acute onset somewhat puzzling. Could be concerning for intracranial bleed vs. encephalitis/meningitis but very unlikely as the lumbar puncture was normal, and without RBCs/xanthochromia. The patient did have mild leukocytosis initially concerning for an infectious etiology although urine and CXR appeared normal - and the leukocytosis resolved within 12hours. On questioning, the patient did not have symptoms concerning for an abdominal or gynecologic process. The patient was felt to likely have a viral syndrome. Urine legionella negative. As per above, no cultures grew back during her hospitalization. . # Elevated lactate: Somewhat odd that this bumped during her ED stay, with volume resuscitation. Patient has not been exercising excessively, experiencing myalgias, using new culprit medications. [**Month (only) 116**] be in setting of tissue damage from high fevers. This resolved within 12 hours. . # TBili: Elevated since [**2190**]. Fractionated bilirubin in the past showed indirect > direct with ?underlying [**Doctor Last Name 9376**] Disease. . Code: Full Code, confirmed with patient Medications on Admission: Multivitamin Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: Viral Illness Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You were admitted with high fevers, headache. Your blood was sampled for infection and your also underwent a lumbar puncture to rule out an infection in your brain/spinal cord. You do NOT have meningitis/encephalitis and do not have a bacterial infection. You likely had a viral illness. . -It is important that you continue to take your medications as directed. We did not make any changes to your medications. . -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. At home, you can try tylenol or motrin/aleve for headaches and fevers should they return. Followup Instructions: Department: [**Hospital3 249**] When: MONDAY [**2200-7-7**] at 1:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2200-5-17**]

[ "079.99" ]

icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

6386, 6392

4437, 6232

340, 363

6459, 6459

3715, 4414

7353, 7819

3010, 3154

6295, 6363

6413, 6438

6258, 6272

6610, 7330

3169, 3696

272, 302

391, 2531

6474, 6586

2553, 2864

2880, 2994

3,369

175,009

25978

Discharge summary

report

Admission Date: [**2110-3-27**] Discharge Date: [**2110-5-15**] Date of Birth: [**2080-7-13**] Sex: M Service: SURGERY Allergies: Pertussis Vaccine,Fluid Attending:[**First Name3 (LF) 5880**] Chief Complaint: abdominal distension and bilious vomiting Major Surgical or Invasive Procedure: 1) Exploratory laparotomy, small bowel resection, removal of jejunal feeding tube and jejunojejunostomy. [**2110-3-27**] 2) Exploratory laparotomy; repair of small bowel perforation x2. [**2110-3-31**] Placement of VAC dressing. 3) Split-thickness skin graft from right thigh to abdominal wound [**2110-5-8**] History of Present Illness: The patient is a 29 year old male with a complicated past medical history including SMA syndrome and several abdominal operations by Dr. [**Last Name (STitle) **] (please see previous discharge summary for further details), presented to [**Hospital1 18**] on [**2110-3-26**] with new onset abdominal distension and bilious emesis at his rehab center. Past Medical History: 1) Cerebral palsy with mental retardation 2) Seizure disorder 3) History of H. pylori gastritis 4) Recent right clavicular fracture on [**2109-9-14**] 5) History of multiple surgeries to the lower extremities for flexion contractures 6) Recurrent Klebsiella UTI, treated with Bactrim, Rocephin and Tequin. 7) SMA Syndrome: Followed by Dr. [**Last Name (STitle) **] (surgery) SBO initially felt secondary to obstipation brought about by codeine use for pain managment secondary to clavicular fracture. A barrium swallow on [**2109-9-21**] was suggestive of partial obstruction at the second portion of the duodenum. However, he continued to have high NG residuals and radiographic features c/w partial SBO despite clearance of stools, which led to a consideration of SMA syndrome. A CT on [**2109-10-2**] showed stable distension of the stomach and duodenum, with proximal duodenal distension without apparent dilatation of the distal duodenum. A repeat EGD on [**2109-10-17**] was performed, at which time duodenal narrowing was not appreciated. A subsequent gastrograffin study, however, showed high grade partial obstruction of the duodenum. Suspected gastric outlet obstruction/partial SBO due to SMA syndrome suggested on radiographic studies, although duodenal narrowing not appreciated on repeat EGD. The patient had had minimal improvement with conservative management, with continued weight loss and inability to tolerate POs. NG tube was maintained, and TPN was continued per nutrition recs. GI consulted, CT angio of abdomen was done. The patient underwent EUS on [**11-11**], duodenal biopsies taken, unable to visualize pancreas, decision made for pancreatic MRI to be done. Surgery consulted, thought clinical picture c/w SMA, plan to have patient undergo surgical decompression in the near future once his nutritional status has improved (goal weight of 105 pounds). The patient was continued on a PPI [**Hospital1 **] for GI protection given his history of fundus ulcers. The patient had a G/J tube placed under IR on [**11-13**], and tube feeds were started 24 hours after placement. Biopsies from duodenum showed mild inactive duodenitis. 8) ARDS [**9-/2109**] at [**Hospital **] Hospital; admitted with abdominal pain, ? hematemesis and suspected SBO. A CT chest and abdomen was performed and reportedly showed multifocal pneumonia with bilateral pleural effusions, no abdominal mass. His clinical picture evolved into an ARDS picture requiring intubation on [**2109-9-22**]. He was treated with Zosyn for presumed aspiration pneumonia; sputum cultures grew [**Female First Name (un) 564**] Albicans. He self-extubated on [**2109-10-6**], and has been stable from a respiratory standpoint since that point. 9) Left LE DVT, diagnosed on [**2109-12-5**], initially treated with lovenox, then switched to coumadin. 10) Pancreatic Head Cystic Lesion, followed q1 year Social History: Mr. [**Known lastname 6164**] is a resident of [**Hospital1 **] Meadows in [**Location (un) **]. Patient reportedly ambulates with assist and wears a helmet for safety in the nursing home. Family History: Not available. Physical Exam: VS- 98.3, 117, 130/72, 20, 100% Gen: nonverbal, uncomfortable Lungs: coarse bilaterally Heart: sinus tachycardia Abdomen: firm and distended, normal rectal tone, guiac +, disimpacted with a large amount of stool in the ED Pertinent Results: [**2110-3-26**] 06:20PM BLOOD WBC-31.0*# RBC-3.74* Hgb-11.2* Hct-33.1* MCV-89 MCH-30.0 MCHC-33.8 RDW-19.5* Plt Ct-768* [**2110-3-27**] 06:17PM BLOOD WBC-4.4# RBC-4.58*# Hgb-14.0# Hct-39.9*# MCV-87 MCH-30.6 MCHC-35.1* RDW-18.0* Plt Ct-328# [**2110-3-28**] 04:21AM BLOOD WBC-19.0* RBC-3.69* Hgb-11.3* Hct-32.0* MCV-87 MCH-30.6 MCHC-35.3* RDW-18.5* Plt Ct-342 [**2110-3-28**] 02:00PM BLOOD WBC-27.1* RBC-3.00* Hgb-9.0* Hct-26.2* MCV-87 MCH-30.1 MCHC-34.5 RDW-18.6* Plt Ct-308 [**2110-3-29**] 03:23AM BLOOD WBC-26.6* RBC-2.77* Hgb-9.0* Hct-24.1* MCV-87 MCH-32.5* MCHC-37.3* RDW-18.7* Plt Ct-288 [**2110-3-30**] 03:01AM BLOOD WBC-32.3* RBC-2.56* Hgb-7.7* Hct-22.8* MCV-89 MCH-30.3 MCHC-34.0 RDW-18.5* Plt Ct-265 [**2110-4-11**] 03:11AM BLOOD WBC-16.0* RBC-2.26* Hgb-6.8* Hct-20.4* MCV-90 MCH-29.9 MCHC-33.1 RDW-17.8* Plt Ct-503* [**2110-4-16**] 02:28AM BLOOD WBC-14.4* RBC-2.66* Hgb-7.9* Hct-23.7* MCV-89 MCH-29.6 MCHC-33.2 RDW-18.1* Plt Ct-723* [**2110-4-17**] 02:06AM BLOOD WBC-20.4* RBC-2.55* Hgb-7.6* Hct-22.9* MCV-90 MCH-29.8 MCHC-33.3 RDW-18.2* Plt Ct-772* [**2110-5-2**] 02:36AM BLOOD WBC-59.8*# RBC-2.81* Hgb-8.5* Hct-25.8* MCV-92 MCH-30.2 MCHC-33.0 RDW-18.4* Plt Ct-690* [**2110-5-2**] 04:55PM BLOOD WBC-42.1* RBC-2.60* Hgb-7.7* Hct-23.7* MCV-91 MCH-29.8 MCHC-32.7 RDW-18.5* Plt Ct-615* [**2110-5-4**] 02:26AM BLOOD WBC-18.4* RBC-2.20* Hgb-6.5* Hct-20.4* MCV-92 MCH-29.3 MCHC-31.7 RDW-19.1* Plt Ct-633* [**2110-5-5**] 02:58AM BLOOD WBC-14.2* RBC-3.03* Hgb-9.3* Hct-27.6* MCV-91 MCH-30.8 MCHC-33.7 RDW-18.9* Plt Ct-492* [**2110-5-14**] 04:03AM BLOOD WBC-13.1* RBC-2.89* Hgb-8.5* Hct-26.6* MCV-92 MCH-29.5 MCHC-32.0 RDW-17.7* Plt Ct-762* [**2110-3-26**] 06:20PM BLOOD PT-12.1 PTT-21.8* INR(PT)-1.0 [**2110-3-26**] 06:20PM BLOOD Glucose-157* UreaN-18 Creat-0.4* Na-135 K-3.3 Cl-88* HCO3-33* AnGap-17 [**2110-3-26**] 06:20PM BLOOD ALT-35 AST-21 AlkPhos-404* Amylase-21 TotBili-0.4 [**2110-3-26**] 06:20PM BLOOD Lipase-12 [**2110-3-26**] 06:20PM BLOOD Albumin-3.6 [**2110-3-27**] 02:57AM BLOOD calTIBC-169* TRF-130* [**2110-5-12**] 03:45AM BLOOD calTIBC-124* Ferritn-1153* TRF-95* Brief Hospital Course: The patient was admitted to [**Hospital1 18**] on [**2110-3-26**] for abdominal distension and bilious emesis. His WBC was 31. He was afebrile. He was hypokalemic and hypochloremic. A CT scan showed distended loops of fecalized small bowel with jejunostomy tube in place and collapse of the transverse colon, descending colon, sigmoid colon. These findings were concerning for small-bowel obstruction. He was admitted to the ICU. He was kept NPO on IV fluids. He was started on Ativan for agitation and morphine for pain. He was started on Lopressor for tachycardia. He was empirically started on Linezolid (history of VRE), Levaquin, and Flagyl. On HD 2, a left sided central venous line was placed and his PICC was removed. Later that day he had an exploratory laparotomy, small bowel resection, removal of jejunal feeding tube and jejunojejunostomy by Dr. [**Last Name (STitle) **] (please see operative note for details). The jejunal feeding tube had a perforation near it with barium and tube feedings. There was a significant amount of barium spillage in the abdomen during the procedure. The cause of the obstruction appeared to be an omental band across the Roux-Y loop just as it entered the distal jejunal anastomosis. The Roux-Y loop appeared to be intact with the duodenum but this could not be assessed completely. He recieved 6 L of IV fluids and albumin boluses post-operatively for oliguria and he eventually responded. Fluconazole was added. An A-line was placed. He was transferred back to the ICU intubated and sedated. He had a JP drain. He was maintained on drips of Fentanyl, Midazolam, and Pitressin. He had an NG tube. His abdomen was left open. On POD 1, he had low grade fevers. His WBC was 19 and hit Hct was stable. On POD 2 he was started on TPN. His hematocrit dropped to 22. He did not recieve blood for this as it was assumed to be dilutional. He was weaned off of pressors later that day. On POD 4, he went to the OR for closure of his open abdomen. He wound up having an exploratory laparotomy; repair of small bowel perforation x2, and placement of VAC dressing (please see operative note for details). He was transferred back to the ICU after his surgery. He was again intubated and sedated. His antibiotics were continued. TNP was continued. On POD [**4-14**], he was afebrile with stable vitals except for tachycardia. His WBC was 37. HIs Hct was stable at 26. He was maintained on Fentanyl and Midazolam drips. His abdomen was soft. He was stable off pressors. On POD [**5-16**], his HG tube was removed. His VAC was changed at the bedside. On POD [**6-16**], his WBC was 23. He ran low grade temperatures. On POD [**7-18**], a right subclavian line was placed. He was febrile to 102. His WBC was 26. His antibiotics were Linezloid, Meropenem, and Fluconazole. VRE was cultured from his peritoneal fluid. He had Klebsiella in his blood. He was also growing Pseudomonas from his urine and sputum. Cefipime was added. His line was changed to a right IJ line. On POD [**8-19**], he continued to be febrile to 102. On POD [**9-19**] his VAC was changed. On POD [**10-21**], he continued to be febrile to 102. His WBC was 25. An echo was done to rule out endocarditis and was negative. A CT was done to rule out an asbcess and showed extensive postoperative change and fluid, with widespread airspace consolidation consistent with pneumonia throughout the lung fields. There was no evidence of anastamotic leak. His A-line tip culture was growing out gram negative rods. This may have been the source of his bacteremia. He was maintained on Meropenem, Cefipime, Linezolid, and Fluconazole. On POD [**11-21**], his WBC was 19 and he continued to be febrile. On POD 14/10, his Tmax was 101. His WBC was 17. HIs VAC was changed. His was started on trials of CPAP with PS ventillation. On POD 15/11, his Hct was 20 and he recieved 1 unit RBCs for blood loss anemia (? source). His WBC was 16. On POD 15/11, lower extremity ultra sounds ruled out DVTs. On POD 17/13, his Tmax was 100 and his WBC was 15. His sedation was weaned (he was still on Fentanyla nd Midazolam drips) and his dilantin level had to be adjusted up. On POD 18/14 his VAC was changed. He was doing well on CPAP/PS. Midazolam was discontinued. On POD 19/15, his WBC was 12 and his Tmax was 100. On POD 20/16, he underwent trach collar trials. His Fentanyl was weaned. He had a breakthrough seizure (30 seconds, GTC), possibly due to a supratheraputic Dilantin level, so his Dilantin was held. He was maintained on 150mg [**Hospital1 **] with a goal of an adjusted Dilantin level of the mid 20s (given his low albumin of 2.4). On POD 21/17, he spiked a fever to 101 and his WBC increased to 20. A CT was done to look for a source of infection and this showed extensive worsening bilateral pneumonia with near total opacification of both lungs, and a new rim enchancement of a large fluid collection along the left abdomen extending into left pericolic gutter that measures 13 x 6 cm. His right IJ line was removed and the tip was cultured. He required increased FiO2 and PEEP. As his PEEP was increased to 15, his FiO2 was weaned to 70%. There was concern for a serious nosocomial pneumonia vs ARDS. A right femoral A-line was placed. On POD 22/18, he was transfused 2 units of RBCs for blood loss anemia (Hct 22, ? source). On POD 23/19, he had successful CT-guided aspiration of left upper quadrant intraabdominal collection, with 200 cc of serous fluid removed. Samples were sent for Gram stain and culture. He was started on Flagyl empirically for C. Difficile, although his toxin levels were negative. On POD 24/20, he was started on Amikacin and Ceftazidime for pneumonia. His other antibiotics were discontinued. On POD 27/23, he had an upper GI series with small bowel follow through, which did not show any stricture or leak. He was started on tube feeds (impact with fiber, full strength through the G-tube, goal 60 cc/hour). On POD 34/30, his TPN was discontinued. His pressure support was weaned to 10. His tube feeds were at 60cc/hour (goal). His WBC was 19 and his Tmax was 98. He did not tolerate a trial of trach collar. His tube feeds had to be held for high residuals. On POD 35/31, his WBC was 24 and he had a low grade fever. A left subclavian TLC was placed and his right IJ was removed and the tip cultured. Later that night, he spiked to 104 and his respiratory status declined. His lungs had bilateral rhonchi an ascultation. Vancomycin was started empirically. On POD 36/32, his G-tube was put to gravity and TPN was re-started due to high residuals. A CT was done to look for an abscess and we found diffuse severe pulmonary opacities and consolidations consistent with ARDS or pneumonia. There were moderate bilateral pleural effusions. There were no acute intraabdominal abnormalities identified. Meropenem was started to broaden his coverage given his history of resistant organisms. His A-line was changed over a wire. His WBC was 59. Propofol was used for sedation. On POD 37/33, his temperature was down to 100 and his WBC was 27. He was started on a Neosynepherine drip for BP control. His tube feeds were restarted. Vancomycin was discontinued. On POD 38/34, he was weaned off pressors. He was afebrile. His WBC was 18. The source of his decompensation was unclear. [**Name2 (NI) **] was on Linezolid in case his blood grew out VRE. His On POD 39/35, he recieved 1 unit of red blood cells for a Hct of 20 due to blood loss anemia. Linezolid was discontinued because his blood was free of VRE. Amikacin and Ceftazidime were continued for Pseudomonas pneumonia and Meropenem for Klebsiella pneumonia. Flagyl was discontinued. His tube feeds were slowly increased. His WBC was 14 and he was afebrile. On POD 40/36, he tolerated a CPAP/PS trial. On POD 41/37, his WBC was up to 19. He was afebrile. Cultures were sent which were subsequently negative. Tube feeds were advanced to goal. His CVL was discontinued and a PICC was placed. On POD 42/38, he went to the OR for a STSG from his right thigh to cover his abdominal wound. The operation went well with no complications (please see operative note for details). Afterwards, he was tramsferred back to the ICU in good condition. On POD 43/39/1, he was afebrile and his WBC was 17. On POD 44/40/2, his A-line was discontinued. On POD 46/42/4, his phenytoin was increased to 200mg Q 12 because of a low level. His dressing was changed on his donor site. On POD 47/43/5, his skin graft dressing was changed-- the graft took well. His ventillator continued to be weaned and he was screened for rehab. He completed his course of Meropenem on [**2110-5-15**] and was discharged to rehab. Medications on Admission: nystatin s/s, metoprolol 25'''', ASA 325, heparin sc, albuterol 2puff q4 prn, ipratropium bromide 2puff qid, RISS, lansoprazole 30', roxicet prn, iron liquid', phenytoin 100mg iv bid, lorazepam 2mg iv prn, levothyroxine 100', reglan 10'''' Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-16**] Drops Ophthalmic PRN (as needed). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation Q4H (every 4 hours). 6. Albuterol 90 mcg/Actuation Aerosol Sig: 6-10 Puffs Inhalation Q4H (every 4 hours). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 8. Methadone 5 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 9. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a day. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day: hold for SBP < 100, HR < 60. 11. Lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4 hours) as needed for agitation. 12. Metoclopramide 5 mg/mL Solution Sig: Ten (10) mg Injection Q6H (every 6 hours). 13. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 14. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 1 days: finish coursewith last dose PM [**2110-5-15**] then discontinue. 15. Heparin Lock Flush 100 unit/mL Solution Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 16. Phenytoin Sodium 50 mg/mL Solution Sig: Four (4) mL Intravenous Q12H (every 12 hours). Goal level [**10-3**]. 17. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection as directed Injection ASDIR (AS DIRECTED): Insulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-65 mg/dL [**12-16**] amp D50 66-120 mg/dL 0 Units 121-140 mg/dL 3 Units 141-160 mg/dL 5 Units 161-180 mg/dL 7 Units 181-200 mg/dL 9 Units 201-220 mg/dL 11 Units 221-240 mg/dL 13 Units 241-260 mg/dL 15 Units 261-280 mg/dL 17 Units 281-300 mg/dL 19 Units 301-320 mg/dL 21 Units > 321 mg/dL Notify M.D. . Discharge Disposition: Extended Care Discharge Diagnosis: small bowel obstruction with perforation, new small bowel perforations, non-healing abdominal wound, ARDS, pneumonia, sepsis, breakthrough seizures, blood loss anemia Discharge Condition: stable, on mechanical ventilation (CPAP w/ pressure support of 10, PEEP 5), no drips. Discharge Instructions: Please call or come to the ED with any fevers > 101, nausea, vomiting, increasing pain, shortness of breath, yellow drainage or redness spreading around the abdominal wound, or any other worrisome issues that may arise. Followup Instructions: Please call the office of Dr. [**Last Name (STitle) **] to schedule a follow-up in [**12-16**] weeks at ([**Telephone/Fax (1) 6449**]. Completed by:[**2110-5-15**]

[ "996.62", "995.92", "569.83", "567.29", "319", "343.9", "482.0", "584.9", "482.1", "038.49", "599.0", "780.39", "557.1", "560.81", "V44.0", "280.0", "997.4", "998.83", "518.5" ]

icd9cm

[ [ [] ] ]

[ "86.69", "00.17", "99.15", "46.73", "54.59", "00.14", "93.59", "38.93", "99.77", "99.04", "54.91", "96.72", "45.91", "45.62", "96.6" ]

icd9pcs

[ [ [] ] ]

17706, 17721

6533, 15331

325, 637

17932, 18020

4429, 6510

18288, 18454

4155, 4172

15621, 17683

17742, 17911

15357, 15598

18044, 18265

4187, 4410

244, 287

665, 1017

1039, 3932

3948, 4139

15,048

107,779

11513

Discharge summary

report

Admission Date: [**2195-9-24**] Discharge Date: [**2195-10-14**] Service: [**Company 191**] Medicine at outside hospital in [**2195-9-21**] for pancreatitis secondary to gallstones, transferred to [**Hospital1 69**] on [**2195-9-24**] for ERCP. Post procedure patient's O2 saturation decreased and patient was hypotensive with metabolic acidosis. He was intubated on [**2195-9-25**] secondary to respiratory fatigue. The patient started on Flagyl and Gentamycin on [**2195-9-24**] secondary to increased temperatures. Vancomycin started on [**2195-9-25**], tube feeds started on [**2195-9-26**]. The patient had episode of NSVT on [**2195-9-28**] which resolved spontaneously. Surgery was consulted secondary to increased temperature despite being on cholecystostomy since patient was not a surgical candidate for cholecystitis which was confirmed by ultrasound. The patient defervesced after drain was placed on [**2195-10-1**]. The patient had repeat run of NSVT on [**2195-10-1**] and was restarted on his beta blocker. On [**2195-10-2**] the patient had new T wave inversions in anterior and lateral leads, however, enzymes were negative. Echocardiogram showed decreased left ventricular systolic function, inferolateral and anterior and septal hypokinesis and 4+ MR. The patient was extubated on [**2195-10-2**] and was started on po diet. Vancomycin was stopped. The patient had been requiring diuresis since extubation. The patient was transferred to floor for further management of cardiac issues. PAST MEDICAL HISTORY: TIAs, hypertension, hypercholesterolemia, multifocal PVCs, diverticulosis, coronary artery disease status post MI, CABG in [**2192**] times five, BPH post TURP, macular degeneration. MEDICATIONS: Home medications, Coumadin, Lipitor, Atenolol, Lopressor. On transfer, Flagyl 500 mg IV q 8 hours, Gentamycin 60 mg IV q 24 hours, Lopressor 12.5 mg po bid, Nystatin swish and swallow qid, Aspirin, Protonix 40 mg po q day, Captopril 25 mg po q 8 hours, Regular insulin sliding scale, Ativan prn, Morphine prn, Albuterol nebs prn. ALLERGIES: Patient allergic to Penicillin. SOCIAL HISTORY: The patient smokes tobacco. PHYSICAL EXAMINATION: Upon transfer heart rate 93, respirations 22, 95% on 2 liters, temperature 97.9, blood pressure 124/84. In general patient is sitting in chair in no acute distress. HEENT, oropharynx with moist mucus membranes. Neck, left subclavian line in place. Cardiovascular, regular rate and rhythm, grade 2/6 systolic ejection murmur heard loudest at apex. Lungs, decreased heart sounds at the bases, left greater than right, expiratory rhonchi. Abdomen, gallbladder drain in place, minimal tenderness around drain site, otherwise soft, nontender, non distended with positive bowel sounds. Extremities, no edema in lower extremities, good pulses bilaterally. LABORATORY DATA: Gallbladder fluid growing rare enterococcus gram stain, 4+ PMN's, no organisms. Chest x-ray showed cardiomegaly with bilateral pulmonary edema, mild CHF, left lower lobe consolidation consistent with pleural effusion and atelectasis vs infection. HOSPITAL COURSE: The patient was continued on Flagyl and Gentamycin IV for cholecystitis. The patient had episode of acute renal failure with rising creatinine. All nephrotoxic drugs were stopped. Renal ultrasound was normal. The patient began responding to fluid boluses. GI, patient had persistently elevated alkaline phosphatase and total bilirubin throughout hospital course. After being transferred to the floor the patient developed new abdominal tenderness around bile drain site. CT of the abdomen was negative for bile leak, but subsequent imaging revealed evidence of a leak. After discussion with the patient, his wife, and his sons, he was taken to ERCP for possible stent placement. ERCP showed bile duct which was not dilated but contained irregular strictures, with small stones at the junction of the cystic duct. Multiple stones were present in the gallbladder. A plastic stent was successfully placed. In the recovery room following the ERCP procedure, the patient had sudden decrease in respiratory effort with loss of consciousness and loss of pulse. The patient was in PEA. Chest compressions were started. Despite receiving Epinephrine, Neo-Synephrine, Ephedrine, Atropine the patient went into new V tach, was shocked at 300 joules. The patient then returned to slow PEA. After 30 minutes of CPR the code was called. Time of death 2:42 p.m. The patient's son, wife, and in-laws were notified. Autopsy was declined. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 4814**] Dictated By:[**Name8 (MD) 7112**] MEDQUIST36 D: [**2195-11-24**] 12:11 T: [**2195-11-26**] 09:06 JOB#: [**Job Number 36696**]

[ "427.1", "998.59", "997.3", "038.9", "428.0", "427.5", "997.1", "518.5", "E879.8" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "51.03", "96.04", "38.91", "51.88", "51.87", "51.85" ]

icd9pcs

[ [ [] ] ]

3134, 4806

2194, 3116

1550, 2125

2142, 2171

14,833

107,544

30012

Discharge summary

report

Admission Date: [**2139-2-9**] Discharge Date: [**2139-2-15**] Date of Birth: [**2106-10-13**] Sex: M Service: PLASTIC Allergies: Penicillins Attending:[**First Name3 (LF) 7733**] Chief Complaint: Left radius/ulnar fracture Major Surgical or Invasive Procedure: 1. Open reduction/internal fixation of left radius/ulnar fracture 2. Delayed primary closure right forearm. History of Present Illness: The pt is a 32 y/o male who was involved in a MVA one month ago and had a fracture to his right radius and ulna. He presented to the [**Hospital1 18**] ED and had a closed reduction of his fractures and had a splint placed. He continues to have pain with his forearm. Follow-up x-rays 4 days prior to admission revealed malalignment. The patient presents for ORIF. Past Medical History: Venous malformation right upper extremity being treated with sclerotherapy Social History: He is a nonsmoker. Family History: Non-contributory Physical Exam: T 97.8 P 83 BP 125/64 R 16 SaO2 97% Gen - nad Lungs - clear Heart - RRR Abd - soft, NT, ND, BS+ Extrem - right upper extremity splinted, diffusely edematous, some numbness to light touch in right thumb, right upper extremity otherwise neurovascularly intact Pertinent Results: [**2139-2-9**] 11:15PM BLOOD WBC-13.4*# RBC-3.87* Hgb-11.7* Hct-33.9* MCV-88 MCH-30.3 MCHC-34.6 RDW-13.5 Plt Ct-128* [**2139-2-9**] 11:15PM BLOOD PT-18.2* PTT-58.7* INR(PT)-1.7* [**2139-2-9**] 11:15PM BLOOD Glucose-136* UreaN-15 Creat-0.7 Na-141 K-4.1 Cl-107 HCO3-25 AnGap-13 [**2139-2-9**] 11:15PM BLOOD Calcium-7.9* Phos-4.2 Mg-1.7 Iron-110 Brief Hospital Course: The patient had an ORIF of his right forearm fractures which he tolerated well. The skin was not closed because of concern of compartment syndrome. The wound was packed with Betadine impregnated Kerlix and this was then covered with several layers of sterile towels held on with an Ace wrap. 2 JP drains were placed in the wound. Post-operatively, the patient was transfused 2 units of packed red blood cells for bleeding that he had in the OR and was started on IV Clindamycin because he had hardware in his arm with an open wound. In the evening following the surgery, the patient had active bleeding from his arm as the drains put out 1200cc of blood. A central line was placed and CVP was transduced. He was transfused one unit of fresh frozen plasma and one unit of cryoprecipitate because his PTT and INR were elevated at 58.7 and 1.7 respectively. The patient was transferred to the SICU for more intensive monitoring. On post-op day 1, he was transfused 2 units of packed red blood cells for a Hct of 21.6. Throughout this episode of bleeding, the pt remained normotensive with adequate urine output. On post-op day 2, his Hct remained stable at 23 and he was transferred to the floor. On post-op day 3, he returned to the OR for a delayed primary closure of his right forearm incisions which he tolerated well. He was transfused another 2 units of packed red blood cells post-operatively. The [**Hospital **] hospital course was also complicated by persistent post-op fever which started on post-op day 1. As his fevers persisted, blood cultures were sent, cvl was pulled and the tip was cultured, urinalysis, and urine culture were also sent. His cultures had no growth. We encouraged the pt to continue to use his incentive spirometer and he was continued on IV clindamycin. On post-op day 4, the pt complained of worsening pain from his right fingers and his dressing was taken down to evaluate for possible compartment syndrome. His arm was soft and he had good perfusion of his fingers. Although he complained of some numbness/tingling in his right thumb, he was otherwise neurovascularly intact. His arm was redressed more loosely and the patient stated that this caused his pain to lessen. During the evening, the patient complained of feeling claustrophobic and depressed and also complained that he was not thinking clearly. These symptoms were attributed to the combination of neuroleptic medications he was taking. He was given 0.25mg of Ativan with good effect. His neurontin dose was decreased and his Dilaudid PCA was discontinued. We continued to monitor his mental status closely. He remained free of the neurologic symptoms. At the time of discharge, the pt was able to ambulate independently and his pain was well controlled with PO dilaudid and clindamycin. He was instructed to keep his dressing on and arm elevated. He will follow up with Dr. [**Last Name (STitle) 5385**] on [**2139-2-17**]. Medications on Admission: None Discharge Medications: 1. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*0* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*25 Capsule(s)* Refills:*0* 3. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO three times a day for 1 weeks. Disp:*21 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Right radius/ulna fractures Right upper extremity venous malformation Discharge Condition: Stable Discharge Instructions: Call your doctor or seek immediate medical attention if you experience increased swelling, numbness, or pain from right hand and arm, or increased drainage, redness, or bleeding from incisions. Also call your doctor if you experience fever, chills, lightheadedness, dizziness, chest pain, shortness of breath, severe abdominal pain, or nausea/vomiting. No driving while taking pain meds. No tub baths or swimming. Keep dressing around right arm and elevate right arm whenever possible. You may move your wrist and elbow. Empty and strip JP drain daily and record output. No heavy lifting with right arm. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 5385**] on Tuesday, [**2139-2-17**]. Call [**0-0-**] for appointment. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 7738**]

[ "905.2", "747.63", "E929.0", "780.6", "733.81", "998.89", "998.11" ]

icd9cm

[ [ [] ] ]

[ "99.04", "86.59", "79.32", "99.07" ]

icd9pcs

[ [ [] ] ]

5136, 5142

1639, 4593

298, 408

5256, 5265

1272, 1616

5920, 6163

957, 975

4648, 5113

5163, 5235

4619, 4625

5289, 5897

990, 1253

232, 260

436, 807

829, 905

921, 941

49,296

124,702

43526

Discharge summary

report

Admission Date: [**2138-4-5**] Discharge Date: [**2138-4-10**] Date of Birth: [**2063-3-6**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 458**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: 2d Transthoracic Echocardiogram History of Present Illness: 75 yo woman with history of obesity, severe AS, CKD (baseline Cr 2.5)PVD, recently admited for decompensated heart failure and evaluatation for AVR ([**Date range (1) 22379**]). During that hospitalization she was diuresed with IV lasix, then transitioned to torsemide 10mg daily. As the patient developed acute renal failure during her hospitalization, the workup for AVR was postponed, specifically cardiac catheterization. The patient was discharged on oral diuretics in an attempt to regain renal function prior to restarting evaluation for AVR. . The patient was at [**Hospital **] rehab for three days before representing. Over the course of those three days, the patient developed chest pain and worsening dyspnea, concerning for flash pulm edema. The family reports that her chest pain was left sided, radiated to her back and left flank. She reported that the chest pain was persistent in nature. In the AM, the patient was given 40mg of IV lasix and placed on CPAP, however did not tolerate well. Cardiac enzymes were sent which showed Trop I of 0.68, CKMB of 1.3, then increased to Trop I 1.07, and CKMB 2.3 the following morning. During that time, the patient's EKGs were unchanged with baseline RBBB. The patient was started on a heparin drip, given ASA, BBlocker, statin. She was then placed on BiPAP by EMS and transferred to [**Hospital1 18**] for further evaluation and treatment. . In the ED, her vital signs were HR 81 BP 122/39 93% on 2L n/c RR 16. In the ED she was placed on CPAP, with an increase in her O2 sat to 98%. The patient had persistent 8/10 chest pain during her stay in the ED, requiring multiple doses of morphine 2mg and 1mg of dilaudid. The patient was found to have a Hct drop to 26.7 and was guaiac positive. Other labs showed Trop of 0.41 and worsening renal function at 2.7. . On transfer to the CCU, the patient was somnolent. She was found to have a decreased respiratory rate and an O2 sat in the 80s on 4L NC. The patient was placed on a non-rebreather and an ABG was sent which showed respiratory acidosis. Her respiratory rate and 02 sat initially improved, however then decreased again. The patient was given 4mg of narcan in an attempt to reverse the effects of the narcotics. Her respiratory status was unstable and the patient was started on CPAP non invasive ventilation and narcan drip. Past Medical History: - Chronic Diastolic CHF - Aortic Stenosis mean gradient 49 - Peripheral Vascular Disease - Hypertension OTHER - Diabetes type II c/b renal dz, ischemic right toe ulcer, neuropathy - h/o ischemic stroke with residual right sided weakness. - h/o GI Bleed/Gastritis - GERD - h/o DVT - h/o depression, anxiety - Chronic Renal Insufficiency - Arthritis - Obstructive Sleep Apnea Social History: Tobacco: 30 pack year history (quit 10yr ago) Denies etoh, drugs. Lives in nursing home. Family History: Family history significant for father with stroke and MI. Physical Exam: Physical Exam VS: T 97.6 HR 88 BP 87/55 RR 16 02 81% on 4L NC General: In NAD, somnolent, arousable but somnolent HEENT: NC, AT, EOMI, PERRLA, MMM CVS: RRR, [**2-14**] holosystolic murmur with no S2, unable to assess JVP RESP: Rhonchi BL anteriorly, no wheezes ABD: Soft, NT, ND, +BS EXT: 1+ BL LE edema, dopplerable pulses bilaterally Neuro: A+Ox3, cn2-12 intact, sensory and motor intact Pertinent Results: Admission labs: [**2138-4-5**] 04:35PM BLOOD WBC-9.6 RBC-2.78* Hgb-8.5* Hct-26.7* MCV-96 MCH-30.6 MCHC-31.8 RDW-14.6 Plt Ct-225 [**2138-4-5**] 04:35PM BLOOD Neuts-81.5* Lymphs-11.7* Monos-4.0 Eos-2.3 Baso-0.4 [**2138-4-5**] 04:35PM BLOOD PT-13.3 PTT-28.0 INR(PT)-1.1 [**2138-4-5**] 04:35PM BLOOD CK(CPK)-70 [**2138-4-6**] 02:48AM BLOOD CK(CPK)-515* [**2138-4-5**] 04:35PM BLOOD cTropnT-0.41* [**2138-4-6**] 02:48AM BLOOD CK-MB-6 cTropnT-0.42* [**2138-4-5**] 04:35PM BLOOD Calcium-9.2 Phos-3.3 Mg-2.2 [**2138-4-5**] 07:44PM BLOOD Type-ART pO2-207* pCO2-54* pH-7.40 calTCO2-35* Base XS-7 . Portable chest ([**4-5**]): The heart is enlarged. There are bibasal effusions present. There is prominence of the pulmonary vasculature consistent with moderate CHF. In addition, there is an infiltrate at the right lung base which may represent superimposed infection. CONCLUSION: Background moderate CHF with possible infiltrate at the right lung base. Please ensure followup to clearance. . ECHO ([**4-7**]): The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is mild functional mitral stenosis (mean gradient 5 mmHg) due to mitral annular calcification. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: poor technical quality due to patient's body habitus. Left ventricular function is mildly hypokinetic, a focal wall motion abnormality cannot be fully excluded. The right ventricle is not well seen. Compared with the prior study (images reviewed) of [**2138-3-28**], global LV systolic function appears mildly hypokinetic on the current study. The degrees of mitral regurgitation and pulmonary hypertension have increased. The degree of aortic stenosis is similar. Brief Hospital Course: Assessment and Plan: Ms. [**Known lastname **] is a 75 yo woman with severe aortic stenosis, diabetes, and morbid obesity who presents with dyspnea. Her respiratory distress is likely multifactorial with contributing factors including respiratory supression from overuse of narcotics in the ED, pulmonary edema secondary to critical aortic stenosis and myocardial demand/ischemia, and underlying OSA. Her respiratory status improved with narcan as did her mental status. She was continued on non-invasive ventilation with CPAP and gently diuresed on a lasix drip. She was kept NPO initally with thought that aspiration may have contributed, but eventually had speech and swallow which showed no evidence of this. Etiology of her respiratory failure most likely CHF from severe AS. Ultimate treatment would be valvuloplasty vs. AVR, however the patient is not a candidate for AVR. Given her poor peripheral access, it would also be difficult to pursue valvulopasty. Her respiratory status improved slightly but continued to have oxygen requirement and was unable to lie flat therefore she would have required intubation for this procedure. She had worsening renal function likely secondary to poor forward flow and required high doses of diuretics to maintain adequate urine output. Patient understood her poor overall prognosis given severity of her aortic stenosis with heart failure. She expressed a desire to discontinue all aggressive measures in favor of comfort care. After multiple discussion with the medical team, patient and family about all possible options, she was made comfort care only. She was transitioned to hospice care, continued on morphine as needed for comfort and expired in the hospital several days later with her family by her side. Medications on Admission: Rosuvastatin 40 mg po daily Torsemide 10mg PO DAILY Hydralazine 10 mg po tid Isosorbide Mononitrate 30 mg PO DAILY Aspirin 81 mg po daily Metoprolol Tartrate 12.5 mg Tablet PO BID Ipratropium q 6 hours Levalbuterol TID Pantoprazole 40 mg po daily Ferrous Sulfate 325 mg po daily Heparin TID (3 times a day). Citalopram 40mg po daily Lidocaine patch Ascorbic Acid 1000 mg Tablet po bid Multivitamin po daily SS humalog Glargine 8U at bedtime Prochlorperazine PO Q6H prn Zolpidem 5 mg PO HS prn Benzonatate 100 mg PO TID prn Lactulose prn. Bisacodyl 10mg po bid prn. Docusate Sodium 100 mg po bid Psyllium tid. Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Primary: Aortic stenosis Acute on Chronic Diastolic CHF Peripheral Vascular Disease Chronic Renal Insufficiency Secondary: Hypertension Diabetes type II GERD Arthritis Obstructive Sleep Apnea Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2138-4-11**]

[ "357.2", "584.9", "327.23", "530.81", "403.90", "780.79", "707.15", "250.40", "428.0", "428.43", "300.4", "716.90", "250.60", "276.2", "426.4", "278.01", "438.89", "410.71", "424.1", "585.9", "518.81" ]

icd9cm

[ [ [] ] ]

[ "93.90", "99.04" ]

icd9pcs

[ [ [] ] ]

8725, 8734

6272, 8034

309, 343

8971, 8980

3746, 3746

9036, 9074

3254, 3313

8693, 8702

8755, 8950

8060, 8670

9004, 9013

3328, 3727

250, 271

371, 2734

3763, 6249

2756, 3131

3147, 3238

28,502

160,072

8675

Discharge summary

report

Admission Date: [**2200-6-1**] Discharge Date: [**2200-6-17**] Date of Birth: [**2140-12-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Intubation Extubation History of Present Illness: 59 yo M with PMH CHF Ef 35% p/w worsening shortness of breath for several weeks. States dyspnea is similar to prior episodes before he had his pleural effusion drained. Also with worsened LE edema. With h/o Afib and pleural effusion. Denies productive cough, sick contacts. [**Name (NI) **] had fever and chills for months. Has not seen a doctor for this. Also states has been drinking 3 pints of Vodka daily and not eating for last several days. Endorses DOE and intermittent chest pressure, but none currently. . Initial ED VS 98.2, 32, 88/47, 15, 96/5L. CXR with increased pleural effusions. Looked fluid overloaded initially but thought he was intravascularly deplete. Recieved 500cc IVF and started on BiPAP per respiratory. Labs were grossly abnormal. Atropine at the bedside but not used. Increased troponin compared to baseline; EKG Atrial fibrillation with slow ventricular response, no obvious ST changes. ED on transfer, 40, 96/47, 18 and 100/BiPAP. . 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 exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Denies Diabetes, Dyslipidemia & HTN 2. CARDIAC HISTORY: Chronic systolic CHF EF~30% -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: # Alcoholism w/ withdrawal seizures, DT's # CRI b/l Cr ~1.3 # DM # Asthma # COPD # HCV # Atrial fibrillation # h/o pancreatitis # h/o of c.diff in [**3-5**] # peripheral neuropathy # h/o VAP # Hepatitis C Social History: Smokes [**11-29**] ppd x 45 years. [**Street Address(1) 30406**]. Drinks 3 pints Vodka daily. Denies other drug use. Family History: No known family history of early CAD; otherwise non-contributory. Physical Exam: VS: T= 97.7 BP= 103/69 HR= 39 RR 15 and 94/5L GENERAL: WDWN, mildly agitated, stating he cannot breath. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Mucosa mildly dry. NECK: Supple with [**Street Address(1) 22116**] ofm 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB except mild end expiratory wheeze, no crackles, or rhonchi. ABDOMEN: Soft, diffusely tender to palpation without localization. No HSM but exam limited. EXTREMITIES: No c/c. 2+ edema in LE b/l to mid-thigh SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP/PT obscured by edema Left: Carotid 2+ DP/PT obscured by edema Pertinent Results: LABS/STUDIES EKG: 38 bpm, atrial fibrillation, no marked changes in ST segments or TW morphology. . CHEST (PORTABLE AP) Study Date of [**2200-6-1**] 6:47 PM 1. Interval increase in size of moderate left pleural effusion, with partially loculated component along the base. 2. Increasing bibasilar opacities which could reflect atelectasis, but infection or aspiration are not excluded. 3. Small right pleural effusion persists. 4. No evidence for congestive heart failure. . ADMISSION LABS: . 121 / 89 / 42 / 109 AGap=23 ------------- 5.4 / 14 / 2.4 . CK: 415 MB: 17 MBI: 4.1 Trop-T: 0.13 Ca: 7.6 Mg: 1.2 P: 4.1 proBNP: [**Numeric Identifier 30407**] WBC 7.3, Hb 9.5, Hct 28, Plt 130 N:78.0 L:16.6 M:4.0 E:1.1 Bas:0.4 BLOOD [**Numeric Identifier **]-NEG Ethanol-205* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG OTHER LABS: [**2200-6-12**] 03:33AM BLOOD PT-15.8* PTT-26.8 INR(PT)-1.4* [**2200-6-12**] 03:06PM BLOOD Glucose-182* UreaN-25* Creat-1.0 Na-140 K-3.9 Cl-97 HCO3-35* AnGap-12 [**2200-6-5**] 04:43AM BLOOD ALT-14 AST-20 AlkPhos-82 TotBili-0.2 Labs on Discharge: [**2200-6-15**] 10:10AM BLOOD WBC-6.6 RBC-2.62* Hgb-7.9* Hct-24.4* MCV-93 MCH-30.2 MCHC-32.5 RDW-18.1* Plt Ct-329 [**2200-6-15**] 10:10AM BLOOD Plt Ct-329 [**2200-6-15**] 10:10AM BLOOD Glucose-194* UreaN-28* Creat-1.1 Na-137 K-4.6 Cl-98 HCO3-30 AnGap-14 [**2200-6-5**] 04:43AM BLOOD ALT-14 AST-20 AlkPhos-82 TotBili-0.2 [**2200-6-15**] 10:10AM BLOOD Calcium-7.9* Phos-3.2 Mg-1.8 IMAGING STUDIES: CXR [**2200-6-1**]: 1. Interval increase in size of moderate left pleural effusion, with partially loculated component along the base. 2. Increasing bibasilar opacities which could reflect atelectasis, but infection or aspiration are not excluded. 3. Small right pleural effusion persists. 4. No evidence for congestive heart failure. ECG [**2200-6-2**]: Irregularly irregular rhythm with a single wider complex beat, probably ventricular. The dominant population shows low voltage, leftward axis and ST-T wave abnormalities. Since the previous tracing of [**2200-6-1**] the ventricular premature beat is new. The rate is faster. QTc interval is shorter. CT Chest [**2200-6-7**]: 1. Increase in volume of left pleural effusion compared to prior study with now moderate-to-large left pleural effusion. 2. Increase in left lower lobe atelectasis compared to prior study. 3. Patchy airspace opacification in the upper lobes bilaterally is nonspecific but may represent evidence for infection or volume overload. 4. Question tiny left sided pneumothorax, more likely to represent small focus of aerated lung. Brief Hospital Course: 1) Dyspnea/Systolic Heart Failure: Patient presented with shortness of breath. On admission it was unclear whether he was fluid overloaded so he was given a fluid challenge which resulted in worsened pulmonary edema and more florid evidence of heart failure exacerbation. He was admitted to the MICU where he requried intubation given his decompensate repiratory status related to his fluid overload. He was aggressively diuresed with a lasix gtt and was able to be extubated on [**2200-6-11**]. He was transitioned from lasix gtt to large IV boluses and eventually transitioned to oral lasix. Patient's metoprolol was also slightly increased from home dose of 300mg daily to 375 mg daily. He was started on an ACE inhibitor. It is unclear what led to heart failure exacerbation. Most likely etiology felt to be medication non-compliance. Patient's volume status and respiratory status stable at time of discharge. We recommend he get an outpatient ECHO and that he follow up in heart failure clinic. Both of these appointments have been scheduled. 2) Atrial Fibrillation - The patient has atrial fibrillation with decreased ventricular response. In CCU, his rate controlling agents given bradycardia. By time of transfer to floor, the patient's HR was high 70-80s. Coumadin was not given secondary to patient preference (he is not on coumadin as an outpatient). Upon arrival to the MICU, the patient was started back on a lower dose of metoprolol. While in the MICU, he had some episodes of tachycardia, requiring his metoprolol to gradually be increased to 125mg po TID. He has remained rate controlled while on the medical floor and is being discharged on Metoprolol succinate 375 mg daily. 3) Alcohol Dependence - Reported h/o DTs with seizures.?????? Patient states seizures are unrelated and he gets them when he's 'hot and cold'. Patient given MIV, thiamine, folate. Put in CIWA scale with valium, requiring 4 doses in CCU. SW consulted. In the MICU, the CIWA protocol was discontinued secondary to the patient's worsening respiratory status and ultimate intubation. While on the floor Pt was not requiring valium per CIWA scale. Recommend that patient be connected with outpatient resources for his alcoholism 4) Anemia - Normocytic anemia. Iron studies normal back in [**4-5**] and not repeated. Likely anemia related to chronic ETOH abuse and subsequent bone marrow suppression. No e/o GI losses. Would recommend age appropriate screening such as colonscopy as outpatient. Hct remained stable around 25-28. 5) ARF: Cr elevated on admission to 2.4 felt to be [**12-30**] prerenal. Cr returned to baseline of 1.1-1.2 after receiving fluids. Likely he had poor forward flow from heart failure exacerbation. 6) Diabetes mellitus type II: pt on ISS while inpt. Should restart metformin as outpt.. 7) Chronic Obstructive Pulmonary Disease: Continued on Advair, Spiriva, and Albuterol prn. 8) Elevated INR/Reduced albumin: Likely related to poor nutrition, though this could also indicate progressing liver disease. Would suggest outpt liver ultrasounds and continued monitoring of this issue. 9) Recurrent left pleural effusion: On last admission, underwent left-sided diagnostic and therapeutic thoracentesis on [**2200-4-14**] with removal of 2.3L transudative fluid. Cytology negative for malignant cells. Attributed to chronic systolic CHF and medication noncompliance. Added hydralazine and isosorbide for better afterload reduction. Adequate room air ambulatory oxygen saturation prior to discharge. Now readmitted with worsened effusion, dyspnea and new O2 requirement likely related to acute CHF exacerbation. Respiratory status improved with aggressive diuresis and patient now sating in high 90's on room air. 10)Mediastinal lymphadenopathy/pulmonary nodules - Noted on prior admission CT scan [**2200-4-14**], recommended follow-up CT in 3 months. Medications on Admission: (Per [**2200-4-16**] d/c summary, pt states does not look at bottles and does not know pharmacy, 'check with my Case Manager') 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)Capsule, Delayed Release(E.C.) PO once a day. 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO at bedtime. 7. Diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 8. 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. 9. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 10. Metformin 500 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 11. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) INH Inhalation once a day. 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 13. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)Tablet Sustained Release 24 hr PO once a day. 14. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Metformin 500 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**11-29**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 14. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. Discharge Disposition: Extended Care Facility: [**Location (un) **] Twin Oaks Discharge Diagnosis: Primary: Congestive heart failure exacerbation, Aspiration pneumonia Secondary: Pleural effusion Discharge Condition: Good, ambulatory, vital signs stable Discharge Instructions: You came to the hospital with shortness of breath. We determined you were having an exacerbation of your heart failure. You required a brief stay in our ICU where you were intubated for airway protection for a short time. We also treated you for a pneumonia with antibiotics. We have made changes to your heart failure medications so as to prevent further exacerbations. NEW MEDICATIONS: --Lisinopril 10mg daily STOP taking: Imdur 30 mg daily Hydralazine 10 mg every 6 hrs CHANGES to medications: --Diltiazem increased to 180mg daily (was 120mg daily) --Lasix increased to 160 mg twice a day (was 40 mg daily) If you experience chest pain, shortness of breath, notice increased difficulty breathing while lying flat, fevers or chills please contact your primary care physician or come to the emergency department for evaluation. You Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: . Please Followup Instructions: We have scheduled you to have an echocardiogram to assess the pumping function of your heart. This test has already been scheduled for [**7-15**] 9am. [**Hospital Ward Name 23**] Bldg floor, [**Hospital Ward Name 516**]. If you need to reschedule the phone number is [**Telephone/Fax (1) 62**]. You have outpatient follow-up appointments scheduled with your Primary Care Provider. [**Name10 (NameIs) 357**] attend all scheduled follow-up appointments: Dr. [**Last Name (STitle) **] (Primary Care Doctor). Tuesday [**2200-6-24**] 7:30 AM. Please call his office at [**Telephone/Fax (1) 11436**] with any questions. You should follow with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] (cardiologist)[**2200-7-28**] at 9am. His office is located on the [**Hospital Ward Name 516**] on [**Hospital Ward Name 23**] [**Location (un) **]. The office phone number is ([**Telephone/Fax (1) 2037**].

[ "291.81", "507.0", "287.4", "V15.81", "428.23", "276.1", "403.90", "276.9", "428.0", "272.4", "425.5", "427.31", "518.89", "787.22", "V45.81", "V45.02", "250.62", "585.9", "303.91", "577.1", "493.21", "785.6", "276.2", "357.2", "V60.0", "584.9", "V02.62" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.93", "96.72" ]

icd9pcs

[ [ [] ] ]

12843, 12900

6013, 9895

334, 358

13041, 13080

3410, 3885

14092, 15017

2397, 2464

11360, 12820

12921, 13020

9921, 11337

13104, 14069

2479, 3391

1920, 2006

275, 296

4480, 4860

386, 1816

3901, 4221

2037, 2244

1838, 1899

2260, 2381

4233, 4461

4878, 5990

68,036

143,191

14825

Discharge summary

report

Admission Date: [**2150-1-2**] Discharge Date: [**2150-2-11**] Date of Birth: [**2072-9-15**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1854**] Chief Complaint: Altered Mental Status, new subdural hematoma Major Surgical or Invasive Procedure: [**2150-1-3**]: Right sided craniotomy for evacuation of subdural hematoma [**2150-1-17**]: Wound exploration and debridement of collection [**2150-1-18**]: Re-exploration of wound collection [**2150-2-1**]: trach/peg History of Present Illness: Mr [**Known lastname **] is a 77M s/p VP shunt placement for normal-pressure hydrocephalus 2 months ago who presented to the emergency department with a new acute, right sided subdural hematoma and a poor neurological examination. Past Medical History: Afib HTN BPH ED Dementia OSA Reflux NPH Social History: Previously living in in-law suite connected to Daughter's house. Family History: Non-contributory Physical Exam: On Admission: Non-reactive right pupil and extensor posturing. Toes upgoing bilaterally. Pertinent Results: Labs on Admission: [**2150-1-2**] 10:30PM BLOOD WBC-11.9* RBC-3.75* Hgb-11.8* Hct-34.4* MCV-92 MCH-31.4 MCHC-34.2 RDW-15.5 Plt Ct-149* [**2150-1-2**] 10:30PM BLOOD Neuts-91.9* Lymphs-5.0* Monos-2.8 Eos-0.2 Baso-0.1 [**2150-1-16**] 05:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Stipple-1+ Acantho-OCCASIONAL [**2150-1-2**] 10:30PM BLOOD PT-14.0* PTT-24.9 INR(PT)-1.2* [**2150-1-2**] 10:30PM BLOOD Glucose-129* UreaN-21* Creat-1.0 Na-134 K-4.4 Cl-100 HCO3-22 AnGap-16 [**2150-1-2**] 10:30PM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0 [**2150-1-3**] 05:38PM BLOOD Phenyto-8.4* [**2150-1-2**] 11:50PM BLOOD Type-ART pO2-252* pCO2-37 pH-7.41 calTCO2-24 Base XS-0 [**2150-1-2**] 11:50PM BLOOD Glucose-126* Lactate-2.0 Na-136 K-4.1 Cl-104 IMAGING: Head CT [**1-2**]: IMPRESSION: Acute large right subdural hematoma measuring up to 2.3 cm with compression on adjacent right cerebral hemisphere, near complete effacement of the right lateral ventricle, 15 mm leftward subfalcine herniation, and complete right uncal herniation. Enlarged left ventricle suggests ventricular entrapment from subfalcine herniation. No comparison images are available to assess for interval change. Head CT [**1-3**]: IMPRESSION: Status post evacuation of right-sided subdural hematoma with small amount of high-density blood remaining layering posteriorly. There is significant decrease mass effect with resolution of right uncal herniation and decreased compression on the right lateral ventricle. Decreased leftward subfalcine herniation. Head CT [**1-15**]: FINDINGS: Heterogeneous fluid collection and subdural hematoma in the right frontoparietal convexity is stable to slightly increased in size compared to prior study. No shift of midline structures is noted. Unchanged intraventricular component of hemorrhage in the occipital [**Doctor Last Name 534**] of the left lateral ventricle is identified. There is no new hemorrhage. Configuration and size of the ventricles is unchanged from prior studies. Post-surgical changes in the right frontal region, small pneumocephalus and craniotomy again identified. Torso CT [**1-17**]: IMPRESSION: 1. Bilateral lower lobe interstitial promenince and linear opacities of uncertain chronicity. Without prior studies, infection cannot be excluded, although the findings may reflect a chronic process. 2. Small pericardial effusion. 3. Diverticulosis without evidence of diverticulitis. CT Head +/- [**1-18**]: FINDINGS: The frontal component of the hypodense right subdural collection appears stable measuring 13.5 mm in maximal transverse dimension. Its isodense occipital component is more conspicuous on the postcontrast images of this study compared to the noncontrast images of this and the previous studies. The hyperdense epidural collection underlying the right frontal/parietal craniotomy is slightly smaller. The overlying right subgaleal collection is also slightly smaller. Enhancement along the dura underlying the craniotomy and along the subgaleal collection is expected in the post- operative setting, but superimposed infection cannot be excluded by imaging.There is no new hemorrhage. There is no shift of normally midline structures or evidence of a major vascular infarct. Configuration and size of ventricles is unchanged from prior studies, with partial effacement of the right lateral ventricle. Fluid in the maxillary sinuses is likely related to intubation. LENIS [**1-13**]: IMPRESSION: No evidence of deep vein thrombosis in either leg. CT Head [**1-25**]: Considering technical differences the right frontal and right occipital extra-axial fluid accumulation is relatively unchanged in size measuring approximately 13 mm in the right frontal region and 12 mm in right occipital region. There has been interval evolution of blood products within the right frontal collection. No new focus of hemorrhage is noted. No infarction or new mass effect is noted. The ventricles and sulci are mildly prominent consistent with involutional changes. The patient is status post right temporoparietal craniotomy with unchanged appearance of the surgical bed. IMPRESSION: Unchanged size of right frontal and right occipital subdural fluid accumulation with interval evolution of blood products within the right frontal region. The study is otherwise unchanged since [**1-24**], [**2149**]. CT Head [**2-3**]: FINDINGS: Frontoparietal craniectomy with unchanged right frontal and occipital extra-axial low-density fluid collections. There is no new focus of hemorrhage. There is a similar mild mass effect exerted on the right frontal and occipital [**Doctor Last Name 534**] ventricles. There is no midline shift. On non-contrast-enhanced images, there is slight asymmetry of the superior sagittal sinus as demonstrated on prior MR from [**2144**] (outside study). There is no abnormal enhancing lesion. IMPRESSION: Unchanged size of right frontal and occipital subdural fluid collection consistent with subacute/chronic subdural hematoma. Brief Hospital Course: The patient was admitted with mental status changes. He had fevers, LLL infiltrate on [**2150-1-4**]. He was started on antibiotics that day. The following day the ICU team stopped the antibiotics due to a clear chest x-ray and normal secretions. He was also extubated that day. On [**1-7**] the patient was transferred to the floor. The patient was not doing well with swallowing and a dophoff was placed for tube feedings. On [**1-10**] there appeared to be a fluid collection in the subgaleal space where the prior surgery was done. The patient's neuro exam remained stable in that he was moving all 4 but he was somewhat lethargic. A repeat head CT on [**1-14**] was stable. The patient had low grade fevers. His fever workup was negative for DVT, PNA, c-diff. His white count was starting to increase however. The patient's neuro exam was improving and he became more alert and engaged by the 23rd. His white count continued to rise and his sed rate was elevated to 70. The patient had tachypnea into the 30s while on the floor and was transferred back to the ICU for respiratory distress. He was reintubated the following day. Neurologically he was also much more lethargic and was not following commands. The patient was taken back to the OR on [**1-17**] for wound wash-out. He had drainge that appeared purulent post-operatively so he was taken to the OR again on [**1-18**] and had a craniectomy. The area was cleaned out and the bone was left off in order to allow the infection to clear. His CT was improved post-operatively. Mr. [**Known lastname **] neuro exam was stable while he was intubated. His cultures grew MSSA so antibiotics were tailored to this. On [**1-19**] he had a-fib/a-flutter and he was started on a diltiazem drip. He was extubated again on [**1-20**], was following commands with all 4 extremities, and was conversant. On [**1-24**] the patient was transfused due to low crit and hypotension. On [**1-27**] the patient was reintubated for continued tachpnea and respiratory distress. Vasopressors were started and he was on diltiazem drip again for a-fib. The dilt was weaned off a few days later. After several family meetings the decision was made to do a trach and peg. The procedures occurred on [**2-1**]. On [**2-2**] a repeat head CT was stable with no obvious fluid collection. The pt's neurological status continued to improve. He was able to be weaned of the vent and was stable for over 24 hours. He was transferred to the stepdown unit on [**2-10**]. He had been getting out of bed to chair with his helmet on in the ICU. He was screened for rehab. The patient is on amiodarone for recent a-flutter. He is to be tapered to 200 mg [**Hospital1 **] on [**2150-2-12**]. He is to be tapered to 200 daily in 1 week on [**2150-2-17**]. He is to follow up with his cardiologist [**Last Name (un) 1025**] [**Location (un) **], at [**Location (un) 620**] upon discharge from rehab. Medications on Admission: unknown Discharge Medications: 1. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 6. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1) Intravenous Q6H (every 6 hours). 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: Right Subdural Hematoma Wound Infection with Leukocytosis Post-Operative Atelectasis Hyponatremia Oral Candidia Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain with & without contrast. Completed by:[**2150-2-11**]

[ "041.11", "327.23", "600.00", "331.5", "401.9", "E878.1", "294.10", "458.29", "518.81", "432.1", "998.32", "276.1", "427.32", "112.0", "263.9", "530.81", "682.8", "996.63", "E878.8", "244.9", "507.0" ]

icd9cm

[ [ [] ] ]

[ "01.25", "86.3", "01.31", "96.72", "02.43", "96.6", "38.93", "96.04", "03.31", "31.1", "43.11" ]

icd9pcs

[ [ [] ] ]

10302, 10372

6208, 9135

363, 582

10528, 10552

1146, 1151

11988, 12219

1003, 1021

9193, 10279

10393, 10507

9161, 9170

10576, 11965

1036, 1036

279, 325

610, 842

1166, 6185

864, 905

921, 987

42,390

112,501

44377

Discharge summary

report

Admission Date: [**2165-11-25**] Discharge Date: [**2165-12-9**] Date of Birth: [**2109-2-8**] Sex: F Service: CARDIOTHORACIC Allergies: Erythromycin Base / Penicillins / Claritin / Lipitor / Latex Attending:[**First Name3 (LF) 922**] Chief Complaint: paroxysmal atrial fibrillation Major Surgical or Invasive Procedure: Bilateral thoracoscopic mini-Mazes, left atrial appendage ligation [**11-27**] History of Present Illness: This 56 year old white female has a several year history of paroxysmal atrial fibrillation. She has continued this despite multiple medication trials. She self referred for evaluation of surgical ablation and was admitted for surgery. Past Medical History: paroxysmal atrial fibrillation s/p DCCV seizure disorder hypertension chronic hyponatremia hyperlipidemia glaucoma obesity s/p R knee surgery s/p L elbow surgery s/p bladder resusupension Social History: The patient is a special education teacher. non smoker, denies ETOH use Family History: noncontributory Physical Exam: Admission: Alert and oriented, exam nonfocal. lungs- clear Cor- AF at 95 BPM, w/o murmur Extremeties- well perfused, palplable pulses, trace edema. Abd- obese, benign. discharge: General: well appearing obese female in NAD VS: 97.9, 114/69, 80SR, 18, 99% on roomair Chest: CTAB Incisions: bilateral thoracotomy incisions both c/d/i without erythema or drainage COR: RRR, no murmur or rub ABD: large, round, soft, NT, ND, +BS Extrem: warm and well perfused, no edema Pertinent Results: Indication: Left ventricular function. Right ventricular function. Acidosis post Maze procedure ICD-9 Codes: 424.0, 424.2 Test Information Date/Time: [**2165-11-28**] at 14:55 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) **], MD Test Type: Portable TEE (Complete) Son[**Name (NI) 930**]: Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2009W000-0:00 Machine: Vivid i-5 Sedation: (See comments below for other sedation.) Patient was monitored by a nurse throughout the procedure Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: >= 55% >= 55% Findings 40 mg of Propofol was given. LEFT ATRIUM: No spontaneous echo contrast in the body of the LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. LEFT VENTRICLE: Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal descending aorta diameter. No atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No masses or vegetations on aortic valve. No AS. Trace AR. MITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral valve. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient was under general anesthesia throughout the procedure. No TEE related complications. Conclusions No spontaneous echo contrast is seen in the body of the left atrium. A patent foramen ovale is present. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Normal biventricular systolic function. Stretched patent foramen ovale is present. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) **] [**Name8 (MD) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2165-11-28**] 18:03 [**2165-12-9**] 07:10AM BLOOD WBC-9.7 RBC-3.74* Hgb-11.7* Hct-32.8* MCV-88 MCH-31.5 MCHC-35.9* RDW-13.2 Plt Ct-425 [**2165-12-7**] 08:00AM BLOOD PT-41.9* INR(PT)-4.6* [**2165-12-8**] 11:00AM BLOOD PT-23.2* INR(PT)-2.2* [**2165-12-9**] 07:10AM BLOOD PT-17.0* INR(PT)-1.5* [**2165-12-6**] 04:52AM BLOOD PT-35.1* INR(PT)-3.7* [**2165-12-9**] 07:10AM BLOOD Glucose-109* UreaN-13 Creat-0.6 Na-135 K-3.9 Cl-97 HCO3-26 AnGap-16 Brief Hospital Course: She was admitted 2 days prior to surgery for heparinization off coumadin. She was taken to the operating room on [**11-27**] where bilateral thoracoscopic mini-Mazes with left atrial appendage ligation was performed. She tolerated the procedure well and was transferred to the ICU in stable condition. She weaned from the ventilator and was extubated on POD 2 after her metabolic acidosis/respiratory failure cleared. A TEE was performed on POD 1 to demonstrate no cardiac pathology. Paravertebral blocks were administered on [**11-28**] for pain control with good results. She was kept in the ICU for pulmonary care and ready for transfer to the floor on POD 5 ([**12-2**]). Amiodarone, beta blockers and antiinflammatory medications were administered to maintain sinus rhythm and control post operative inflammatory response. However on POD# 6 pt developed Afib, flutter which was rate controlled. Coumadin was resumed at home dose of 5 mg but INR rose to 5.6- coumadin was held and d/c was post-poned. That evening she went into atrial flutter and her lopressor was increased. On post-operative day 9 she was electively cardioverted to sinus rhythm. INR normalized and the patient was maintained on lower doses of coumadin than previously due to concommitant amiodarone administration. She continued to progress and she was ready for discharge to rehab on POD # 12 where she will undergo further conditioning to increase strength, endurance and activities of daily living. All follow up appointments were advised. Medications on Admission: Keppra 1500mg [**Hospital1 **] Tegretol XR 400mg [**Hospital1 **] Diltiazem SR 180mg/D Ativan 0.5 mg/D ASA 325mg/D Lopressor 150mg TID Coumadin 5mg/D Xalantan 0.05% ophth. 1 gtt OU qHS Pantoprazole 40mg/D Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 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. Disp:*50 Tablet(s)* Refills:*0* 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 6. Carbamazepine 100 mg Tablet Sustained Release 12 hr Sig: Four (4) Tablet Sustained Release 12 hr PO BID (2 times a day). 7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg 2x/day for 1 week, then 200mg 2x/day for 1 week, then 200mg/day until further instructed. Disp:*120 Tablet(s)* Refills:*0* 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:*qs * Refills:*0* 12. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Tablet(s) 13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-15**] Puffs Inhalation Q6H (every 6 hours) as needed. 16. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 17. Warfarin 1 mg Tablet Sig: .5 Tablet PO once a day: .5mg alternating with 0mg for goal INR 2-2.5 (atrial fibrillation). Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: paroxysmal strail fibrillation s/p bilateral thoracoscopic mini-Mazes, left atrial appendage ligation hypertension obesity seizure disorder hyperlipidemia glaucoma endometriosis s/p bladder resuspension s/p R knee surgery s/p L elbow surgery s/p appendectomy Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) wound clinic in 2 weeks Dr. [**Last Name (STitle) 73**] in 2 weeks Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**11-15**] weeks ([**Telephone/Fax (1) 608**]) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (ENT) as an outpatient to evaluate mass on left vocal cord please call for appointments Completed by:[**2165-12-9**]

[ "272.4", "427.31", "427.32", "365.9", "518.0", "429.89", "997.39", "345.90", "276.1", "617.9", "787.91", "278.00", "401.9", "790.92", "518.5", "276.4", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "38.91", "37.33", "96.71", "03.91" ]

icd9pcs

[ [ [] ] ]

8427, 8497

4714, 6239

357, 438

8800, 8807

1540, 4691

9211, 9662

1021, 1038

6495, 8404

8518, 8779

6265, 6472

8831, 9188

1053, 1521

287, 319

466, 703

725, 915

931, 1005

16,892

104,254

3495

Discharge summary

report

Admission Date: [**2102-4-8**] Discharge Date: [**2102-4-17**] Date of Birth: [**2041-2-3**] Sex: F Service: MEDICINE/ACOVE HISTORY OF THE PRESENT ILLNESS: This is a 61-year-old woman with left breast cancer status post chemotherapy and radiation treatment in [**2099**] who was recently diagnosed with liver metastases, who was admitted on [**2102-4-8**] with complaints of fatigue, decreased oral intake, hypotension, and acute renal failure secondary to acute tubular necrosis and contrast-induced nephropathy. The patient's creatinine was noted to be 5.7 on admission, and her normal baseline creatinine is 1.2. The patient initially was admitted to the Medical Intensive Care Unit and was aggressively fluid resuscitated with a return of her systolic blood pressure to a baseline of 100-110 and her creatinine improved to 1.6. The patient became fluid overloaded in the Intensive Care Unit with net 25 liters positive fluid intake. She demonstrated significant third spacing of her fluids with total body anasarca. The [**Hospital 228**] hospital course has been complicated by leukocytosis without fever, and with an elevated total bilirubin. In the Intensive Care Unit, the patient empirically was started on ampicillin, levofloxacin, and Flagyl for a question of biliary sepsis. An abdominal ultrasound on [**2102-4-9**], however, showed no common bile duct dilatation, and no evidence of cholecystitis. In addition, an MRCP was performed on [**2102-4-11**] which showed no intra or extrahepatic duct dilatation but did show diffuse metastatic disease to the liver and splenomegaly with diffuse anasarca. The ERCP Service was consulted and felt that there was no need for ERCP at this time given these imaging findings. The patient also has been complaining of severe back pain. An MRI of the L spine was obtained which showed no evidence of metastatic disease to the L spine and the pain was thought to be secondary to capsular distention from her extensive hepatic metastatic disease. The Pain Service was consulted and the patient was placed on a Ketamine drip briefly but then was transitioned to Dilaudid and morphine orally p.r.n. with good pain relief. An epidural catheter was considered; however, after further discussion with the patient, the patient's family, and Dr. [**First Name (STitle) **], the patient's oncologist, it was thought that the epidural catheter would not be the best decision given the management issues surrounding taking care of an epidural catheter. The patient was also started on Xeloda for her metastatic breast cancer while in the Intensive Care Unit. She was transitioned out of the Intensive Care Unit on [**2102-4-15**]. PAST MEDICAL HISTORY: 1. Left breast cancer in [**2099**], status post chemotherapy and radiation treatment in [**2100-10-23**], status post lumpectomy and axillary lymph node dissection. Liver metastases diagnosed in [**2102-3-23**]. 2. Hypothyroidism. 3. Hypertension. 4. Depression. 5. Sciatica. ADMISSION MEDICATIONS: 1. Atenolol 50 mg p.o. q.d. 2. Roxicet one tablet p.o. q. six hours. 3. Levoxyl. 4. Fioricet one tablet q.a.m. 5. Paxil 20 mg p.o. q.d. 6. Tamoxifen 20 mg p.o. q.d. SOCIAL HISTORY: The patient smoked one pack per day times 20 years, now quit. She had minimal alcohol use. She is self-employed and has a 21-year-old step-son. FAMILY HISTORY: Positive for liver cancer in her father at age 86, mother with coronary artery disease in her 80s. PHYSICAL EXAMINATION ON ADMISSION: General: On admission, the patient was a pleasant elderly woman in no acute distress. She had difficulty speaking secondary to a dry mouth. Vital signs: Temperature 98, blood pressure 111/37, heart rate 72, respiratory rate 18, oxygen saturation 99% on room air. HEENT: Pupils equal, round, and reactive to light. Extraocular movements intact. Sclerae anicteric. The oropharynx was dry and perched. No lymphadenopathy. No jugular venous distention. Cardiovascular: Normal S1 and S2 with a regular rate and rhythm without murmurs, rubs, or gallops. Pulses paradoxus was less than 10. Lungs: Minimal crackles at the right base, otherwise clear to auscultation. Abdomen: Soft, diffuse tenderness, especially in the right upper quadrant without masses. Decreased bowel sounds throughout with liver edge palpable below the rib cage. Extremities: There was 1+ edema bilaterally in the lower extremities below the knees. Neurologic: Alert and oriented times three. Cranial nerves II through XII were intact. Strength was [**2-25**] bilaterally. LABORATORY/RADIOLOGIC DATA: White count 12.1, hematocrit 32, platelets 243,000. The Chem-7 was within normal limits. The LFTs were remarkable for an ALT of 198, AST 526, alkaline phosphatase 451, total bilirubin 2.0, albumin 3.0. CEA on [**2102-4-5**] was 203, CA19-9 32 and CA27.29 459. Chest x-ray: Enlarged heart with atelectasis at the left costophrenic angle and low lung volumes. No pneumothorax. No pleural effusions. No pulmonary opacities. HOSPITAL COURSE: As noted above, the patient was transferred out of the Intensive Care Unit on [**2102-4-15**]. However, on [**2102-4-16**], the patient became hypotensive with blood pressures running 70/40 without response to fluid boluses. In addition, the patient's urine output significantly declined to less than 100 cc in an eight hour shift. The patient's Foley catheter was replaced times two without any success in urine output. A bladder scan was obtained which showed 330 cc present; however, it was felt that this result was likely erroneous given the patient's anasarca. The Foley was removed and a voiding trial was attempted; however, the patient did not urinate successfully and, therefore, the Foley catheter was replaced. The patient's creatinine rose from 1.6 to 1.9 on [**2102-4-16**]. It was thought that her hypotension may have been secondary to increasing dose of narcotics, as well as the patient was likely intravascularly volume depleted. The patient's volume issues were extremely difficult to handle as the patient clearly demonstrated anasarca with third spacing issues; however, the patient likely was intravascularly volume depleted. The patient's nutritional status was extremely poor as she was unable to eat much orally and it was decided during her Intensive Care Unit stay that TPN should not be initiated given her fluid spacing issues. The patient's albumin was noted to be 1.8 which was likely contributing to her third spacing. Given the patient's poor prognosis and profound hypotension, a brief family meeting was initially held with the patient's brother and sister in-laws without the husband being present. At that time, it was decided that aggressive measures to increase her blood pressure via pressors was not indicated. It was also reiterated that the goal of care at this time was comfort. Further discussion occurred with the cross-covering medicine team and the patient's husband and at that time it was again re-emphasized that the role of pressor treatment in the Intensive Care Unit would likely be only a transient measure as the patient does have progressive metastatic breast cancer and was likely not to recover. On [**2102-4-17**], the patient became progressively unresponsive and more hypotensive with near aneuric urine output. The patient was made CMO on the morning of [**2102-4-17**] after further discussion with the husband and the patient's proxy. The patient was made comfortable with a morphine drip and all other medications were terminated. The patient expired shortly thereafter at 9:30 p.m. on [**2102-4-17**]. CONDITION ON DISCHARGE: Expired. DISCHARGE DIAGNOSIS: Metastatic breast cancer with extensive liver metastases. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], M.D. [**MD Number(1) 1208**] Dictated By:[**Last Name (NamePattern1) 1336**] MEDQUIST36 D: [**2102-4-26**] 04:05 T: [**2102-4-29**] 14:17 JOB#: [**Job Number 16056**]

[ "785.59", "V10.3", "197.7", "570", "584.5", "038.9", "286.7", "276.5", "E947.8" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3384, 3505

7698, 8033

5055, 7641

3031, 3203

3520, 5037

2724, 3008

3220, 3367

7666, 7676

65,538

156,029

36681

Discharge summary

report

Admission Date: [**2200-7-7**] Discharge Date: [**2200-7-11**] Service: MEDICINE Allergies: Levofloxacin / Metronidazole / Alendronate Sodium / Risedronate Sodium Attending:[**First Name3 (LF) 3556**] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: This is a 87 year old female with ahistory of brain tumor s/p resected (gets treatment at [**Hospital1 2025**] with records pending). She was in rehab when she fell. At the time she was on coumadin for a-fib (with INR 1.3) She went to [**Hospital **] hospital and was found to be hyponatremic there (Na 114). Her family states Na runs low -120s - usually 123 per family but no records are currently available (ED/MICU staff trying to get from [**Hospital1 2025**].) A CT was done at the OSH and the pt was transferred here for neurosurg with question of possible punctate bleed. A repeat head CT was done in the ER and neurosugery felt that surgery was not indicated. However, she was admittted to the MICU for management of her hyponatremia. On presentation she was more obtunded on presentation initially - had gag reflex - not oriented, Past Medical History: - Lt insular tumor, recently dx at [**Hospital1 2025**]; undergoing XRT; -HTN -Afib on coumadin - hyponatremia (chronic) Social History: Not obtained Family History: Non-contributory Physical Exam: General Appearance: No acute distress, Thin Eyes / Conjunctiva: PERRL, No(t) Sclera edema, EOMI Head, Ears, Nose, Throat: Normocephalic, left forehead lac sutured Cardiovascular: (PMI Normal), (S1: Normal), (S2: Distant) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Rhonchorous: ) Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t) Clubbing Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): person, season, Movement: Purposeful, Tone: Not assessed, mild right facial droop, intermittently able to follow commads, occ mumbles. Pertinent Results: Labs on Admission [**2200-7-7**] WBC-14.1* RBC-3.69* Hgb-11.7* Hct-34.4* MCV-93 MCH-31.6 Plt Ct-167 Neuts-88.5* Lymphs-6.3* Monos-4.5 Eos-0.4 Baso-0.3 PT-15.2* PTT-25.6 INR(PT)-1.3* Glucose-141* UreaN-14 Creat-0.6 Na-114* K-4.4 Cl-86* HCO3-18* AnGap-14 Calcium-7.9* Phos-2.7 Mg-1.7 Cortsol-4.0 . . . . . . . . . Other Studies: [**2200-7-7**] EKG: Ventricularly paced rhythm, probably there is atrial spike but they are difficult to discern. No previous tracing available for comparison. [**2200-7-7**] CT head w/o contrast: Hypodensity with mild mass effect in the left external capsule, subinsular region, lentiform nucleus and corona radiata, which may represent the known tumor and/or sequela of therapy. 4 mm focus of blood products within this abnormality. Detailed record of prior tumor treatment and comparison with previous studies is needed for a more meaningful interpretation. If indicated, MRI with gadolinium would provide more information about the tumor. [**2200-7-7**] AP CXR: Mild cardiomegaly. No radiographic evidence for pneumonia or congestive heart failure. [**2200-7-7**] 2 View Hip Xray: 1. Acute fractures through the left superior and inferior pubic rami. 2. Linear density through vertebral body L5 which may represent a compression fracture. Radiographs of the lumbar spine are recommended for further evaluation. [**2200-7-7**] CT w/o L spine: 1. Transitional anatomy at the thoracolumbar and lumbosacral junctions, as detailed above. If surgery is contemplated, then accurate vertebral numbering should be obtained by radiographs of the entire spine. 2. Mild deformity of L1 vertebral body, without definite acute fracture lines, but of unknown chronicity. No evidence of L5 vertebral body fracture. 3. Grade 1 anterolisthesis of L4 on L5 with corticated bilateral L4 pars defects, which appears chronic. 4. 3 mm non-obstructing left renal stone. Cystic lesions in the liver and left kidney, incompletely characterized. Sigmoid diverticulosis. Brief Hospital Course: This is a 87 year old female with PNET tumor undergoing palliative radiation, hyponatremia, afib on coumadin and recent fall presenting from OSH small punctate intracranial hemorrhage and hyponatremia. 1) Punctate Intracranial Hemorrhage: This was likely caused by anticoagulation and getting XRT as it is near the tumor mass. Neurosurgery felt that no intervention was needed at this time. We gave the patient Vitamin K IV and planned to hold her warfarin for 7 days (restart [**7-14**] in pm). We also continued her on her home dose of antiseizure medications. 2) Hyponatremia: The patient has had a history of prior adrenal mass resection for benign cause, and was on fludrocort at [**Hospital1 2025**] in past 2 month. There was a question if possible adrenal pathology or her antiseizure meidcations were causing hyponatremia. But given that her baseline is 120s and she needed her anti-seizure medications, we treated her with hypertonic saline to return her to her baseline. Her mental status improved as her sodium improved. 3) Intracranial Mass: 1.7 cm in left insula, primative neuroectodermal tumor (PNET), s/p craniotomy, getting palliative XRT at [**Hospital1 2025**]. We continued her home dose of decradron and Bactrim prophylaxis. 4) Seizure disorder: We continued her Keppar and Carbamazepine. 5) Hypothyroidism: synthroid 25 mcg 6) Afib s/p ablation and placement of cardiac pacer ([**2197**]), sub-therapeutic on presentation INR 1.3. The patient was on Imdur for unclear reason at home. Given normal blood pressures in the ICU, we did not restart it. We also held her Coumadin and plan to hold it for a total of 7 days. 7) Left Pubic Fx: The patient complained of leg pain and received a hip x-ray which showed a pubic fx. Orthopedics was consulted and decided to treat with tylenol prn for pain and conservative management. 8) Restless Legs: Continued Gabapentin 100 mg QPM 9) Osteoporosis: On calcium carbonate 10) Anemia: chronic, cont to trend, wnl MCV and RDW likely ACD. 11) UTI: Pt had E coli UTI. She was treated with Cefpodoxime 7 day course. [**Date range (1) 82964**]. She should have repeat urine cx as an outpatient to ensure clearance of infection. MICU Course: Pt hyponatermic, given 3% saline for brief period until Na corrected to 122, which is consistent with her outpatient Na levels. Na observed and remained stable since. Seen by Neurosurgery, which did not feel any intervention was necessary regained intracranial mass. Ortho c/s for pelvic fx, which recommended PT and weight bearing as tolerated. PT worked with patient in ICU. Medications on Admission: carbamazepime decadron gabapentin keppra levothyoxine imdur prilosec Discharge Disposition: Extended Care Facility: [**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**] Discharge Diagnosis: Primary Diagnosis 1. Hyponatremia 2. Subarachnoid hemorrhage 3. s/p fall, pubic rami fracture 4. UTI Secondary Diagnosis PNET Discharge Condition: Hemodynamically stable, Na 120-126 Discharge Instructions: You were admitted to the hospital after a fall. You had low sodium levels, a pubic fracture, and a small bleed in your brain. The bleed was stable and resolved. We held your Coumadin which increases teh risk of bleeding. The orthopedic specialists did not feel you needed surgery for your hip fracture. Your sodium levels improved and you were able to bear weight on your hip with assist. We made the following changes to your medications 1. We added Tylenol as needed for pain 2. We added Cefpodoxime for a UTI for 4 [**12-20**] more days 3. We held your Coumadin for 7 days ([**Date range (1) 15660**]) Please return to the ER or call your primary care doctor if you develop worsening pain, chest pain, shortness of breath, confusion, seizures, weakness, dizziness, or any other concerning symptoms. Followup Instructions: Please follow up with your primary care doctor and other regular doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]. You are [**Last Name (Titles) 1988**] for XRT at [**Hospital 1121**] Cancer Center at 12:15pm on Monday [**7-14**]. Call your radiation oncologist at ([**Telephone/Fax (1) 82965**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

[ "V13.01", "V15.3", "191.8", "599.0", "041.4", "564.09", "733.00", "285.29", "345.90", "V58.61", "401.9", "E934.2", "431", "244.9", "E888.8", "333.94", "E879.2", "287.5", "873.0", "808.2", "276.1", "427.31" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6933, 7044

4220, 6813

282, 288

7215, 7252

2221, 4197

8104, 8550

1349, 1367

7065, 7194

6839, 6910

7276, 8081

1382, 2202

238, 244

316, 1159

1181, 1303

1319, 1333

820

180,654

5775

Discharge summary

report

Admission Date: [**2142-8-16**] Discharge Date: [**2142-8-27**] Date of Birth: [**2077-4-26**] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6736**] Chief Complaint: Large left renal cell carcinoma with tumor thrombus in the inferior vena cava just below the hepatic vessels. Major Surgical or Invasive Procedure: Left radical nephrectomy with inferior vena cavotomy and complete excision of renal vein with inferior vena caval reconstruction and removal of tumor thrombus. History of Present Illness: The patient presented to the emergency room with left sided pain and on further workup was noted to have a large left renal mass. Further workup revealed inferior vena caval thrombus just below the level of the hepatic vessels in the inferior vena cava and the patient was also noted to have a pulmonary embolus. He and his family fully understand the procedure, alternative therapies, benefits, and risks including death, pulmonary embolism, need for reoperation, myocardial infarction, CVA, embolism to other organs, need for long-term ventilation, damage to adjacent organs including spleen or pancreas, need for colon resection. They wished to proceed. Past Medical History: Mr [**Known lastname 22956**] has a past medical history significant for IDDM, HTN, hyperlipidemia, right-sided claudication (scheduled for angiogram in early [**Month (only) 216**]), and depression. In his past surgical history, he has had a cholecystectomy. Social History: Mr [**Name13 (STitle) **] is an ex-smoker of 20 years, with a previous 20-pack year status. He denies any recreational drug use, and intakes alcohol socially. Family History: This patient's family history is negative for any genitourinary malignancy; his mother died of brain cancer and his father died of a myocardial infarction at the age of 59. Pertinent Results: . . [**8-16**] ECHO: Conclusions: 1. Echogenic structure seen in IVC consistent with Thrombus or tumor. This extends upto 4 cm below the junction of the hepatic vein and the IVC. Flow is seen around the thrombus. 2. No atrial septal defect is seen by 2D or color Doppler. 3. 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%). 4. Right ventricular chamber size and free wall motion are normal. 5. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 6. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 7. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-15**]+) mitral regurgitation is seen. 8. There is a trivial/physiologic pericardial effusion. 9. Prior to IVC cross clamping portion of the IVC thrombus no longer seen. RV function still appears good. No echogenic structures in the RA or RV. Flow present in the main PA, Left and Right Pas. . . CXR [**8-17**]: There is no pneumothorax or pleural effusion. Mediastinal widening is probably due to vascular engorgement in the supine position. Tips of the right internal jugular catheter and endotracheal tube are at the upper margins of the clavicles, both at the thoracic inlet. Nasogastric tube passes to the mid stomach. Lungs low in volume but grossly clear. Heart size normal. Mediastinum midline. No significant free subdiaphragmatic gas. . . CXR [**8-19**]: Left lower lobe atelectasis and bilateral pleural effusion, small on the left and small-to-moderate on the right, which developed after [**8-17**] are stable since [**8-18**]. Heart is normal size. ET tube, right supraclavicular central venous line, and nasogastric tube are in standard placements. No pneumothorax. . . CXR [**8-21**]: Compared with [**2142-8-20**], the tip of the ETT appears to have been pulled back somewhat and now projects roughly 5 cm above the carina. The right lung remains grossly clear. There is diffuse haziness overlying the left lung which may be due to a left pleural effusion and associated linear perihilar densities may represent associated atelectasis. The apparent widening of the superior mediastinum is probably secondary to patient rotation to the right, with similar appearances seen on prior films from [**8-19**] and [**2142-8-17**]. Please correlate clinically. . . [**2142-8-20**] 9:40 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2142-8-22**]** GRAM STAIN (Final [**2142-8-20**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2142-8-22**]): SPARSE GROWTH OROPHARYNGEAL FLORA. . . [**2142-8-20**] 9:35 am SWAB Site: RECTAL Source: Rectal swab. **FINAL REPORT [**2142-8-22**]** R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2142-8-22**]): No VRE isolated. . . [**2142-8-20**] 9:35 am MRSA SCREEN Site: RECTAL Source: Rectal swab. **FINAL REPORT [**2142-8-22**]** MRSA SCREEN (Final [**2142-8-22**]): NO STAPHYLOCOCCUS AUREUS ISOLATED. . . [**2142-8-18**] 8:18 am SPUTUM Site: ENDOTRACHEAL **FINAL REPORT [**2142-8-21**]** GRAM STAIN (Final [**2142-8-18**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. RESPIRATORY CULTURE (Final [**2142-8-21**]): MODERATE GROWTH OROPHARYNGEAL FLORA. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE. MODERATE GROWTH. BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN. . . Brief Hospital Course: Mr. [**Known lastname 22956**] was admitted for his procedure on [**2142-8-16**]. He was prepared and consented for surgery as per standard. At this time, Mr [**Known lastname 22956**] was aware of all potential risks and benefits of his procedure. His family was also aware, and it was noted that his wife is extremely supportive and involved in the situation. In the operating room, Total estimated blood loss was approximately 5000 cc. The patient received a total of 6 units of packed red blood cells and 2 units of fresh frozen plasma during the case. There were no major intra-operative complications during the case. . Mr [**Known lastname 22956**] then spent 6 days in the ICU. Over the course of 6 days, he was extubated, had his NGT removed, and his pressors (Levophed and Neo) were stopped. His anticoagulation medications were held during the duration of his ICU care. He recieved supportive care, and was seen by the nutrition team. In addition, the renal team followed him to ensure adequate renal function. During his stay in the ICU, he was started on broadspectrum antibiotics for a possible chest infection; the patient had thick copious secretions and a chest xray was obtained. His sputum was found to be gram stain positive, and hence, he was started on Levaquin and vancomycin. . Once Mr [**Known lastname 22956**] was stable, he was transferred to the floor. On the floor, he was re-started on his coumadin with a target INR of 2.0 - 3.0. He appeared to be depressed by members of housestaff and his family. Psychiatry was asked to see him, and they advised outpatient follow-up and adjusted his antidepressant medication dosages. . Mr [**Known lastname 22956**] was seen by a social worker, where he was able to discuss his recent cancer diagnosis, and his recent surgery. It was felt this visit slightly lifted his spirits, as he began to ambulate more often with encouragement. He was seen by physical therapy to assist with ambulation. . Upon discharge, Mr [**Known lastname 22956**] was in a stable condition. His staples were removed, his FOley removed and his pain under control. His coumadin levels are to be followed by his PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. His family continued to be extremely supportive, with regular visits and discussions with members of housestaff regarding his progress. . He was discharged to a rehab facility. His expected duration of stay at this facility is less than 30 days. Medications on Admission: Ativan 1 mg Tablet . AVANDIA 4MG Tablet . HUMULIN 70/30 70-30U/ML Suspension . HUMULIN N 100U/ML Suspension . Lisinopril 20 mg Tablet . Meclizine 12.5 mg Tablet . REMERON 15MG . Simvastatin 40 mg Tablet . WELLBUTRIN SR 150MG Tablet Sustained Release . Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for Vertigo. 6. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed. 12. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime for 1 doses. Disp:*1 Tablet(s)* Refills:*0* 13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*20 Capsule(s)* Refills:*2* 14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO four times a day as needed for flatulence for 3 days. Disp:*12 Tablet, Chewable(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Doctor First Name 37**] House Rehab & Nursing Center - [**Location (un) 38**] Discharge Diagnosis: Renal cell carcinoma. Discharge Condition: Stable. Discharge Instructions: You are being prescribed a narcotic pain medication. DO NOT DRIVE OR OPERATE HEAVY MACHINERY WHILE TAKING THIS MEDICATION. IT [**Month (only) **] MAKE YOU DROWSY. Contact a physician for fever >100.5, bleeding or increasing redness from incisions, difficulty swallowing or breathing, headache, nausea or vomiting, double or blurry vision, or any other concerns. Please continue all home medications and those given to you by your surgeon. You are currently receiving coumadin therapy. The target INR range for you is 2.0-3.0. Please visit your primary care physician to adjust your coumadin dosage as appropriate and to remain within a therapeutic range. Please follow up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5847**] in regards to your recent diagnosis, coumadin levels and antidepressant medications. Followup Instructions: Please arrange a follow-up appointment with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] calling ([**Telephone/Fax (1) 4376**]. . You should also arrange a follow-up outpatient appointment with a psychiatry service: please call [**Telephone/Fax (1) 1387**] ([**Hospital1 18**] outpatient psychiatry service). . Please arrange a follow-up appointment with the Oncology service - Dr [**Last Name (STitle) 1729**] may be reached at ([**2142**]. . Please follow up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5847**] in regards to your recent diagnosis, coumadin levels and antidepressant medications. Completed by:[**2142-8-27**]

[ "189.0", "511.9", "440.21", "401.9", "518.0", "415.11", "453.2", "198.89", "593.2", "E878.6", "E849.8", "584.9", "486" ]

icd9cm

[ [ [] ] ]

[ "38.07", "38.91", "99.04", "55.51", "38.93", "39.59", "38.67" ]

icd9pcs

[ [ [] ] ]

10240, 10347

6030, 8501

425, 587

10412, 10421

1943, 6007

11350, 12057

1750, 1924

8817, 10217

10368, 10391

8527, 8794

10445, 11327

275, 387

615, 1274

1296, 1557

1573, 1734

49,580

125,592

51777

Discharge summary

report

Admission Date: [**2199-8-27**] Discharge Date: [**2199-8-30**] Date of Birth: [**2160-5-7**] Sex: F Service: MEDICINE Allergies: Ampicillin / Penicillins / Morphine Hcl Attending:[**First Name3 (LF) 3326**] Chief Complaint: scheduled IV high-dose methotrexate with leucovorin rescue for EBV-derived CNS lymphoma Major Surgical or Invasive Procedure: -Continuous [**Last Name (un) **]-venous hemodialysis History of Present Illness: 39-year-old woman with h/o type I diabetes since age 14 months, glomerulonephritis, kidney transplants in [**2174**] and [**2177**], and a double kidney and pancreas transplant on [**2188-11-20**], who has newly diagnosed EBV-driven CNS lymphoma. She was discharged on [**2199-8-19**] following an identical course of MTX and leucovorin- this admission required both HD and CVVH to manage toxicity in the setting of her renal transplant. Since discharge, the patient has been anxious, expresses desire to live with sister in [**Name (NI) 7168**], does not want to be burden for her parents. Pt has been feeling well physically, (-) SOB/chest pain, (-) n/v/d/f/c, (-) dizziness/confusion. Currently, the patient feels well and has no complaints. Past Medical History: PAST ONCOLOGIC HISTORY: ====================== Her neurological problems began in [**2199-3-22**] when her mother noted psychomotor slowing, short-term memory problems, inability to tolerate stress, and tremors in the hands. By [**2199-4-22**], she had additional symptoms including word-finding difficulty and slurred speech. Her mother took her to [**Hospital3 3583**], and she was released. Her mother then took her to see a neurologist at [**Hospital3 417**] Hospital, and he put her on Zoloft for possible depression. She was admitted to the [**Hospital1 827**] on [**2199-5-28**] for admitted [**2199-5-28**] for elective ventral hernia repair with mesh. She also had a workup for her mental status status change. A head MRI without gadolinium performed on [**2199-5-31**] showed moderate atrophy and mild periventricular hyperintensities. There was a question of mild communicating hydrocephalus. A spinal tap performed on [**2199-6-3**] showed 2 WBC, 49 protein, and 72 glucose, but she was positive for EBV PCR in the CSF. But HHV-6, HSV1 and 2, and [**Male First Name (un) 2326**] virus PCR were all negative. She was placed on 15 days of IV ganciclovir for meningoencephalitis with positive EBV PCR in CSF. A repeat lumbar puncture on [**2199-6-21**] yield negative EBV PCR, both qualitative and quantitative, in the CSF. But her memory function improved but it was still off. A repeat head MRI without gadolinium showed 3 hyperintense FLAIR lesions in the left caudate, right parietal periventricular region, and left frontal region near the surface of the brain. She underwent a stereotaxic brain biopsy by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. on [**2199-8-1**] and the pathology showed EBV-driven CNS lymphoma. Her cyclosporin was taken off subsequently. I saw her for the first time in the [**Hospital **] clinic on [**2199-8-13**], and her lumbar puncture that day showed 6 WBC, 61 protein, 56 glucose, atypical lymphocytes on cytology and negative flow cytometry. She also had an FDG-PET of the entire body on [**2199-8-14**]. It showed focal increased uptake in known right parietal (SUVmax 5.0) and left basal ganglia lesions (SUVmax 6.8), and there was no FDG avid disease outside the brain. She has just finished cycle 1 of MTX with leucovorin rescue. . PAST MEDICAL HISTORY: ==================== She had a history of diabetes, and it resolved after her double kidney and pancreas transplant on [**2188-11-20**]. She has hypertension and hypercholesterolemia, but no COPD. She was diagnosed with EBV encephalitis in [**2199-5-22**] and treated with gancyclovir. She had her first kidney transplant in [**2174**], and then a second kidney transplant in [**2177**], followed by a double kidney and pancreas transplant on [**2188-11-20**]. Social History: She lives with her parents in [**Location (un) 3320**], MA. She does not smoke cigarettes, drink alcohol, or use illicit drugs Family History: Her parents are healthy. Her two sisters are healthy. She does not have children. Her grandfather had NIDDM and her great grandmother apparently had IDDM. Physical Exam: On presentation to the Floor: Vitals - T: 98.1 BP: 146/94 HR: 84 RR: 16 02 sat: 99% RA GENERAL: NAD SKIN: warm and well perfused, no excoriations or lesions, no rashes [**Location (un) 4459**]: AT/NC, [**Location (un) 3899**], PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, poor dentition, nontender supple neck, no LAD CARDIAC: RRR, S1/S2, II/VI systolic murmur at LUSB 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, follows commands, A and O x 3 Pertinent Results: [**2199-8-27**] 04:37PM WBC-7.0 RBC-2.84*# HGB-8.7*# HCT-26.6* MCV-94 MCH-30.5 MCHC-32.6 RDW-16.9* [**2199-8-27**] 04:37PM PLT COUNT-587*# [**2199-8-27**] 04:37PM PT-12.0 PTT-24.5 INR(PT)-1.0 . [**2199-8-27**] 04:37PM GLUCOSE-127* UREA N-63* CREAT-2.9* SODIUM-136 POTASSIUM-5.4* CHLORIDE-106 TOTAL CO2-20* ANION GAP-15 . [**2199-8-27**] 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2199-8-27**] 05:30PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-2 [**2199-8-27**] 02:34PM URINE pH-7 HOURS-24 VOLUME-2150 CREAT-42 TOT PROT-146 PROT/CREA-3.5* . [**2199-8-28**] 12:00AM PT-11.8 PTT-24.1 INR(PT)-1.0 . CXR [**2199-8-27**] FINDINGS: In comparison with the study of [**8-1**], the patient has taken a much better inspiration. There is still enlargement of the cardiac silhouette with tortuosity of the aorta, but no vascular congestion, pleural effusion, or acute pneumonia. Left subclavian PICC line extends to the upper to mid portion of the SVC. Double lumen catheter extends to the upper portion of the right atrium. Brief Hospital Course: 39F with ESRD s/p DDRT x3 (panc/kidney in [**2187**]), recently diagnosed with CNS lymphoma. Pt is undergoing cycle [**12-27**] of every-other-week MTX. In order to get reasonable levels and provide clearance, the patient was started on CVVH. # EBV-Drived CNS Lymphoma: Patient tolerated IV high-dose methotrexate well; she was started on hemodialysis 6 hours later and simultaneously started on leucovorin rescue. On [**2199-8-28**] she was transferd to the [**Hospital Unit Name 153**] for CVVH, which she tolerated well hemodynamically. This was continued until 72 hours after the methotrexate infusion. His goal levels were met at 24 hours < 10, 48 hours < 1, and 72 hours < 0.1. Once she arrived at this level, it was felt she was stable for discharge. She was followed closely by renal. # Psych: While getting CVVH, the patient wanted to leave against medical advice. Emotionally, it was very difficult for her to be connected to the CVVH machine for two days. There was some discussion # Hyperkalemia- patient arrived with K of 4.5, but this corrected with IVF. # Encephalopathy: Some of her neurological impairment was thought to be due to residual effects of EBV meningoencephalitis, but outpatient note suggested more likely to be lymphoma effects. Dr.[**Name (NI) 94547**] outpatient note suggests prominent features are memory impairment and emotional lability. Dr. [**Last Name (STitle) 724**] suggested methylphenidate as a possible aid to improved cognition. Her encephalopathy did not progress and remained at baseline throughout her stay. # Kidney Transplant: She was followed by the renal transplant team while in the hospital. She tolerated Hemodialysis well . # Pancreas Transplant: Stable. Cellcept was held for 1 day, but restarted per the renal team on day 2 of admit. . # Type I Diabetes: She had a pancreas transplant and she is no longer a diabetic # Hypertension: Stable readings and continued on home medications. Medications on Admission: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. CellCept [**Pager number **] mg Tablet Sig: One (1) Tablet PO twice a day. 6. Sodium Bicarbonate 650 mg Tablet Sig: Three (3) Tablet PO twice a day. Disp:*180 Tablet(s)* Refills:*2* 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 9. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day as needed for swelling. 12. Renagel 400 mg Tablet Sig: Three (3) Tablet PO three times a day. 13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* Discharge Medications: 1. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML Injection PRN (as needed) as needed for line flush: Daily and then as needed. Disp:*1 box* Refills:*3* 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 4. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic [**Hospital1 **] (2 times a day) as needed for with dressing changes. Disp:*1 tube* Refills:*0* 5. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Sevelamer HCl 400 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep/anxiety. 12. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day: Take [**11-23**] tablet daily for the next week and then take 1 tablet daily from then on. . Disp:*30 Tablet(s)* Refills:*2* 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day as needed for swelling. 14. Aranesp (Polysorbate) 100 mcg/0.5 mL Syringe Sig: 0.5 ML Injection once a week. 15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: Primary: 1. Central Nervous System Lymphoma 2. Diabetes Type I s/p kidney and pancreas transplant Secondary: -Hypertension Discharge Condition: At the time of discharge patient's methotrexate level was 0.08, her vital signs were stable, she was tolerating her diet without difficulty, and she was considered medically stable for discharge. Discharge Instructions: You were admitted to [**Hospital1 18**] for methotrexate therapy to treat your Central Nervous System Lymphoma. Since you have had kidney transplant you needed CVVH (continuous dialysis) to help protect your kidney. After receiving your chemotherapy on the oncology service you were transferred to the intensive care unit (ICU) for the continuous hemodialysis. After two days of continuous hemodialysis your methotrexate level had decreased to a safe level and you were able to be discharged from the hospital. . When you were in the hospital you were seen by the transplant team, who felt that your cell cept should be stopped. They stopped your cell cept to help your immune system try to fight the virus associated with your lymphoma. You should continue to take your prednisone as previously directed. You should have your pheresis catheter flushed after you leave the hospital, Dr. [**Last Name (STitle) **] will get in touch with you about where to get this done. You will also have VNA coming in to help flush you PICC line. You should not shower with the lines in place, as wet dressings can cause infections. Bathing is ok, but please keep the dressings dry. . Changes made to your medication regimen: 1. Stopped Cellcept ***Please continue to take all other medications as previously directed.*** . Please call your doctor or return to the hospital if you experience any fever, chills, nausea, vomiting, diarrhea, chest pain, shortness of breath, swelling in your legs, headache, confusion, slurred speech or any other concerning symptoms. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) **] on [**2199-9-27**], the appointment is listed below: Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2199-9-27**] 10:10 You will also need another cycle of methotrexate in two weeks, please follow up with Dr.[**Name (NI) 6767**] office about scheduling.

[ "256.4", "E878.0", "V42.83", "200.50", "E933.1", "996.81", "V58.65", "403.90", "348.30", "585.9", "582.9", "276.7", "326", "V58.11", "584.9", "285.9" ]

icd9cm

[ [ [] ] ]

[ "39.95", "99.25" ]

icd9pcs

[ [ [] ] ]

10847, 10885

6222, 8181

387, 443

11052, 11250

5091, 6199

12857, 13259

4223, 4381

9350, 10824

10906, 11031

8207, 9327

11274, 12834

4396, 5072

260, 349

471, 1222

3595, 4061

4077, 4207

15,073

119,700

28841

Discharge summary

report

Admission Date: [**2160-9-11**] Discharge Date: [**2160-9-12**] Date of Birth: [**2095-7-4**] Sex: M Service: NEUROSURGERY Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 1835**] Chief Complaint: Subdural Hematoma Major Surgical or Invasive Procedure: None History of Present Illness: Pt. is a 65 y/o with a hx of alcoholism, PVD on [**Hospital 28492**] transferred from OSH with SDH and midline shift. He presented to [**Hospital3 4298**] with the "worst headache of his life" which per records started at 6PM. GCS 15 on arrival to OSH at 12A. CT showed SDH, INR 3.1. Pt. developed progressive lethargy and was intubated and transferred here for further care. Given 10 mg SC Vit K and 10 mg IV Vit K at OSH as well as 65 gm mannitol, no FFP given at OSH. Received paralytics (rocuronium) with intubation at 1:40 A. Received 4 mg Ativan, 200 mg Fentanyl, and 8 mg Morphine while being medflighted. Past Medical History: Migraine Hypertension MI PVD s/p bypass Social History: Alcoholism other unknown Family History: Unknown Physical Exam: BP- 143/53 HR- 81 RR- 16 O2Sat 100% Gen: intubated Neck: in c collar CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: intubated. No spontaneous movement of any extremities, does not open eyes to voice or sternal rub. Cranial Nerves: L pupil 4 mm, fixed, R pupil 3 mm, fixed. No corneals on either side, no gag. Motor: No spontanous movement or response to pain Sensation: no response to painful stimuli in any extremity Reflexes: trace throughout, toes mute bilaterally Pertinent Results: [**2160-9-11**] 03:20AM BLOOD WBC-4.8 RBC-3.72* Hgb-11.9* Hct-32.6* MCV-88 MCH-32.0 MCHC-36.5* RDW-14.1 Plt Ct-161 [**2160-9-11**] 05:00AM BLOOD PT-12.8 PTT-29.4 INR(PT)-1.1 [**2160-9-11**] 03:20AM BLOOD Plt Ct-161 [**2160-9-11**] 03:20AM BLOOD PT-29.7* PTT-35.9* INR(PT)-3.1* [**2160-9-11**] 03:20AM BLOOD UreaN-19 Creat-0.9 [**2160-9-11**] 03:20AM BLOOD Amylase-44 [**2160-9-11**] 03:20AM BLOOD ASA-NEG Ethanol-90* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: Pt was admitted to the Neurosurgery Service with exam consistent to brain death. Unfornately he was transferred to late. A repeat head CT showed: large L subdural, ~ 1.5 cm largest width, with acute and chronic components, with 2 cm midline shift and effacement of 3rd ventricle. He was admitted to the ICU to follow exam for brain death. He passed away on his first hospital day. Medications on Admission: Coumadin 6 mg QD Aspirin 81 QD Atenolol 100 QD Colchicine 0.6 QD Lipitor 40 QD Nifedical 60 QD Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[**2160-11-26**]

[ "401.9", "V58.61", "443.9", "432.1", "250.00", "412" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "99.07" ]

icd9pcs

[ [ [] ] ]

2773, 2782

2211, 2598

317, 323

2833, 2842

1722, 2188

2895, 2931

1088, 1097

2744, 2750

2803, 2812

2624, 2721

2866, 2872

1112, 1308

260, 279

351, 967

1463, 1703

1347, 1447

1332, 1332

989, 1030

1046, 1072

10,220

108,580

54176+59583

Discharge summary

report+addendum

Admission Date: [**2118-5-20**] Discharge Date: [**2118-6-8**] Date of Birth: [**2051-6-14**] Sex: M Service: TRANSPLANT SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 66 year-old male with a history of hepatitis C virus and hepatocellular carcinoma who presented on [**5-20**] for orthotopic liver transplant. PAST MEDICAL HISTORY: 1. Hepatocellular carcinoma. 2. Hepatitis C. 3. Gastroesophageal reflux disease. 4. Hepatic encephalopathy. 5. Coronary artery disease with two vessel disease, status post stenting of right coronary artery and mid left anterior descending artery. MEDICATIONS ON ADMISSION: 1. Flomax .4 mg po q.d. 2. Hydroxizine 25 mg prn. 3. Aspirin 325 po q.d. 4. Colchicine .6 mg b.i.d. 5. Prozac 20 mg po q.d. 6. Ranitidine 150 mg po b.i.d. 7. Metoprolol 50 mg po b.i.d. SOCIAL HISTORY: The patient is a recent smoker having quit two weeks prior to admission. Was smoking one pack per day. Lives with his wife in [**Name (NI) 24979**] [**State 350**]. PHYSICAL EXAMINATION ON PRESENTATION: Temperature 97.6. Heart rate 62. Blood pressure 178/77. Respiratory rate 18. O2 saturation 98% on room air. On examination prior to admission, HEENT examination was within normal limits. Cranial nerves were intact. Heart sounds were normal with no murmur or bruit. Chest was clear to auscultation and percussion. Abdomen was soft and nontender, no palpable masses and no peripheral edema. [**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**] Dictated By:[**First Name3 (LF) 111032**] MEDQUIST36 D: [**2118-6-8**] 01:13 T: [**2118-6-8**] 13:27 JOB#: [**Job Number **] Name: [**Known lastname 18216**], [**Known firstname **] Unit No: [**Numeric Identifier 18217**] Admission Date: [**2118-5-20**] Discharge Date: [**2118-6-8**] Date of Birth: [**2051-6-14**] Sex: M Service: ADDENDUM: LABORATORY/RADIOLOGIC DATA: On admission, the white blood cell count was 8.3, hematocrit 43.2, platelet count 89,000. PT 15.7, PTT 44.9, INR 1.6. Chemistries: Sodium 140, potassium 3.8, chloride 102, bicarbonate 27, BUN 15, creatinine 0.9, glucose 104. ALT 33, AST 29, alkaline phosphatase 100, total bilirubin 0.8. HOSPITAL COURSE: The patient was taken to the Operating Room on [**2118-5-20**] and underwent an orthotopic cadaveric liver transplant. Please see the operative note for details. Postoperatively, the patient was transferred to the Surgical Intensive Care Unit. Perioperative immunosuppression consisted of Solu-Medrol as well as CellCept. Perioperative antibiotics consisted of Unasyn. Neoral was also started postoperatively. Postoperatively, the patient was transfused platelets and fresh frozen plasma on postoperative day number zero. On postoperative day number one, the patient's troponin was measured and was found to be 4.1 which eventually peaked to 32.4 on postoperative day number two and subsequently normalized to a level of 1.3 by postoperative day number ten. Preoperatively, on exercise tolerance test the patient was noted to have a severe partially reversible apical left ventricular wall defect. Postoperatively, the patient's blood glucose was also somewhat elevated, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 616**] Diabetes Center consult was obtained during the hospitalization. The patient remained intubated following the procedure until postoperative day number seven. However, due to respiratory distress the patient was reintubated on postoperative day number nine through postoperative day number 11. By postoperative day number 12, the patient was off the ventilator. On postoperative day number seven, ultrasound-guided right thoracentesis was performed for a right pleural effusion. The patient underwent bronchoscopy with bronchoalveolar lavage on postoperative day number ten while in the SICU. The patient was also covered postoperatively with vancomycin. The Gram's stain from the BAL sample was notable for gram-positive cocci with culture growing out sparse gram-negative rods. The patient was started on a course of levofloxacin which was to continue for two weeks and will continue on discharge. During the SICU stay, following thoracentesis, the patient was diuresed. By postoperative day number 15, the patient was transferred to the floor and was improving medically. However, of note, his mental status was still altered. He was still exhibiting confusion and a one-to-one sitter was assigned. His total bilirubin peaked at 9.6 on postoperative day number eight and trended down subsequently and was 2.4 on discharge. The sitter was discontinued on the morning of postoperative day number 18, with continued improvement in the patient's mental status. The patient's analgesia on transfer to the floor had been managed to Dilaudid and standing low-dose Haldol was added to the patient's regimen. By postoperative day number 19, the patient was ambulating with physical therapy with improved mental status, was tolerating p.o. and was thus prepared for transfer to a rehabilitation facility for continued physical therapy. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Discharged to an extended care facility. DISCHARGE DIAGNOSIS: 1. Hepatitis C virus. 2. Hepatocellular carcinoma. 3. Status post orthotopic liver transplant on [**2118-5-20**]. 4. Status post postoperative myocardial infarction. 5. Delayed graft function. 6. Preservation injury. 7. Postoperative pleural effusion, status post thoracentesis. 8. Hyperglycemia. 9. Coronary artery disease. 10. Gastroesophageal reflux disease. 11. Gout. DISCHARGE MEDICATIONS: 1. Valgancyclovir 450 mg p.o. q.d. 2. Fluconazole 400 mg p.o. q.d. 3. Bactrim double-strength one tablet p.o. q.d. 4. Aspirin 81 mg p.o. q.d. 5. Lopressor 75 mg p.o. b.i.d. 6. Famotidine 20 mg p.o. b.i.d. 7. Amlodipine 5 mg p.o. q.d. 8. Hydralazine 40 mg p.o. q. six hours p.r.n. systolic blood pressure greater than 160. 9. Cyclosporin 100 mg p.o. q. 12 hours, with dose to be adjusted per levels. 10. Levofloxacin 500 mg p.o. q.d. times 14 days, course to end on [**2118-6-18**]. 11. CellCept 1,000 mg p.o. b.i.d. 12. Prednisone 10 mg p.o. q.d. 13. Haldol 1 mg IM b.i.d., to be discontinued as mental status improves. 14. Insulin NPH 10 units q.a.m. with Humalog insulin sliding scale. FOLLOW-UP: The patient was instructed to follow-up in [**Hospital 2247**] Clinic and was provided teaching regarding medications as well as administration of insulin. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-922 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2118-6-8**] 02:01 T: [**2118-6-8**] 14:12 JOB#: [**Job Number 18218**]

[ "410.71", "070.54", "997.1", "274.9", "155.0", "511.9", "997.3", "571.5", "414.01" ]

icd9cm

[ [ [] ] ]

[ "33.24", "50.59", "96.71", "99.15", "96.04" ]

icd9pcs

[ [ [] ] ]

5697, 6774

5292, 5674

641, 834

2293, 5178

179, 340

362, 615

851, 2275

5203, 5271

25,415

170,171

53004

Discharge summary

report

Admission Date: [**2128-12-22**] Discharge Date: [**2128-12-23**] Service: EMERGENCY Allergies: Penicillins / Ceftriaxone / Keflex Attending:[**First Name3 (LF) 2565**] Chief Complaint: Tachypnea and Altered Mental Status Major Surgical or Invasive Procedure: foley catheter History of Present Illness: This is a [**Age over 90 **]yo F with a MMP who lives in a nursing home and was found unable to speak easily with respiratory rate in the 30s, pulse 100, Temp 99 and )2 sat of 88% on 2L that improved on 4L. Patient is alert and oriented x3 at baseline. Pt was discharged from [**Hospital1 18**] on [**12-14**] following left AKA on [**12-9**]. Pt was also discharged on a 2 week course of Meropenem for resistant Klebsiella UTI. Per EMS, on arrival O2 sat 88% and wheezing but otherwise well-appearing, responded well to nebs. . In the ED, the patient's vitals were, T: 102 BP: 144/57 P: 145 RR:40 02: 100% RA. Patient had a WBC count of 16.4 and a UA with moderate Leuks and >50WBC's. CXR was significant for mild pulmonary edema and a proBNP>[**Numeric Identifier **]. Patient was given 750mg Levaquin, 1g Vancomycin, 500mg Meropenem for antibiotics in additional to tylenol for fever and dilaudid for pain. The patient was transferred to the ICU for further work-up and treatment of severe sepsis. Past Medical History: Left above-the-knee Amputation [**12-9**] Hypertension. Severe arthritis with contractures. Bed bound with multiple chronic contractures. Sacral decubitus ulcers. Rheumatoid arthritis. Chronic renal insufficiency. Neurogenic bladder. Dementia Status post total hip replacement in [**2116**]. History of depression. History of anxiety. Constipation. Klebsiella UTI/Urosepsis Type 2 diabetes, Diet-controlled. Diverticulosis and diverticulitis Social History: Has lived at [**Hospital **] nursing home x several years. Is bedbound and needs assistance w/ ADLs like eating/dressing/toileting because of her contractures and pain. She is DNR/DNI. Family History: NC Physical Exam: VS: Temp: 99 BP: 128/69 HR: 125 RR: 31 O2sat: 98% on 4L NC GEN: uncomfortable, moaning 'help' HEENT: R>L pupil, EOMI, anicteric, MM dry, arcus senilus NECK: no supraclavicular or cervical lymphadenopathy, no jvd RESP: coarse breath sounds bilateral, tachypneic CV: difficult to appreciate [**2-6**] loud, coarse breath sounds ABD: nd, +b/s, soft, nt EXT: L AKA, RLE warm, well perfused SKIN: no rashes/no jaundice NEURO: Alert and oriented to place Pertinent Results: [**12-21**] - CXR - IMPRESSION: Mild pulmonary edema. [**2128-12-21**] 10:50PM BLOOD WBC-16.4*# RBC-3.81* Hgb-11.5* Hct-35.3* MCV-93# MCH-30.0 MCHC-32.5 RDW-17.4* Plt Ct-344# [**2128-12-21**] 10:50PM BLOOD Neuts-94.0* Bands-0 Lymphs-3.5* Monos-2.4 Eos-0.1 Baso-0.1 [**2128-12-21**] 10:50PM BLOOD Glucose-288* UreaN-36* Creat-1.3* Na-154* K-4.4 Cl-116* HCO3-27 AnGap-15 [**2128-12-21**] 10:50PM BLOOD CK-MB-NotDone proBNP->[**Numeric Identifier **] [**2128-12-21**] 10:50PM BLOOD cTropnT-0.18* [**2128-12-21**] 10:50PM BLOOD CK(CPK)-17* [**2128-12-22**] 06:37AM BLOOD Type-ART Temp-37.2 pO2-89 pCO2-44 pH-7.41 calTCO2-29 Base XS-2 [**2128-12-21**] 10:59PM BLOOD Lactate-2.8* [**2128-12-21**] 11:40PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2128-12-21**] 11:40PM URINE RBC-0-2 WBC->50 Bacteri-MOD Yeast-MANY Epi-0-2 [**2128-12-22**] 09:47AM URINE RBC-11* WBC-153* Bacteri-NONE Yeast-NONE Epi-0 [**2128-12-22**] TTE: The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Overall left ventricular systolic function is moderately depressed (LVEF= 35-40 %) with apical akinesis/hypokinesis. Cannot exclude apical thrombus (apical views are technically suboptimal). Right ventricular chamber size and free wall motion are 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. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: A/P: [**Age over 90 **]yo F with MMP who presents with dyspnea, fever and altered mental status found to have urosepsis. . # Severe Sepsis - WBC 16.4, T 102, Tachypnea to 40., lactate 2.8, abrupt alteration in mental status. Chronic Klebsiella UTI with UA significan t for >50 WBCs and moderate leukocyte esterase. Patient received broad coverage with vanc, levo, meropenem in ED; given persistance of UTI, known resistance of the organism to quinolones, and likely reistant to meropenem, was switched to aztreonam on arrival to the MICU. Pt received gentle IVFs in setting of radiographic evidence of mild pulmonary edema and BNP>70,000 suggestive of CHF. Patient remained fluid responsive throughout the first hours of admission and then became progressively tachycardic and tachypnic. The patient died at 5:10am on [**2128-12-23**] from respiratory failure secondary to urosepsis and congestive heart failure. # CHF/Respiratory Failure - BNP>70,000 and mild pulmonary edema on CXR, MI v troponin leak in setting of tachycardia. Clinically dry, no elev JVP, however, lung sounds were very coarse. Patient received IVF boluses in attempt to maintain urine output and blood pressure. When patient became tachypnic, a trial of BIPAP was attempted, but the patient persisted to breath near 40 times per minute while maintaining oxygen saturations in the high 90s. # Tachycardia - likely secondary to respiratory effort v pain. Patient was initially treated with fentanyl and morphine for pain. Patient then developed AFIB w/ rapid ventricular rate with intermittent episodes of hypotension requiring the use of IV lopressor and digoxin to obtain rate control. # Pain: s/p L AKA [**12-9**], rheumatoid arthritis. Pain control was provided with fentanyl patch and prn morphine. # HTN: Hold BBlocker # DM: Diet controlled per report. Patient was managed on fingersticks q4h and an insulin SS. # F/E/N: Puree foods, gravy thick. Honey thick liquids. Replete lytes PRN. # PPx: Bowel regimen, PPI, sq Heparin # Access: PIVs # Code Status: DNR/DNI, it was discussed with patient's health care proxy the grave nature of her sepsis and impending respiratory failure. After the patient was unable to tolerate BIPAP in the setting of tachypnea, tachycardia, and hypotension, goals of care were transitioned to comfort measures only. # Communication: son [**Name (NI) 109259**] [**Name (NI) 12246**], HCP was made aware of [**Hospital 228**] medical course throughout this admission and was notified at the time of death. Medications on Admission: 1. Acetaminophen 160 mg/5 mL Solution TID 2. Zinc Sulfate 220 (50) mg Capsule PO TID W/MEALS 3. Hexavitamin Tablet PO BID 4. Docusate Sodium 50 mg/5 mL Liquid PO BID 5. Bisacodyl 5 mg Tablet, Delayed Release Two Tablet PO DAILY 6. Lorazepam 0.5 mg Tablet Sig: 0.25mg Tablet PO Q6H as needed for anxiety. 7. Magnesium Hydroxide 400 mg/5 mL Suspension 30 ML PO Q6H PRN constipation. 8. Fentanyl 100 mcg/hr Patch Transdermal Q72H 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet PO DAILY 10. Calcium Carbonate 500 mg Tablet, Chewable PO TID W/MEALS 11. Albuterol Sulfate 0.083 % Solution Sig: One Inhalation Q6H 12. Ipratropium Bromide 0.02 % Solution Sig: One Inhalation Q6H as needed. 13. Metoprolol Tartrate 25 mg Tablet PO BID 14. Hydromorphone 4 mg Tablet PO Q4H prn pain, 8mg q4h severe pain 15. Heparin 5,000 unit/mL SC TID 16. Meropenem 500 mg Recon Soln 500 mg IV Q8H for 14 days. 17. Ascorbic Acid 500 mg Tablet PO TID 18. Docusate Sodium 100 mg Capsule PO BID Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Urosepsis Congestive Heart Failure Hypercarbic Respiratory Failure Atrial Fibrillation Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None

[ "V49.76", "707.05", "403.90", "038.9", "714.0", "428.0", "427.31", "518.81", "427.5", "V09.81", "311", "294.8", "707.03", "041.3", "585.9", "250.00", "995.92", "785.0", "599.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7873, 7882

4300, 6828

281, 297

8012, 8022

2502, 4277

8075, 8082

2013, 2017

7844, 7850

7903, 7991

6854, 7821

8046, 8052

2032, 2483

206, 243

325, 1328

1350, 1794

1810, 1997

62,199

110,277

26741

Discharge summary

report

Admission Date: [**2190-10-11**] Discharge Date: [**2190-10-13**] Date of Birth: [**2118-3-22**] Sex: M Service: SURGERY Allergies: Morphine Attending:[**First Name3 (LF) 2777**] Chief Complaint: Greater than 6-cm aneurysm of the descending thoracic aorta Major Surgical or Invasive Procedure: PROCEDURES: 1. Stent graft repair of descending thoracic aortic aneurysm with the [**Doctor Last Name 4726**] tag endoprosthesis x2. The first endoprosthesis is the following: Catalog number [**Serial Number 65878**], lot number [**Serial Number 65879**]; second one is catalog number [**Serial Number 65880**], lot number [**Serial Number 65881**]. 2. Thoracic aortography. History of Present Illness: History of Present Illness: Mr. [**Known lastname 28221**] is a 72 year old male with known thoracic aortic aneurysm who recently underwent endovascular repair of his abdominal aortic aneurysm in [**2190-2-28**]. His past medical history is also notable for coronary artery disease and he is status post coronary artery bypass grafting surgery. His postoperative course since [**2190-2-28**] has been unremarkable and he has made excellent recovery. Given his thoracic aortic aneurysm has now slightly increased in size since previous study, he presents for endovascular repair of his descending thoracic aortic aneurysm. Past Medical History: -MIx3, status-post stent [**98**] years ago, and CABG and [**Hospital3 **] 5 years ago. -Diabetes Mellitus II, not on medication. -s/p Cholecystectomy -s/p Colon CA, status-post resection x2 (no radiation) -Manic depression -History of pneumothorax (at age 35) s/p thoracotomy -OSA Social History: SOCIAL HISTORY: Quit smoking 5 years ago, social EtOH, lives in [**Location (un) **] alone; performs all activities of daily living. Family History: FAMILY HISTORY: Dad had 2 aortas (?) and cerebral aneurysms, Diabetes, manic depression and colon cancer in dad Physical Exam: Physical Exam: Pulse: 74 Resp: 16 B/P Right: 132/60 Left: 128/62 Height: 71" Weight: 209 General: WDWN in NAD Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] OP benign Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] I/VI systolic murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Well healed laparotomy and cholecystectomy incisions. Extremities: Warm [X], well-perfused [X] No Edema. Right groin incision well healed Varicosities: Left GSV surgicall absent above knee 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: None appreciated Left: None appreciated Pertinent Results: [**2190-10-12**] 04:00AM BLOOD WBC-7.0 RBC-4.02* Hgb-11.7* Hct-34.3* MCV-85 MCH-29.0 MCHC-34.0 RDW-13.0 Plt Ct-194 [**2190-10-12**] 07:13AM BLOOD PT-12.7 PTT-24.9 INR(PT)-1.1 [**2190-10-12**] 04:00AM BLOOD Glucose-127* UreaN-17 Creat-0.9 Na-140 K-4.1 Cl-107 HCO3-27 AnGap-10 [**2190-10-12**] 04:00AM BLOOD ALT-37 AST-41* AlkPhos-63 TotBili-0.4 [**2190-10-11**] 12:05PM BLOOD Glucose-141* Lactate-1.2 Na-139 K-4.4 Cl-106 [**2190-10-11**] 08:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.016 [**2190-10-11**] 08:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ECHO: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. The descending thoracic aorta is markedly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic wall is thickened consistent with an intramural hematoma. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Torn mitral chordae are present. There is no systolic anterior motion of the mitral valve leaflets. No mitral regurgitation is seen. There is no pericardial effusion. Brief Hospital Course: Mr. [**Known lastname **],[**Known firstname **] was admitted on [**10-11**] with Thoracic aortic aneurysm. He agreed to have an elective surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. Pre hydrated with bicarb and mucomyst. It was decided that she would undergo a Endovascular repair of thoracic aortic aneurysm. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. Post-operatively, he was extubated and transferred to the CVICU for further stabilization and monitoring. Perioperative AB given. He was then transferred to the VICU for further recovery. While in the VICU he recieved monitered care. When stable he was delined. His diet was advanced. A PT consult was obtained. When he was stabalized from the acute setting of post operative care, he was transfered to floor status On the floor, he remained hemodynamically stable with his pain controlled. He progressed with physical therapy to improve her strength and mobility. He continues to make steady progress without any incidents. He was discharged home in stable condition. Medications on Admission: Zetia 10mg daily Gemfibrozil 600mg twice daily Lithium 600mg daily Toprol 50mg daily Omeprazole 20mg daily Simvastatin 80mg daily Aspirin 81mg daily Discharge Medications: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Lithium Carbonate 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO once a day for 10 days. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Thoracic aortic aneurysm. Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Aortic Aneurysm Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**3-2**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**5-3**] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 7477**] Date/Time:[**2190-11-17**] 8:00 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2190-11-18**] 10:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2190-11-18**] 11:15 Completed by:[**2190-10-13**]

[ "414.00", "412", "327.23", "V45.81", "250.00", "530.81", "V45.82", "600.00", "441.2" ]

icd9cm

[ [ [] ] ]

[ "39.79", "88.72" ]

icd9pcs

[ [ [] ] ]

6540, 6546

4331, 5631

330, 724

6616, 6625

2776, 4308

9215, 9670

1864, 1961

5831, 6517

6567, 6595

5657, 5808

6649, 8635

8661, 9192

1992, 2757

231, 292

780, 1376

1398, 1681

1713, 1832