ChanBeDu/relevant_section_length · Datasets at Hugging Face

16,975

100,446

15512

Discharge summary

report

Admission Date: [**2122-3-28**] Discharge Date: [**2122-3-31**] Date of Birth: [**2041-6-29**] Sex: F Service: MEDICINE Allergies: Morphine / Motrin / Levaquin Attending:[**First Name3 (LF) 689**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 80yo female with multiple medical problems including hypertension, recent ICU admission with pulmonary edema and ARDS, and previous admission for septic hip treatment was admitted with shortness of breath and chest pain. . She has had several recent admissions to [**Hospital1 18**] within the last 3 months. - [**Date range (1) 44958**] - She was admitted with a right septic hip and underwent a washout and repair. She was discharged to complete a 6 week course of nafcillin - [**Date range (1) 44959**]/09 - She was hospitalized with shortness of breath. During that admission, she was found to have bilateral infiltrates consistent with multifocal pneumonia and superimposed pulmonary edema, as well as diffuse alveolar hemorrhage. For the pneumonia, she was treated with broad spectrum antibiotics of vancomcyin, zosyn, and azithromycin. For the pulmonary edema, she was treated aggressively with diuretics, nitroglycerin, and beta blockers. For the diffuse alveolar hemorrhage, she was treated for a short time with steroids complicated by delirium and underwent an extensive autoimmune work-up which was negative. She was discharged to rehab with 2L O2 and furosemide 40mg PO bid. . While at Rehab, she has developed multiple complications, including delirium, acute renal failure, fever, chest pain, and shortness of breath. Her delirium was thought likely related to medications (received a short course of baclofen), infection, and renal failure. Regarding her acute renal failure, her creatinine increased to 2.6 from 1.5 within 2 days after discharge, her furosemide and anti-hypertensives were discontinued, and she was started on IVF. Regarding her fever, she was febrile as high as 102 at the rehab. Regarding her chest pain and shortness of breath, she was evaluated by a pulmonary consultant on the day of her transfer and she was thought to be in a CHF exacerbation. . Upon arrival to the ED, temp 100.2, HR 86, BP 133/50, RR 18, Pulse ox 77% on room air. While in the ED, she remained afebrile, normotensive, and 96-10% on NRB. She received SL NG x 3 and was then started on a nitro drip for chest pain. She had blood cultures drawn and received zosyn. She also received zosyn for pneumonia, was started on a heparin drip for treatment of a presumed pneumonia, and also given fentanyl 25mcg IV x 1 for treatment of chest pain. . Upon arrival to the floor, she initially reported [**7-24**] chest pain, which she describes as located across her left anterior chest, character is pleuritic, duration is intermittent, worsened with deep inspiration or movement, and reliever with hydromorphone and rest. Additional review of systems is notable for the following: shortness of breath, fatigue, back pain (chronic and unchanged), lower extremity swelling, and neck pain (chronic and unchanged). Her delirium has markedly improved according to her daughters. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools, red stools. He denies shaking chills, rigors. dysuria, diarrhea, abdominal pain, cough, sputum production. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. . Past Medical History: 1. Coronary Artery Disease s/p CABG and bioprosthetic AVR in [**2119**] 2. Diastolic Heart Failure 3. Type 2 Diabetes Mellitus complicated by neuropathy 4. Chronic Renal Insufficiency 5. Hypertension 6. Diverticulitis 7. Hyperlipidemia 8. Hypothyroidism 9. Endometriosis . PAST SURGICAL HISTORY: 1. s/p R Hip hemiarthroplasty after fracture in [**2111**]. 2. Right hip washout and head replacement [**2122-1-17**] 3. s/p b/l TKR 4. s/p appendectomy, 5. s/p TAH-BSO, 6. status post right carpal tunnel release, status post tonsillectomy. 7. s/p Nissen 8. s/p CABG in [**5-20**] . Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension . Cardiac History: CABG, in [**2119**] anatomy as follows: LIMA --> LAD . Percutaneous coronary intervention: not applicable Social History: - Home: previously lived independently on [**Location (un) **]; was living with her daughter / health care proxy in preparation for an upcoming right hip revision until her multiple, recent hospitalizations; currently at [**Hospital 100**] Rehab - Tobacco: Denies - Alcohol: previous history of alcohol abuse > 30 years ago Family History: Non-contributory Physical Exam: VS: T 96.7 / HR 75 / BP 126/42 / RR 27 / Pulse ox 100% on 15L NRB Gen: WDWN elderly female in mild respiratory distress requiring NRB. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with elevated JVP to the earlobe. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [**3-20**] mechanical systolic murmur at the LUSB. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Well-healed anterior midline sternotomy scar. bibasilar crackles with right middle lung crackles as well Abd: Obese, Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: trace - 1+ bilateral lower extremity edema. No femoral bruits. Right hip without evidence of inflammation - no erythema, tenderness, pain, or swelling Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Admission Labs [**2122-3-28**] 02:00PM BLOOD WBC-15.3* RBC-2.84*# Hgb-9.0* Hct-25.1* MCV-88 MCH-31.7 MCHC-35.9* RDW-15.6* Plt Ct-227 [**2122-3-28**] 02:00PM BLOOD Neuts-88.7* Lymphs-8.4* Monos-2.3 Eos-0.4 Baso-0.2 [**2122-3-28**] 02:00PM BLOOD PT-14.1* PTT-31.7 INR(PT)-1.2* [**2122-3-28**] 02:00PM BLOOD Glucose-126* UreaN-17 Creat-1.5* Na-135 K-4.7 Cl-103 HCO3-21* AnGap-16 [**2122-3-28**] 02:00PM BLOOD CK-MB-NotDone proBNP-9713* [**2122-3-28**] 02:00PM BLOOD cTropnT-0.27* [**2122-3-28**] 10:28PM BLOOD Calcium-8.8 Phos-4.5 Mg-1.9 [**2122-3-29**] 05:18AM BLOOD calTIBC-185* VitB12-564 Folate-3.8 Ferritn-661* TRF-142* [**2122-3-28**] 02:16PM BLOOD Lactate-1.2 [**2122-3-28**] 10:28PM BLOOD CK-MB-NotDone cTropnT-0.20* [**2122-3-29**] 05:18AM BLOOD CK-MB-NotDone cTropnT-0.15* [**2122-3-28**] 10:28PM BLOOD CK(CPK)-55 [**2122-3-29**] 05:18AM BLOOD CK(CPK)-28 [**2122-3-28**] 10:28PM BLOOD Glucose-123* UreaN-19 Creat-1.7* Na-138 K-5.6* Cl-104 HCO3-22 AnGap-18 [**2122-3-29**] 05:18AM BLOOD Glucose-97 UreaN-20 Creat-1.8* Na-134 K-4.7 Cl-101 HCO3-23 AnGap-15 [**2122-3-29**] 01:58PM BLOOD Glucose-123* UreaN-22* Creat-1.7* Na-136 K-4.2 Cl-99 HCO3-24 AnGap-17 [**2122-3-29**] 05:18AM BLOOD WBC-10.6 RBC-2.74* Hgb-8.5* Hct-24.6* MCV-90 MCH-31.0 MCHC-34.5 RDW-15.8* Plt Ct-208 . Discharge labs: [**2122-3-31**] 05:55AM BLOOD WBC-7.8 RBC-2.90* Hgb-9.1* Hct-25.4* MCV-88 MCH-31.3 MCHC-35.7* RDW-15.7* Plt Ct-310 [**2122-3-31**] 05:55AM BLOOD Plt Ct-310 [**2122-3-31**] 05:55AM BLOOD Glucose-117* UreaN-26* Creat-1.9* Na-133 K-4.3 Cl-93* HCO3-27 AnGap-17 [**2122-3-31**] 05:55AM BLOOD CK(CPK)-12* [**2122-3-31**] 05:55AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.2 [**2122-3-29**] 05:18AM BLOOD calTIBC-185* VitB12-564 Folate-3.8 Ferritn-661* TRF-142* . [**2122-3-29**] CXR: There is fluctuating appearance of the parenchymal opacities consistent with recurrent pulmonary edema. Compared to the most recent chest radiograph from [**2122-3-28**], there is interval progression of parenchymal opacities involving the entire lungs that is worrisome for interval worsening of pulmonary edema. No appreciable pleural effusions have been seen, although small amount of pleural fluid cannot be excluded. No changes in the sternotomy wires position as well as in the cardiomediastinal contour have been demonstrated. The fluctuating character of the parenchymal opacities is more consistent with pulmonary edema than infection, although underlying foci of infection or ARDS cannot be completely excluded. . [**2122-3-29**] LENIs: IMPRESSION: No evidence of DVT seen in either lower extremity. . [**2122-3-29**] Renal US : IMPRESSION: No evidence of hydronephrosis although the right kidney appears smaller than the left. Brief Hospital Course: This is a 80yo female with history of multiple medical problems including recent right hip infection, diastolic dysfunction, recent hospitalization with intubation, and Type 2 Diabetes Mellitus was admitted with shortness of breath. . 1. Shortness of Breath: Etiology of her shortness of breath is likely multifactorial. Differential diagnosis includes congestive heart failure exacerbation related to her recent medication changes and fluid administration, pneumonia in the setting of rehab stay / recent hospitalization / recent intubation, and splinting secondary to her chest pain. An additional possibility includes pulmonary embolism given her recent hospitalization and immobilization. Unfortunately she is not a candidate for a CTA at this time due to her renal failure, and VQ scan would likely not be helpful due to her diffuse and patchy infiltrates. She was briefly started on heparin gtt on admission. Bilateral LENI's were negative on [**3-29**]. Pulm was consulted and thought CHF most likely and PE unlikely so heparin gtt was stopped, vanco/zosyn for HAP were started on [**3-28**] and continued. The pt was diuresed initially on lasix gtt which was transitioned to [**Hospital1 **] lasix prior to transfer. At the time of transfer, she continues to c/o inability to take a deep breath but EKG is without changes and pt has only slight crackles on exam. Would recommend pt be kept only slightly negative at OSH as her Cr remains above baseline at 1.9. . 2. Chest Pain: Etiology of her chest pain is unclear. Differential includes pain related to pneumonia, GERD and esophageal irritation s/p intubation and NGT placement on prior admission. Pt c/o odynophagia but has no evidence of aspiration. Pericarditis, pulmonary embolism, or costochondritis were all considered unlikely. Her description of her pain is also not consistent with acute coronary syndrome, and her ECG is also unremarkable for ACS. She was treated for HAP as above and given dilaudid PRN with poor control of her pain at baseline. In future, GI or ENT could be consulted to evaluate this odynophagia. PPI was continued here. . 3. Fever and Leukocytosis Most likely [**2-16**] pneumonia. At the time of transfer to the OSH, blood and urine cultures remain without growth and rapid viral testing was negative. The pt is being continued on vanco/zosyn for HAP. The pt needs to be on bactrim s/p osteo for 6 months but this is on hold while pt on vanco/zosyn. This should be restarted after current abx finished. . 4. Acute Renal Failure Etiology of her acute renal failure likely secondary to dehydration and aggressive diuresis. Avoided further nephrotoxins, held ACEI and NSAIDs. In future, would recommend gentle diuresis. . 5. Coronary Artery Disease Continued aspirin and statin. CP not thought c/w ACS. Elevated trops in setting of unremarkable CK and MB were thought [**2-16**] renal failure. ECG unchanged. Beta blocker held in setting of CHF exacerbation and ACEI held in setting of ARF. . 6. Anemia Patient's hematocrit has decreased from 33 at last discharge to 25 here this admission. Hct remained stable until discharge. Iron studies d/w anemia of chronic disease. Retic count elevated at 2.4 prior to discharge. Would recommend continuing to trend Hct and guaiac of stools. . 7. Hypothyroidism Stable, continued levothyroxine . #. Code: FULL CODE, confirmed with patient and daughter #. Communication: Patient; Daughter and HCP [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 44960**] Medications on Admission: REHAB MEDICATIONS: 1. Levothyroxine 100 mcg PO Qday 2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, 3 patches 12hrs on, 12 hours off 3. Omeprazole 20mg PO daily 4. Simvastatin 40 mg PO Qday 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet PO BID 6. Bisacodyl 10mg PR daily prn 7. Tylenol 975mg PO tid 8. Aspirin 81 mg PO Qday 9. Calcium Carbonate 350 mg PO TID 10. Cholecalciferol (Vitamin D3) 800 unit PO Qday 11. Vitamin B12 500mcg PO daily 12. Conjugated Estrogens 0.3 mg PO Qday 13. Ferrous Sulfate 325 mg (65 mg Iron) PO Qday 14. Gabapentin 200mg PO tid 15. Heparin 5000 units SC bid 16. Insulin humalog sliding scale Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Insulin Lispro 100 unit/mL Solution Sig: One (1) sliding scale Subcutaneous ASDIR (AS DIRECTED). 9. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 19. Vancomycin 1000 mg IV Q48H Day 1 - [**2122-3-28**] 20. Piperacillin-Tazobactam Na 2.25 g IV Q6H Day 1 - [**2122-3-28**] 21. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN Please hold for RR < 12 and/or sedation. Thanks. 22. Ondansetron 4 mg IV Q8H:PRN Discharge Disposition: Extended Care Discharge Diagnosis: Hospital acquired Pneumonia diastolic CHF Acute on Chronic renal failure CAD Anemia Discharge Condition: stable. O2 sat mid 90's on 2L NC. Afebrile. Not tachycardic. BP stable Discharge Instructions: You were admitted here with CHF exacerbation. While you were here, you were diuresed. You were also treated for hospital acquired pneumonia. You were briefly started on a heparin drip for possible pulmonary embolism but this was stopped when pulmonary consult thought this diagnosis was very unlikely. You continue to complain of chest pain despite on EKG changed and we think this could be due to mechanical trauma from recent intubation and NG tube. . Please follow up as below. . Please see attached for your medications at transfer. . Please call your doctor or return to the ED if you have any chest pain, increasing shortness of breath, vomitting, blood in your stools or any other concerning symptoms. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: [**Hospital **] clinic: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2122-4-23**] 10:00 CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2122-4-29**] 1:30 Please follow up with Dr. [**Last Name (STitle) **] as directed by the staff at [**Hospital1 **] [**Location (un) 620**] Completed by:[**2122-3-31**]

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Discharge summary

report

Admission Date: [**2116-6-8**] Discharge Date: [**2116-6-10**] Date of Birth: [**2075-4-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: RV thrombus seen on echo Major Surgical or Invasive Procedure: None History of Present Illness: 41yoM with h/o stage IV L tonsillar small cell ca who was admitted to [**Hospital3 **] last Friday after he lost consciousness for "two seconds" and had a fall and hurt his L shoulder. He deneis any CP, palpitations, dizziness, post-ictal period, b/b incontinence, tongue biting, and knew where he was immediately after regaining consciousness. He endorses that he has been dehydrated and has had poor PO due to loss of appetite, such that he was actually going to be admitted for J tube placement when this event occurred. . At LGH he was 98.1 p104 18 107/67 98%RA. He had several EKG's which were tachycardic and show S1Q3T3 but no acute ST changes. Admitted to telemetry unit and ruled out for MI by enzymes and had normal EKG on admission. Through admission they felt it was less likely that he had a seizure. He was given IVF's. He then developed NSVT on day #2, review of the strips shows 5-8 beat runs, and was started on Amiodarone gtt, changed to PO dose today. He then had an echo showing large thrombus in RV and is transferred to [**Hospital1 18**] for further management/intervention. . Vitals on transfer: 97.9 118/81 81 18. Labs on d/c Na 133, K 4.4, CO2 28, BUN/Cr 9/0.52, BNP 177. His Hct was stable in the mid 30's, WBC's elevated up to 14, and thrombocytopenic in the low 100's. Dilantin level low and he was loaded. He had a CT C-spine concerning for metastases (see report below) and a left shoulder plain film concerning for mets (see below). . ROS is as above, including anorexia, wt loss (225 --> 140 now), chronic constipation and vomiting, dehydration. Chronic L shoulder pain. . No CP, palpitations, DOE, leg swelling, dizziness. Past Medical History: 1. CARDIAC RISK FACTORS: Pt denies 2. CARDIAC HISTORY: Pt denies 3. OTHER PAST MEDICAL HISTORY: - RV thrombus seen on echo [**2116-6-8**] - s/p J tube placement [**2116-6-5**] - Left tonsillar small cell carcinoma, stage 4, BT1, N3M0 --> with vocal cord paralysis and weight loss, with some regurgitation and aspiration - Tumor surrouding L internal carotid and inter.... base (unclear OSH report) - Headaches, seizures due to tumor, last seizure [**4-18**] and on Dilatin at home. Social History: Lives at home with fiance and daughter (? fiance's daughter?) -Tobacco history: Long history of smoking ppd x20yrs, quit last Friday -ETOH: Rare -Illicit drugs: None . Family History: HTN Brother with "tumor in the back of the head, the same type as mine" No sudden cardiac death, no arrythmias . Physical Exam: 97.6 85 126/93 21 90-93% on RA Thin, hoarse sounding man in no distress, conversant, appears fatigued but able to appropriately relate his history. EOMI, sclera normal. JVD not elevated. CTAB no w/c/r/r but diffuse poor air movement RRR, with fixed split S2, heart sounds best heard at BUSB's, and possible, very faint diastolic murmur best at BUSB's. Radial pulses palpable, DP's not Abd with staples midline, appears c/d/i, non-erythematous, non-infected. J tube noted, well placed, no oozing. Abd is NT ND. No BLE edema noted CN 2-12 noted, no facial droop or dysarthria noted but voice sounds hoarse. Unable to turn his neck to the L without pain, and is also weak. LUE is hypotonic and unable to spontaneously move his LUE proximal muscles or shoulder shrug, but does have distal hand grip that is weaker compared to R. His RUE proximal and distal muscles are normal tone and strength. BLE's proximal and distal muscles are normal strength and sensation. Pertinent Results: [**2116-6-8**] 05:23PM BLOOD WBC-13.6* RBC-4.29* Hgb-13.6* Hct-40.7 MCV-95 MCH-31.6 MCHC-33.3 RDW-15.7* Plt Ct-92* [**2116-6-8**] 05:23PM BLOOD PT-14.3* PTT-28.9 INR(PT)-1.2* [**2116-6-8**] 05:23PM BLOOD Glucose-110* UreaN-11 Creat-0.5 Na-134 K-4.4 Cl-97 HCO3-29 AnGap-12 [**2116-6-8**] 05:23PM BLOOD Calcium-9.2 Phos-3.1 Mg-2.0 [**2116-6-8**] 05:23PM BLOOD Phenyto-<0.6 Brief Hospital Course: Mr [**Known lastname 85005**] is a 41yoM with stage IV L tonsillar small cell cancer, h/o seizures, who was admitted to LGH for syncopal episode of unclear etiology and through workup was found to have RV thrombus vs tumor, who is transferred to [**Hospital1 18**] for further management. . 1. RV thrombus vs tumor: Patient underwent gated CT chest that was revealing for likely thrombus in RV, PE, and pulmonary infarcts. LENIs were negative for DVTs bilaterally. He was initially treated with heparin gtt and then transitioned to lovenox. CT surgery evaluated patient. Patient remained hemodynamically stable and so thrombolytics and surgery was not pursued. Patient expressed that he wanted to go home and did not want to stay in the hospital. His outpatient oncologists was contact[**Name (NI) **] who stated that patient was a candidate for palliative chemotherapy and confirmed that he has progressive malignancy with poor response to chemo/radiation. Patient was discharged with lovenox. - Patient will need repeat echocardiogram within 3 weeks. - Continue lovenox . 2. Syncopal episode: Likely related to RV thrombus and PE. Amiodarone, which wsas started at OSH for NSVT was stopped. Patient had 3-4 beats of NSVT on telemetry but otherwise no arrythmia. A head CT was done and was negative for metastasis. Her outpt oncologist confirmed that MRI head did not show evidence of metastasis. . 3. Stage IV tonsillar small cell carcinoma: Diagnosed about a year ago and is s/p chemo and radiation finished in [**12/2115**], no surgery. Already metastatic. Discussed with Dr. [**Last Name (STitle) 22658**] at LGH; patient candidate for palliative chemotherapy and is also undergoing evaluation for surgical intervention of skull based met for palliation. . 4. Nutrition: S/p J tube placement [**2116-6-5**] due to persistent n/v and decreased PO intake, likely due to the malignancy, although further w/u for this is not noted in OSH reports. Patient tolerating tube feeds in house. . . 5. Leukocytosis: Likely related to PE, stress rx to thrombus. No evidence of infection. . 6. Thrombocytopenia: No clear etiology. OSH was 104 and is high 90's here. DDx including drug effect (Heparin, does not appear pt received ABx at OSH), metastases to BM. No evidence of bleeding or unstable Hct. Unlikely to be HIT; could be related to consumption secondary to underlying clot. He does have repeat labs two days following discharge for repeat PLT check which will be faxed to Dr[**Name (NI) 85006**] office. . 7. Dilantin was continued for his seizure history. . 8. Left shoulder pain: Concerning lesions on x-ray for metastasis; will require further outpatient follow up. . 9. Pain control - Mr [**Known lastname 85005**] is being sent home with a small supply of Dilaudid in addition to lyrica, methadone, desipramine, and flexeril. Medications on Admission: HOME MEDICATIONS: 1. Temazepam 15mg qhs 2. Fioricept 1-2 tabs q6 prn headache 3. Methadone 5mg [**Hospital1 **] 4. Gabapentin 300 mg tid --> pt states now switched to Lyrica 5. Flexeril 10 mg tid 6. Dilatin 100 tid --> was increased to 200 mg [**Hospital1 **] at LGH 7. Reglan 10mg tid 8. Prednisone 20 mg [**Hospital1 **] --> pt states outside Onc started him on this last Wednesday 9. Desipramine 25 mg daily 10. Ativan 1 mg tid 11. Compazine 10 mg q6prn . DISCHARGE MEDICATIONS: 1. Fioricept two tabs q6 prn 2. Tylenol 3. Amiodarone 200 daily 4. Atenolol 25 daily 5. Coumadin 2.5 daily 6. Flexeril 10 q8 7. Noripramine 25 hs 8. Benadryl 25 IV q6 prn itching 9. Colace 10. Heparin gtt 11. Dilaudid PCA 0.2mg lockout 10 mins with IV breakthrough 12. Lactulose prn constipation 13. Ativan 1mg PO q8 prn 14. Magnesium oxide 400 [**Hospital1 **] 15. Methadone 10 [**Hospital1 **] 16. Reglan 10 IV q6 prn 17. Narcan prn, part of PCA protocol 18. Nicotine patch 19. Zofran 4mg IV prn 20. Protonix 40 mg daily 21. Dilantin 200 mg PO bid 22. Prednisone 20 mg [**Hospital1 **] 23. Lyrica 100 [**Hospital1 **] . Discharge Medications: 1. Methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 2. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 3. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). Disp:*60 syringes* Refills:*2* 4. Outpatient Lab Work Please check CBC [**6-12**] and fax results to Dr. [**Last Name (STitle) 22658**] 5. Desipramine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day) as needed for constipation. Disp:*600 cc* Refills:*0* 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 12. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. 13. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for pain. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 15. Phenytoin 100 mg/4 mL Suspension Sig: Two Hundred (200) mg PO twice a day. Disp:*500 cc* Refills:*2* 16. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 17. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours for 7 days. Disp:*56 Tablet(s)* Refills:*0* 18. Lactulose 10 gram/15 mL Solution Sig: Ten (10) mg PO twice a day as needed for constipation. Disp:*900 cc* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **]Hospice Discharge Diagnosis: RV thrombus PE Squamous cell metastastic lesion to base of skull Discharge Condition: A&Ox3 Discharge Instructions: You were transfered to the BDIMC because of a clot seen in your heart at [**Hospital6 3105**]. While you were here we did a CT scan that showed clots in your lungs and a clot in your heart. We have treated you with lovenox, a blood thinner. Your loss of consciousness was likely secondary to this clot. We did a CT scan of your head that did not show any intracranial metastasis, but did show the metastasis to the base of your skull which is old. You will need to follow up with Dr. [**Last Name (STitle) 22658**] your oncologist as an outpatient. He will need to repeat an echocardiogram to monitor the clot in your heart. Your platelets were low, likely from the clot and possibly from medications you have received. Your VNA nurse [**First Name (Titles) **] [**Last Name (Titles) 19697**] a platelet count and Dr. [**Last Name (STitle) 22658**] will follow up on this. The following changes were made to your medications: 1. Start Lovenox: this is an injection that you will give to yourself twice daily. It is a blood thinner that was started for your clots. 2. Increase Methadone from 5mg to 10mg twice daily. This was increased at LGH. This will help control your pain related to cancer. 3. Increase Lyrica from 75mg to 100mg, also increased at LGH, to better control your pain. 4. Start Dilaudid as needed for pain. This is a very sedating medication. Take only as directed. This should not be taken with alcohol or while driving. You will need to discuss with Dr. [**Last Name (STitle) 22658**] your long term pain management. 5. Start senna, colace, bisacodyl, and lactulose as needed for constipation. These are stool softners to be started since your pain medications can cause constipation. 6. Increased Dilantin from 100mg three times a day to 200mg twice a day, for seizures. You should not be driving since you have had an active seizure within the past six months. 7. Start Omeprazole daily. You are on several sedating medications (dilaudid, ativan, methadone). You should take this as directed, not with alcohol or while operating a motor vehicle. Since you have had a recent seizure, prior to this hospitalization, you should not be driving. You should follow up with your oncologist as directed below. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 22658**] on Tuesday [**6-16**] at 9:30 am at [**Hospital6 3105**]. He will need to repeat an echocardiogram and follow up on your platelets.

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icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

10291, 10345

4246, 7093

337, 344

10454, 10462

3851, 4223

12755, 12948

2740, 2855

8248, 10268

10366, 10433

7119, 7119

10486, 12732

2870, 3832

2108, 2118

7137, 7578

273, 299

372, 2031

2149, 2537

2053, 2088

2553, 2723

77,177

100,449

43795

Discharge summary

report

Admission Date: [**2137-8-16**] Discharge Date: [**2137-8-29**] Service: MEDICINE Allergies: Atenolol Attending:[**First Name3 (LF) 3984**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: endotracheal intubation tracheotomy tube placement placement of PEG (feeding) tube History of Present Illness: 86 year old male with pmh of COPD, CAD, HTN, DMII who was feeling weak and having difficulty standing at the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] and was found to have an O2 sat of 46% on 2L NP, and only marginal improvement to 63% on 5L NP. He was placed on NRB and transported to [**Hospital1 18**]. Full vitals prior to transfer were T 98.4, BP 149/84, P121, RR22. Allergies atenolol and Tylenol #3. . In the [**Hospital1 18**] ED, he was able to state his name, though appeared distressed. He was moving all of his extremities. Intial vitals were: T: 100.5 BP 133/68, HR 114, Sat 100% on NRB with a RR in the 30s. His rectal temperature was 101 F. He was intubated and sedated on fentanyl and Versed. He had a CXR that showed multifocal pneumonia. He was given 1g tylenol, 750mg of IV levofloxacin and 750cc of NS. EKG showed, sinus tach at 111, LAD, NI, TWF in aVL, poor baseline. On transfer vitals: T 98.3 HR 101 BP 110/61 Sat 98% on CMV mode, TV 500, FiO2 50%, RR 24 and PEEP 5. . On transfer to the MICU, he is intubated and completely sedated. Not responding to commands. Past Medical History: (Per OMR) DM (DIABETES MELLITUS) LUNG DISEASE, CHRONIC OBSTRUCTIVE HYPERTENSION, ESSENTIAL LOW BACK PAIN FTT (Failure to Thrive) in Adult Hypotension BLINDNESS - LEGAL HISTORY CORNEA TRANSPLANT GLAUCOMA - PRIMARY OPEN ANGLE DEPRESSIVE DISORDER CANCER OF PROSTATE TUBERCULOSIS BRONCHIECTASIS CORONARY ARTERY DISEASE RECTAL BLEEDING Social History: Former truck driver, and prior worked in a defense factory. Currently residing in [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. HCP [**Name (NI) **] [**Name (NI) **], daughter [**Name (NI) 40477**] [**Name (NI) **]. Also, granddaughter in the area, involved in his care. - Tobacco: Quit smoking 20 years ago, smoked from 18 - 65; used to smoke 1PPD - Alcohol: Heavy drinker while a smoker - Illicits: Unknown Family History: DM in father and mother. [**Name (NI) **] cancers. Physical Exam: Admission Exam: Vitals: T: 98.5 BP: 119/63 P: 101 R: 20 O2: 100% on CMV, 500, 50%, 14 and 5. General: Intubated, sedated not responding to commands HEENT: Sclera anicteric, Cataracts bilterally, non-responsive pupils (blind) mildly dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Mechanical breath sounds with minimal wheezing. Rhonchi in the right upper lung zone CV: Normal rate Regular rate, II/VI holosystolic murmur obscuring S1 no rubs, gallops Abdomen: soft, mildly distended, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, + clubbing on right hand, missing 4 digits on left hand, chronic venous stasis changes on bilateral lower extremities, and multiple 1cm areas of ulceration, no edema Neuro: Non-responsive on sedation Discharge physical exam General Appearance: Thin Eyes / Conjunctiva: cataracts, nonresponsive pupils b/l Head, Ears, Nose, Throat: Normocephalic, Poor dentition Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : , No(t) Rhonchorous: ) Abdominal: Soft, Non-tender, Bowel sounds present, Peg site intact Musculoskeletal: Muscle wasting Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Pertinent Results: Admission Labs: [**2137-8-16**] 08:05AM BLOOD WBC-8.8# RBC-3.43* Hgb-9.9* Hct-29.2* MCV-85 MCH-28.9 MCHC-34.0 RDW-14.0 Plt Ct-217 [**2137-8-16**] 08:05AM BLOOD Neuts-81.1* Lymphs-12.5* Monos-5.6 Eos-0.4 Baso-0.4 [**2137-8-16**] 08:05AM BLOOD PT-13.0 PTT-25.3 INR(PT)-1.1 [**2137-8-16**] 08:05AM BLOOD Glucose-234* UreaN-19 Creat-1.1 Na-141 K-4.9 Cl-103 HCO3-31 AnGap-12 [**2137-8-16**] 08:05AM BLOOD proBNP-754 [**2137-8-16**] 08:05AM BLOOD cTropnT-0.01 [**2137-8-16**] 08:05AM BLOOD Triglyc-64 [**2137-8-16**] 09:27AM BLOOD Type-ART Temp-38.6 Rates-/28 PEEP-5 pO2-53* pCO2-67* pH-7.28* calTCO2-33* Base XS-2 Intubat-INTUBATED Vent-CONTROLLED [**2137-8-16**] 08:12AM BLOOD Lactate-1.1 . Discharge labs: [**2137-8-29**] 05:41AM BLOOD WBC-10.4 RBC-2.85* Hgb-8.2* Hct-24.7* MCV-87 MCH-28.6 MCHC-33.1 RDW-13.9 Plt Ct-462* [**2137-8-29**] 05:41AM BLOOD PT-14.0* PTT-26.7 INR(PT)-1.2* [**2137-8-29**] 05:41AM BLOOD Glucose-123* UreaN-20 Creat-1.0 Na-140 K-3.9 Cl-102 HCO3-33* AnGap-9 [**2137-8-29**] 05:41AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.5 [**2137-8-28**] 03:38AM BLOOD Vanco-15.3 [**2137-8-29**] 06:08AM BLOOD Type-ART Temp-37.2 Rates-[**10-9**] Tidal V-500 PEEP-5 FiO2-40 pO2-97 pCO2-53* pH-7.43 calTCO2-36* Base XS-8 Intubat-INTUBATED Vent-CONTROLLED [**2137-8-26**] 02:01PM BLOOD Lactate-0.7 K-3.9 [**2137-8-21**] 05:10PM OTHER BODY FLUID Polys-44* Lymphs-19* Monos-0 Mesothe-17* Macro-20* . CXR [**2137-8-16**] 1. Multifocal opacities with a more confluent opacity in the right upper lung field. These findings are worrisome for multifocal pneumonia. 2. Bilateral small pleural effusions. 3. Mild to moderate pulmonary edema. . Echo [**2137-8-16**] Normal biventricular cavity size with normal regional and low normal global left ventricular systolic function. Pulmonary artery hypertension. Mild-moderate mitral regurgitation. These findings are suggestive of a primary pulmonary process (OSA, COPD, etc.). . CT Chest [**2137-8-22**] 1. Multifocal pneumonic consolidation predominantly involving the right upper lobe. 2. Moderate loculated effusion along right minor fissure and minimal simple effusion bilaterally. 3. Borderline enlarged mediastinal lymph nodes. Prominent right hilar appearance could be due to enlarged lymph node or from enlarged vessles, however defining a cause was limited due to lack to intravenous contrast administration. 4. Bilateral pleural calcifications. Please correlate with clinical history for asbestos exposure. If a history is established, follow-up imaging surveillance is recommended. . Dishcarge Chest xray [**2137-8-29**]: In the interval from the prior examination, an endotracheal tube has been removed and tracheostomy has been placed in standard position. Right-sided PICC is unchanged with tip reaching the low SVC. There is no significant change in multifocal opacities, greatest at the right base. Trace pleural effusions may be present. No pneumothorax is seen. The cardiomediastinal silhouette is not significantly changed. . Microbiology: BAL RESPIRATORY CULTURE (Final [**2137-8-24**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. ~[**2125**]/ML. 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. _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 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 Brief Hospital Course: 86 year old male with a history of COPD, DMII, CAD and HTN who was admitted with respiratory failure and multifocal pneumonia. . # Respiratory failure: History of COPD, found to be hypoxic at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] to 46% on 2L. CXR showed multifocal pneumonia. He was given levofloxacin in the ED and was intubated. Febrile to 101 rectally in the ED. Failed extubation due to respiratory fatigue, tachypnea, and worsening shortness of breath. He was re-intubated and underwent bronchocopy. BAL revealed MRSA. IP has was consulted for a tracheotomy tube/PEG which were performed on [**8-27**]. Pt to continue vanco for a total of 14 days to end [**9-4**]. He may continue to require Oxycodone as needed for pain related to his tracheostomy tube. His discharge chest xray showed increased opacities that were attribute to de-recruitment off the higher ventilator settings. Would recommend monitoring respiratory status, fever curve (currently afebrile) and ventilator requirements and would re-image or consider antibiotics if his clinical status changes. Plan to wean ventilator as tolerated. . # DMII: On oral hypoglycemics at home. On insulin SS in house. He was started on tube feeds which were at goal at discharge. Home metformin and glipizide were held- would restart at time of discharge to home. . # HTN: On diltiazem at home (ER). He was started on lisinopril which was at 40mg. he initially required IV hydral, which was transitioned to amlodipine 10mg daily. . # CHF/Venous stasis: On furosemide. Chronic venous stasis changes. EF 50-55% this admission, echo showed pulmonary HTN. He was diuresed, ultimately put on a standing dose of [**Hospital1 **] Lasix to remain euvolemic. Lytes were checked and K was replaced aggressively. He was on furosemide 40mg daily at discharge. Would recommend checking [**Hospital1 **] electrolytes and replete as necessary. Goal for diuresis has been 500 cc negative daily following in/outs. . # Glaucoma: Legally blind due to acute angle glaucoma, also with bilateral cataracts. Continued home eye drops. . # Anemia: Unclear baseline. MCV normal. Will monitor. No signs of bleeding, Hct stable. . Full Code Medications on Admission: ([**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Med Rec) Metformin 1000mg PO BID Dorzolemide/Timolol 2%-0.5% 1gtt both eyes, [**Hospital1 **] Erythromycin opth, 5mg/gm, apply left eye HS Lumigam 0.03% gtt, 1 gtt each eye HS glipizide 10mg PO BID [**Last Name (un) 7139**] 128; 5% gtts - 1 gtt each eye Q6H Famciclovir 500mg; 0.5 tabs PO daily Omeprazole 20mg PO daily Citalopram 10mg PO daily Diltiazem CR 180mg PO daily fluticasone nasal spray 1 spray each nostril daily furosemide 20mg PO daily Spiriva 18mcg 1 cap, daily Artificial tears [**Hospital1 **] Bromide Tartrate 0.2% 1 gtt each eye [**Hospital1 **] Calcium cab w/ D 600mg-400IU 1 tab [**Hospital1 **] Guaifenesin 100mg/5ml; 30mls PO BID Trazadone 50mg PO HS Tylenol 650mg PO prn Bisacodyl 10mg PR prn constipation milk of mag 30mls daily prn compazine 10mg TID prn nausea fleet enema daily prn albuterol nebs Q6H prn SOB Discharge Medications: 1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**12-30**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 2. acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever: do not exceed 3 grams daily. 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (2) **]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for sob/wheeze. 4. acyclovir 200 mg Capsule [**Month/Day (2) **]: Two (2) Capsule PO Q12H (every 12 hours). 5. amlodipine 5 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable PO BID (2 times a day). 8. citalopram 20 mg Tablet [**Month/Day (2) **]: 1.5 Tablets PO DAILY (Daily). 9. chlorhexidine gluconate 0.12 % Mouthwash [**Month/Day (2) **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day): Use only if patient is on mechanical ventilation. 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 11. glucagon (human recombinant) 1 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 12. dorzolamide-timolol 2-0.5 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 13. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) ml PO BID (2 times a day). 14. erythromycin 5 mg/gram (0.5 %) Ointment [**Hospital1 **]: 0.5 gram gram Ophthalmic QHS (once a day (at bedtime)). 15. fluticasone 50 mcg/Actuation Spray, Suspension [**Hospital1 **]: One (1) Spray Nasal DAILY (Daily). 16. furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 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. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) injection Injection TID (3 times a day). 19. insulin regular human 100 unit/mL Solution [**Hospital1 **]: One (1) sliding scale Injection ASDIR (AS DIRECTED): following enclosed humalog sliding scale. . 20. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: Six (6) Puff Inhalation QID (4 times a day). 21. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 22. latanoprost 0.005 % Drops [**Last Name (STitle) **]: One (1) Drop Ophthalmic HS (at bedtime). 23. Lorazepam 0.5-1 mg IV Q4H:PRN aggitation 24. lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 25. lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 26. cholecalciferol (vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 27. oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: Ten (10) ml PO Q6H (every 6 hours) as needed for pain: hold for sedation. 28. vancomycin 500 mg Recon Soln [**Last Name (STitle) **]: 1250 (1250) MG Intravenous Q 24H (Every 24 Hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Pneumonia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname **] It was a pleasure taking care of you here at [**Hospital1 18**]. You were admitted with pneumonia and required IV antibiotics. These will be continued at rehab. Due to respiratory distress, you were intubated and placed on a ventilator ("life support") until your lungs fully recovered. You continued to show improvement but will benefit from a longer weaning from the ventilator, thus a trachestomy tube was placed. This will be removed when you are fully able to breathe on your own. A peg tube (feeding tube through your stomach) was also placed to facilitate feeding until you are able to eat fully. You will need to continue the IV antibiotics for another week. The following changes were made to your medications. STARTED Albuterol inhaler 6 puffs prn SOB STARTED acyclovir 400mg Q12 STARTED amlodipine 10mg daily for hypertension STARTED Docusate sodium for constipation STARTED Heparin subcutaneous TID STARTED ipratropium bromide inhaler STARTED lansoprazole for reflux STARTED lorazepam for anxiety STARTED lisinopril for hypertension STARTED lactulose for constipation STARTED oxycodone for pain related to your tracheostomy STARTED Vancomycin (IV antibiotic) for your pneumonia, this will complete on [**9-4**] for total 14 day course. STARTED insulin coverage INCREASED furosemide/lasix dose to 40mg daily INCREASED citalopram 30mg daily STOPPED glipizide STOPPED omeprazole STOPPED diltiazem STOPPED metformin STOPPED trazodone STOPPED compazine STOPPED famciclovir Followup Instructions: You will need to follow up with your primary care doctor when you are discharged from rehab. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

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icd9cm

[ [ [] ] ]

[ "31.1", "43.11", "96.72", "33.24", "96.6" ]

icd9pcs

[ [ [] ] ]

14135, 14201

7617, 9823

224, 308

14255, 14255

3793, 3793

15931, 16153

2278, 2330

10815, 14112

14222, 14234

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2345, 3774

177, 186

336, 1453

3809, 4480

14270, 14368

1475, 1808

1824, 2262

25,759

176,721

11298

Discharge summary

report

Admission Date: [**2128-8-14**] Discharge Date: [**2128-8-20**] Date of Birth: [**2059-12-4**] Sex: M Service: CHIEF COMPLAINT/IDENTIFICATION: The patient is a 68 year old man with a history of atrial fibrillation, myocardial infarction times four, and coronary artery bypass grafting times three in [**2113**], who presents from an outside hospital with persistent chest pain following an episode of rapid ventricular response with his atrial fibrillation. PAST MEDICAL HISTORY: 1. Coronary artery disease, coronary artery bypass grafting times three in [**2113**] with left internal mammary artery to left anterior descending artery, saphenous vein [**Year (4 digits) **] to ramus intermedius and saphenous vein [**Year (4 digits) **] to right posterolateral. 2. Diabetes mellitus type 2, diagnosed two years ago, on oral hypoglycemic agents. 3. History of pacemaker placement for "three seconds of asystole" in [**2120**], pacer taken out for repeated Staphylococcus aureus infections. MEDICATIONS ON ADMISSION: Enteric coated aspirin 325 mg p.o.q.d., metoprolol 12.5 mg p.o.q.d., Lipitor 10 mg p.o.q.d., Zestril 5 mg p.o.q.d., Flovent 220 mcg two puffs b.i.d., Coumadin 7.5 mg p.o.q.d. except for 10 mg p.o.q. Friday, Glucotrol, and Lasix. ALLERGIES: Isuprel inhaler. HISTORY OF PRESENT ILLNESS: The patient was in his usual state of health and developed retrosternal chest pain with shortness of breath and diaphoresis at rest. The patient took three sublingual nitroglycerin without resolution of his ten out of ten chest pain. The patient presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital in [**Location (un) 5028**] and was noted to be in atrial fibrillation with a ventricular rate in the 160s. His systolic blood pressure was approximately 120. His ventricular rate was controlled with intravenous diltiazem. He also received heparin, Integrilin and intravenous nitroglycerin. The patient also received a dose of morphine and, despite the therapies, continued to have chest pain. He was transferred by [**Location (un) 7622**] to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] and received 200 mcg of fentanyl during the flight. Upon arrival, the patient was chest pain free. The patient claims that he has had increasing dyspnea on exertion over the past few weeks with climbing a flight of stairs. During that period of time, he also had some occasional retrosternal chest pain, which had been relieved with nitroglycerin. SOCIAL HISTORY: The patient has a remote history of smoking and quit in [**2112**]. He drinks alcohol occasionally and lives at home with his wife. [**Name (NI) **] is currently retired, and previously worked as a longshoreman. He has three children. FAMILY HISTORY: The patient's father died of prostate cancer and his mother died after three strokes. PHYSICAL EXAMINATION: On physical examination on arrival, the patient had a temperature of 96.1, heart rate 80, irregularly irregular, blood pressure 107/52, respiratory rate 20 and oxygen saturation 99% on two liters nasal cannula, with a weight of 90 kilograms General: Well appearing man in no acute distress. Head, eyes, ears, nose and throat: Oropharynx moist, no lymphadenopathy, anicteric sclerae. Cardiovascular: No jugular venous distention, normal S1 and S2, no S3 or S4, no murmurs or peripheral edema, palpable pulses in extremities. Respiratory: Unremarkable apart from scattered crackles and wheezes. Neurologic examination: Alert and oriented times three, no focal deficits. LABORATORY DATA: Platelet count was 247,000, hematocrit 37.6, and white blood cell count 15.7 with 92 neutrophils, 6 lymphocytes and no bands. Partial thromboplastin time 85.3 on heparin, and INR was elevated at 3.2 with Coumadin. Chem-7 was unremarkable apart from a potassium of 5.9 due to a hemolyzed sample and a BUN of 25 and creatinine 1.2. Cardiac enzymes showed a CK of 122, MB fraction 10 and troponin 2.2. Calcium was 9.4 and magnesium 1.9. Electrocardiograms at the outside hospital demonstrated the patient to be in atrial fibrillation with a rate of 150 and a left bundle branch block with ST depressions in leads V2 to V6; the ST depressions subsequently improved once the patient's rate was brought down to a rate of 100. Electrocardiogram on arrival at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] showed the patient to be in atrial fibrillation at a rate of 90 with a left bundle branch block and no ischemic changes. Chest x-ray was normal, without any evidence of congestive heart failure or pneumonia. HOSPITAL COURSE: The patient was not catheterized immediately due to his elevated INR. He was continued on the heparin and nitroglycerin and Integrilin until his INR decreased. The patient was taken to the cardiac catheterization laboratory on [**2128-8-16**]. On catheterization, the patient was found to have a patent left internal mammary artery to left anterior descending artery [**Last Name (LF) **], [**First Name3 (LF) **] occluded saphenous vein [**First Name3 (LF) **] to the ramus intermedius and a patent saphenous vein [**First Name3 (LF) **] to the right posterolateral. The patient was noted to have a normal circumflex artery and a 30% left main lesion. At the time of cardiac catheterization, the patient was felt to be of higher risk for percutaneous coronary intervention, thus he did not receive any intervention. The patient continued on his heparin and his Integrilin and nitroglycerin were weaned off. The patient remained without chest pain during his entire hospital stay. It was noted on the night of admission that the patient had a 15 beat run of nonsustained ventricular tachycardia. The patient was generally asymptomatic after that episode, apart from some mild palpitations and slight lightheadedness. Because of this event, the electrophysiology department was consulted. Upon discussion with the patient, the patient declined an AICD. It was also felt, due to the patient's refusal to have a pacemaker because of his previous bad experience with pacemakers, that the patient should not be started on amiodarone because of the potential to require a pacemaker afterwards. The patient had his metoprolol and lisinopril titrated upwards during his hospital stay. On [**2128-8-19**], the patient underwent a stress Cestimibi study, which demonstrated an area of mild reversibility in his lateral wall. He also had a fixed defect inferiorly. His left ventricular ejection fraction was noted to be at 44%. During the three minutes that he was able to tolerate the modified [**Doctor First Name **] protocol, the patient experienced some lightheadedness and a drop in his blood pressure from 130 systolic to 100 systolic. Following the stress Cestimibi study, the patient's options were discussed and the patient elected to proceed with medical management at this time. The patient was discharged to home on [**2128-8-20**] in stable condition. FOLLOW-UP: The patient was instructed to follow up with his primary care physician on [**2128-8-23**] for his INR check. He is to be on Lovenox 60 mg subcutaneously twice a day while warfarin was being loaded and until further notified by his primary care physician. DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg p.o.q.d. Metoprolol 75 mg p.o.b.i.d. Lisinopril 10 mg p.o.q.d. Lipitor 10 mg p.o.q.d. Zestril 5 mg p.o.q.d. Flovent 220 mcg two puffs b.i.d. Albuterol p.r.n. Lovenox 60 mg s.c.b.i.d. until notified by primary care physician to stop. Lasix 20 mg p.o.q.h.s. Glucotrol as directed. [**Name6 (MD) 9272**] [**Name8 (MD) 9273**], M.D. [**MD Number(1) 9274**] Dictated By:[**Name8 (MD) 26201**] MEDQUIST36 D: [**2128-8-20**] 14:01 T: [**2128-8-24**] 17:56 JOB#: [**Job Number 36262**]

[ "414.02", "272.0", "414.01", "427.31", "V17.3", "250.00", "410.91", "427.1", "593.9" ]

icd9cm

[ [ [] ] ]

[ "88.53", "37.22", "99.20", "88.56" ]

icd9pcs

[ [ [] ] ]

2860, 2947

7438, 7984

1040, 1300

4771, 7415

2970, 3570

1329, 2587

3595, 4753

499, 1013

2604, 2843

54,805

131,907

6022

Discharge summary

report

Admission Date: [**2130-9-26**] Discharge Date: [**2130-10-7**] Date of Birth: [**2063-11-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5119**] Chief Complaint: Prostate cancer admitted for prostatectomy Major Surgical or Invasive Procedure: Open retropubic simple prostatectomy [**2130-9-26**] Central venous line placement Arterial line placement History of Present Illness: Initial history and physical is as per the [**Hospital Unit Name 153**] team - 66 yo French-Creole speaking male w/ a h/o of DMII on oral hypoglycemics, HTN, and prostate cancer who presented for prostatectomy for prostate cancer. He has had multiple bouts of urinary retention in the past, has had a rapidly increasing PSA and given the risk of impotence and incontinence after surgery a more conservative suprapubic partial prostatectomy was performed with plans for future radiation therapy. His prostatectomy was complicated by a difficult intubation per anesthesia given his neck size and difficulty visualizing his vocal cords given large eppiglotis. He had an estimated blood loss of 1500cc and rec'd 2 units PRBC and 6L of crystalloid in the OR and was transferred to the [**Hospital Unit Name 153**] as he remained intubated and for hemodynamic monitoring. Prior to transfer he was hemodynamically stable, intubated and sedated. Past Medical History: -DM Type 2 since [**2120**] -Prostate cancer, biopsy in [**2124**] with adenocarcinoma, in [**6-27**] -Adenocarcinoma, [**Doctor Last Name **] score 6 (3+3), involving approximately 5% of the core tissue -Colonoscopy [**2125**] w/ adenoma -R cataract surgery -HTN Social History: The patient is a French Creole-speaking male who came from [**Country 2045**] at the end of [**Month (only) 116**] for care of his prostate condition in the United States. Currently living [**Location (un) 6409**] with his daughter. The patient has a remote history of smoking approximately four pack years. The patient has about five alcoholic drinks per week. The patient denies illicit drug use. The patient is not sexually active for about a year given impotence. Family History: The patient does not know about medical conditions of his family. He has two brothers and two sisters as well as seven kids and five grandkids, all of which he says are healthy. Physical Exam: Vitals: T: 95.9 BP: 142/70 HR: 62 O2 sat: 100% on AC ventilation 14 x 550 with a PEEP of 5 and FiO2 of 40% GEN: intubated, sedated, NAD HEENT: PERRL, sclera anicteric, MMM NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, soft heart sounds PULM: Lungs CTAB ABD: Soft, NT, ND, - BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: does not respond to verbal stimuli, responds to painful stimuli, PERRL- pupils are 2mm bilaterally Pertinent Results: [**2130-9-26**] 05:36PM WBC-18.8*# RBC-2.99*# HGB-9.2* HCT-25.5*# MCV-86 MCH-30.9 MCHC-36.1* RDW-13.2 [**2130-9-26**] 05:36PM NEUTS-90.7* LYMPHS-7.5* MONOS-1.5* EOS-0.1 BASOS-0.1 [**2130-9-26**] 05:36PM PLT COUNT-324# [**2130-9-26**] 05:36PM GLUCOSE-212* UREA N-13 CREAT-0.9 SODIUM-142 POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-29 ANION GAP-11 [**2130-9-26**] 05:36PM CK(CPK)-89 [**2130-9-26**] 05:36PM CK-MB-4 cTropnT-<0.01 [**2130-9-26**] 05:36PM CALCIUM-8.1* MAGNESIUM-1.0* [**2130-9-26**] 03:50PM TYPE-ART PO2-184* PCO2-37 PH-7.51* TOTAL CO2-31* BASE XS-6 INTUBATED-INTUBATED Brief Hospital Course: Mr. [**Known lastname **] is a 66 year old male with a PMH significant for prostate cancer and type 2 DM admitted for prostatectomy complicated by hospital-acquired pneumonia and sepsis. 1. Sepsis: Likely secondary to hospital-acquired pneumonia. Patient developed a fever, leukocytosis, and hypotension on POD #1 and was found to have a new infiltrate on CXR. He was intially treated with norepinephrine for pressor support that was titrated off, and he was extubated succesfully prior to transfer from the MICU. 2. Hospital acquired pneumonia: Treated with vancomycin and ceftazidime for 8 days. Culture data negative. For insurance reasons the patient could not go home nor a [**Hospital1 1501**] to get IV antibiotics, so his course was completed at [**Hospital1 18**]. 3. Prostate CA: Patient is s/p suprapubic prostatectomy for prostate cancer with multiple bouts of urinary retention (partial prostatectomy with plans to have radition therapy in future), EBL 1500cc. Rec'd 6L IVF and 2uPRBC in OR, and 1U pRBCs after arriving in [**Hospital Unit Name 153**]. CBI discontinued on [**9-27**]. The patient was followed by the urology team throughout his hospital course. His foley was discontinued and he was voiding well at discharge. The patient was instructed to follow up with his urologist in [**12-21**] weeks. 4. Anemia: patient with significant hematocrit drop during hospital course requiring 2 units PRBC likely secondary to blood loss from surgery. Hemolysis labs negative and CT abdomen/pelvis negative for bleed. Hematocrit was stable for the remainder of his course. The patient has a colonoscopy scheduled for [**Month (only) **] (schedeuled by PCP) 5. Type 2 DM: Initially held oral hypoglycemics, A1C was 10% in [**Month (only) 205**], had been as high as 13% in the past. During admission, was covered with ISS and accuchecks. Before discharge the patient was taking decent po and was restarted on his glyburide and metformin. 6. HTN: Oral lisiinopril were held secondary to sepsis, but was restarted during admission when patient was hemodynamically stable. 7. Hypercholesterolemia: Continued simvastatin. 8. F/E/N: [**Doctor First Name **] diet 9. Proph: Heparin for DVT 10. Code: Full Medications on Admission: glyburide 10mg [**Hospital1 **] lisinopril 10mg po daily Metformin 1000mg po bid Simvastatin 20mg po daily Flomax 0.4mg qhs Discharge Medications: 1. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Healthcare associated pneumonia Prostate cancer s/p prostatectomy. Discharge Condition: Good Discharge Instructions: -Take all medications as prescribed -Follow up with your PCP regarding this hospitalization in [**12-21**] weeks. -Follow up in [**12-21**] weks with you urologist. -Return to ED if you experience chest pain, shortness of breath, fever/chills, are unable to urinate or have any other worrisome signs/symptoms Followup Instructions: 1. Please follow up with your Urologist Dr. [**Last Name (STitle) 770**] in [**12-21**] weeks. Please call [**Telephone/Fax (1) 23685**] on Monday to arrange this appointment. - 2. Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6522**] in [**12-21**] weeks. Please call [**Telephone/Fax (1) 250**] on Monday to arrange this appointment. [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2130-10-7**]

[ "185", "285.1", "997.31", "507.0", "038.9", "250.00", "788.20", "995.91", "E878.6", "401.1", "272.0", "518.5" ]

icd9cm

[ [ [] ] ]

[ "60.4", "40.3", "96.72" ]

icd9pcs

[ [ [] ] ]

6264, 6270

3568, 5802

358, 467

6381, 6388

2953, 3545

6745, 7337

2233, 2413

5976, 6241

6291, 6360

5828, 5953

6412, 6722

2428, 2934

276, 320

495, 1439

1461, 1727

1743, 2217

78,149

133,857

6+55180

Discharge summary

report+addendum

Admission Date: [**2175-3-12**] Discharge Date: [**2175-3-24**] Date of Birth: [**2105-11-5**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Progressive lethargy and collapse Major Surgical or Invasive Procedure: ACA aneursym coiling History of Present Illness: HPI: This is a 69 year old male who is primarily Russian speaking who was reportedly outside fishing when he slipped and fell.He now presents to the ED with his wife who reports that he has become progressively lethargic today. The patient is unable to report a review of systems due to his lethargy. Upon seeing the patient we recommended an emergent CTA. Past Medical History: PMHx:spondylosis, chronic low back pain associated with degenerative changes. Followed by Dr. [**Last Name (STitle) 79**] for prostate cancer. Chronic lymphocytic leukemia, which has been very stable. Social History: Lives with Wife Family History: NC Physical Exam: On Admition: Gen: lethargic, atraumatic HEENT: Pupils: PERRL 4-mm EOMs pt not participating in exam Neuro: Mental status: opens eyes to stimulation, lethargic. Orientation: not answering questions, but following simple commands Language:pt lethargic/non verbal at time of exam and emergently brought to CTA- Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Visual fields- not tested III, IV, VI: Extraocular movements- not tested V, VII: Facial strength and sensation intact and symmetric. VIII: [**Name (NI) 80**] pt did not participate IX, X: Palatal elevation- pt did not participate [**Doctor First Name 81**]: Sternocleidomastoid and trapezius- pt did not participate XII: [**Name (NI) 82**] pt did not participate. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength appears full, pt grips with bilat hands [**5-9**] lifts all extremities off the bed to command Sensation: Intact to light touch, proprioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: pt too lethargic to perform Pertinent Results: CT head: Extensive bilateral subarachnoid hemorrhage. Recommend head CTA to evaluate for an intracranial aneurysm. Findings were discussed with Dr. CTA: FINDINGS: There is a 3 mm x 3 mm saccular outpouching from the region of the anterior communicating artery (2:317), consistent with aneurysm. This has a very narrow neck, and would be amenable to endovascular intervention. No other aneurysm or vascular abnormality is seen. There is stenosis at the origin of the right vertebral artery. Otherwise, the carotid and vertebral arteries and their major branches are patent, with no evidence of stenosis or occlusion. The distal cervical internal carotid arteries measure 5 mm on the right, and 5 mm on the left. Mild-to-moderate multilevel cervical spine degenerative changes are noted. IMPRESSION: 3 mm saccular aneurysm arising from the anterior communicating artery, with narrow neck. Brief Hospital Course: Mr. [**Known lastname 83**] was admited on [**2175-3-12**] and became increasingly lethargic and transferred to the ICU for further care under the Neurosurgery service. A diagnostic CTA revealed a large ACOM aneursym which was coiled the following day. Post Coiling the pt. was admitted to the ICU with a ventricular drain. There were no incidences of increased intracranial pressure or decline. A cerebral perfusion study performed [**3-15**] confirmed the lack of vasospasm and develoing strokes. He had some R shoulder weakness and shoulder X-ray was concerning for rotator cuff injury and orthopedics was consulted. On [**2179-3-16**]/14/15 his ventricular drain was clamped and reopened due to elevated ICP levels. On [**3-19**] he was transferred to the SDU and continued to remain stable. He had his ventricular drain clamped on [**3-21**] and after 48 hours of the clamping trial he had a CT done which was stable without any evidence of hydrocephalus. At this time the drain was pulled. He was placed on a fluid restriction for a brief period of time for a drop in his Na level, and also on salt tabs, upon discharge to rehab we have removed the fluid restriction, but we are continuing the salt tabs, we advise that the Na level be checked every other day, and the salt tabs may be d/c'ed when Na is stable on serial checks. Upon discharge his Na is 138. He is now ready for discharge to rehab. On discharge his exam is as follows: Alert and Oriented X2 Moving all extremities with full strength slight Right Drift, which has been persistant throughout his hospitalization, and possibly secondary to a rotator cuff injury. Medications on Admission: [**Name (NI) 84**] wife Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-6**] Tablets PO Q4H (every 4 hours) as needed for Headaches. 11. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours): Continue for [**2175-4-2**]. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Acom Aneursym Subarachnoid Hemorrhage Discharge Condition: 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. ?????? You may wash your hair only after sutures and/or staples have been removed. You may have your staples removed at the rehab facility or you can make an appointment in our office to have them removed in 10 days from the date of discharge. ?????? 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. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you 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: Follow-Up Appointment Instructions ??????Please return to the office in 10 days for removal of your staples or sutures, or you may have them d/c'ed at rehab. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.[**First Name (STitle) **], to be seen in ___4____weeks. ??????You will not need a CT scan of the brain without contrast. Completed by:[**2175-3-24**] Name: [**Known lastname 38**],DMITRIY Unit No: [**Numeric Identifier 39**] Admission Date: [**2175-3-12**] Discharge Date: [**2175-3-24**] Date of Birth: [**2105-11-5**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 40**] Addendum: Prior to removing the ventricular catheter on [**3-23**] a CSF sample was sent. As of [**3-24**] the following results were back: WBC 0 RBC 0 Lymph 0 Mono 0 Total protien 30 Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] [**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**] Completed by:[**2175-3-24**]

[ "430", "E885.9", "185", "276.1", "780.60", "204.10", "840.4", "721.3", "331.4", "721.0", "729.89" ]

icd9cm

[ [ [] ] ]

[ "02.39", "38.91", "39.72", "88.41" ]

icd9pcs

[ [ [] ] ]

8920, 9125

3096, 4739

351, 373

5924, 5932

2183, 2183

7959, 8897

1035, 1039

4813, 5749

5863, 5903

4765, 4790

5956, 7936

1054, 1164

278, 313

401, 762

1381, 2164

2192, 3073

1179, 1365

784, 986

1002, 1019

40,179

183,432

41766

Discharge summary

report

Admission Date: [**2164-7-17**] Discharge Date: [**2164-7-23**] Date of Birth: [**2087-11-14**] Sex: F Service: MEDICINE Allergies: hydrochlorothiazide / Prochlorperazine / amiodarone Attending:[**First Name3 (LF) 1436**] Chief Complaint: palpitations Major Surgical or Invasive Procedure: EP study History of Present Illness: 75yo female with h/o multiple PCI's (LAD stent; 70% OM stenosis and RCA occlusion medically managed), ischemic heart failure with EF 35-45% with posterobasal aneurysm, s/p ICD after VTach during NSTEMI for which she received a DDD/ICD, s/p VTach ablation [**6-/2163**] who initially presented to [**Hospital6 33**] with palpitations and a shock from her ICD within the last few weeks. Per report, she had recently been admitted in [**Month (only) 547**] and [**6-29**] with firing of her defibrillator. On [**2164-7-8**] she was feeling unwell on newly started flecanide with intermittent nausea/vomiting. Additionally was suffering from lightheadedness and falls without LOC. She denies firing of her AICD at that time. On initial evaluation she was found to be dehydrated with hyponatremia of 126. Her felcanide was decreased from 100 to 50 mg po BID as she was having nausea. She was admitted for evaluation. Sodium corrected daily to greater than 135. Per verbal report and telemetry strips, the patient had episodes of wide complex tachycardias. Per OSH [**Month (only) 16**] review, procainamide was started on [**2164-7-16**]. Per verbal report and review of EKG's from the OSH, a coronary catherization was performed apparently to assess for an ischemic source of her VT. No documentation of the catherization is provided with the patient on transfer. No discharge summary accompanies the patient on transfer. In the CCU, patient is fatigued but otherwise without complaints. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: . CARDIAC RISK FACTORS: NO Diabetes, NO Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CHF EF 35-45% with posterobasal aneurysm - Atrial fibrillation -PERCUTANEOUS CORONARY INTERVENTIONS: Multiple PCI's and VTach ablation at [**Hospital1 2177**] - LAD stent - 70% obtuse marginal branch stenosis and an occluded RCA which are medically managed -PACING/ICD: [**Company 1543**] DDD ICD for VT during NSTEMI, s/p VT ablation [**2163-7-11**] @ [**Hospital1 2177**] -> 3cm below mitral annulus on inferoseptal wall with matching ablation on RV side of septum - Admitted [**Hospital3 **] then transfer to [**Hospital1 18**] [**9-/2163**] for VT with 2 morphologies and ICD shock s/p substrate based ablation [**2163-10-5**] - H/o prolonged QT on Amiodarone 3. OTHER PAST MEDICAL HISTORY: - C. diff colitis- [**2163-6-29**] - PVD s/p PTCA of bilateral lower extremities [**2160**] - High grade renal artery stenosis of L renal artery - carotid artery stenosis - vertebral artery stenosis - s/p thyroidectomy for toxic multinodular goiter; hypothyroidism. - s/p appendectomy - COPD Social History: Patient lives alone in [**Location (un) 90723**], NH, in housing for the elderly. Used to work in distribution at Talbots clothing. Used to smoke 1 ppd x 60 years ex-smoker, quit several years ago. Has not had alcohol for years. She used to drink occassionally. Denies IVDU. Family History: No family history of CAD. Negative for early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.4, 162/92, 94, 20, 98% RA GENERAL: elderly female in NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. CN II-XII intact. NECK: Supple. Laying flat, JVP prominent. Carotid bruits present. CARDIAC: RR, normal S1, S2. III/VI systolic murmer loudest in aortic region. No thrills, lifts. No S3 or S4. Radiation of murmur to carotids per above. ICD pocket on left appears CDI. LUNGS: CTAB, no crackles, wheezes or rhonchi. Diminished breath sounds at bases bilaterally. Resp were unlabored, no accessory muscle use. ABDOMEN: Soft, NTND. No HSM or tenderness. Diffuse ecchymoses from heparin injections. EXTREMITIES: No c/c/e. R groin cath site with achieved hemostasis. No bruit. No hematoma. Mottling of lower extremities bilaterally. NEURO: AOX3. Can move toes and squeeze hands. No CN deficits on examination. PULSES: Right: Carotid 2+ Femoral 1+ DP/PT are faint but dopplerable Left: Carotid 2+ Femoral 1+ DP/PT are faint but dopplerable DISCHARGE PHYSICAL EXAM Temp 98.3, HR 76, BP 117-128/73-75, O2 sat 98% RA Weight: 48.4 kg . HEENT: supple, no JVD CV: RRR, 2/6 systolic murmur at apex Chest: CTAB posteriorally Abd: NT/ND Extr: no edema Pertinent Results: ADMISSION LABS [**2164-7-17**] 08:10AM BLOOD WBC-5.8 RBC-3.57* Hgb-10.8* Hct-34.9* MCV-98# MCH-30.3 MCHC-31.0 RDW-13.6 Plt Ct-215 [**2164-7-17**] 08:10AM BLOOD Neuts-73.8* Lymphs-15.3* Monos-5.6 Eos-3.8 Baso-1.4 [**2164-7-17**] 08:10AM BLOOD PT-11.1 PTT-34.9 INR(PT)-1.0 [**2164-7-17**] 08:10AM BLOOD Glucose-88 UreaN-9 Creat-0.9 Na-135 K-3.6 Cl-98 HCO3-27 AnGap-14 [**2164-7-17**] 08:10AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.9 [**2164-7-19**] 05:30AM BLOOD TSH-1.4 IMAGING CXR [**7-18**] CT ABD/PELVIS [**7-19**]: IMPRESSION: 1. No retroperitoneal bleed. 2. Severe atherosclerosis of the abdominal aorta and intraperitoneal arteries, without aneurysmal formation. 3. Slight apparent enlargement of the right adnexa in comparison with the left, not well evaluated with CT. If warranted, a pelvic ultrasound may be performed to exclude ovarian cyst or enlargement. . Labs at discharge: [**2164-7-23**] 06:41AM BLOOD WBC-6.0 RBC-3.34* Hgb-10.3* Hct-31.5* MCV-94 MCH-30.8 MCHC-32.6 RDW-14.6 Plt Ct-190 [**2164-7-23**] 06:41AM BLOOD Glucose-79 UreaN-12 Creat-1.0 Na-136 K-4.0 Cl-100 HCO3-29 AnGap-11 Urine: [**2164-7-22**] 05:40PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.015 [**2164-7-22**] 05:40PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG [**2164-7-22**] 05:40PM URINE RBC-10* WBC->182* Bacteri-MOD Yeast-NONE Epi-0 [**2164-7-22**] 05:40PM URINE WBC Clm-FEW Mucous-RARE Brief Hospital Course: Ms. [**Known lastname 90719**] is a 75 year old female with history of hypertension (HTN), coronary artery disease (CAD) and difficult to control Ventricular tachycardia (VT) status post implantable cardiodefibrillator (ICD) who presented with recurrent VT. She underwent ablation of [**8-5**] VT tracks in the cath lab but continued to have VT afterward, necessitating continued therapy with mexilitine. . # VT: Patient has complicated history of VT s/p ICD placement and continues to have bouts of VT despite flecanide/procainamide. Spontaneously resolves on telemetry. Patient is symptomatic, feeling unwell and nervous. She was maintained on procainamide to reduce the duration of VT until taken to the ablation by the electrophysiology team. On [**7-17**] she underwent VT track ablation of [**8-5**] different tracks but continued to have VT aferward. She was hypotensive after the case and was on pressors for 24 hours. She was also intubated for the ablation and was electively maintained on mechanical ventilation and sedation for the full night of the 19th to let her sympathetic drive resolve in hopes of reducing her VT episodes. She was sucesfully extubated on [**7-18**] and her pressors were weaned off on [**7-18**] with a 500 cc bolus of NS. Her hematocrit dropped and she did recieve 2 units of packed RBCs as well as a CT abd and pelvis which was negative for retroperitoneal hematoma. She was taken off procainamide after the case and started on mexilitine 150 mg [**Hospital1 **]. # CAD: Had a stent in LAD from prior. No chest pain during admission and EKGs were not consistent with ischemia. She underwent a cardiac cath at the OSH before transfer to [**Hospital1 18**] on this admission which was negative for further ischemic lesions per verbal report. Continued clopidogrel, aspirin, pravastatin, metoprolol succinate 50 mg, lisinopril 5 mg daily. # Chronic systolic heart failure (sCHF): Known to have EF of 35%, although no echos in our system. During hospitalization, optimized and not fluid-overloaded, not symptomatic. Was continued on metoprolol succinate 50 mg daily, furosemide 40 mg daily, lisinopril 5 mg daily. # HYPOTHYROIDISM: status post thyroidectomy. Continued home regimen of levothyroxine 50 mcg daily. Normal TSH. # gastroesophageal reflux disease (GERD): continued Ranitidine. # Chronic obstructive pulmonary disorder (COPD): continued Spiriva # Dysuria and Frequency: s/p foley catheter, pos U/A, culture results are pending at time of discharge. Urine grew e-coli, sensitive to Bactrim on [**7-24**]. Treating with 7 day course of Bactrim . COMM: [**Name (NI) 13291**] [**Name (NI) 90719**] (son) [**Telephone/Fax (1) 90720**] [**First Name8 (NamePattern2) **] [**Known lastname 90719**] Harding (daughter) [**Telephone/Fax (1) 90721**] TRANSITIONAL ISSUES: -Slight apparent enlargement of the right adnexa noted on CT. If warranted, a pelvic ultrasound may be performed to exclude ovarian cyst or enlargement. - Uptitrate [**Telephone/Fax (1) **] or beta blocker as needed for hypertension Medications on Admission: . Information was obtained from . 1. Aspirin 325 mg PO DAILY 2. Tiotropium Bromide 1 CAP IH DAILY 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Clopidogrel 75 mg PO DAILY 6. Zolpidem Tartrate 5 mg PO HS 7. Mexiletine 100 mg PO Q12H 8. Pravastatin 40 mg PO HS 9. Metoprolol Tartrate 25 mg PO BID 10. Ranitidine 150 mg PO BID 11. Lorazepam 0.5 mg PO BID:PRN PRN ANXIETY 12. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours Hold for K >4 13. Promethazine 25 mg PO Q6H:PRN nausea Discharge Medications: 1. Lorazepam 0.5 mg PO BID:PRN PRN ANXIETY 2. Mexiletine 150 mg PO Q12H 3. Lisinopril 5 mg PO DAILY Hold for SBP<100 4. Metoprolol Succinate XL 50 mg PO DAILY Hold for SBP<100 or HR<60 5. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours 6. Promethazine 25 mg PO Q6H:PRN nausea 7. Zolpidem Tartrate 5 mg PO HS 8. Aspirin 325 mg PO DAILY 9. Clopidogrel 75 mg PO DAILY 10. Furosemide 40 mg PO DAILY 11. Levothyroxine Sodium 50 mcg PO DAILY 12. Pravastatin 40 mg PO HS 13. Ranitidine 150 mg PO BID 14. Tiotropium Bromide 1 CAP IH DAILY 15. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Hospital **] Nursing Home - [**Location (un) 5087**] Discharge Diagnosis: Ventricular tachycardia Ischemic Cardiomyopathy Acute on Chronic systolic congestive heart failiure Coronary artery disease Positive urinalysis 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: Your ICD fired because of ventricular tachycardia and you were sent to [**Hospital1 18**]. An EP study was done but the doctors were not [**Name5 (PTitle) 460**] to do an ablation procedure to prevent more ventricular tachycardia. Your mexilitine was increased to 150 mg twice daily and you have had no further VT. Weigh yourself every morning, call Dr. [**Last Name (STitle) 13177**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. You have symptoms of a urinary tract infection and was started on an antibiotic for 7 days to treat the infection. Followup Instructions: Name: [**Last Name (LF) 13177**], [**First Name3 (LF) 28239**] V. MD Location: [**Hospital3 **] Cardiology Address: [**Street Address(2) **] # 1, [**Location (un) **], [**Numeric Identifier 2876**] Phone: ([**2164**] Appt: [**8-9**] at 9:45am

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icd9cm

[ [ [] ] ]

[ "96.04", "37.27", "38.91", "96.71", "37.34" ]

icd9pcs

[ [ [] ] ]

10772, 10888

6530, 9336

326, 337

11076, 11076

5055, 5924

11849, 12098

3614, 3748

10150, 10749

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274, 288

5943, 6507

365, 2203

11091, 11235

3010, 3304

2225, 2293

3320, 3598

24,993

162,311

23722

Discharge summary

report

Admission Date: [**2113-7-21**] Discharge Date: [**2113-7-25**] Date of Birth: [**2063-8-28**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 3326**] Chief Complaint: Cirhhosis; Observation s/p TIPS Major Surgical or Invasive Procedure: Trans-intrahepatic portosystemic shunt procedure (TIPS) History of Present Illness: 49 y/o m with EtOH induced cirrhosis, h/o SBP, H63D homozygosity who was recently admitted to [**Location (un) **] [**2033-7-17**] for hyponatremia and worsening ascites. He was given IVF per his report and his Na improved and he recieved a paracentesis as well, and per his report was not infected. Although he takes daily cipro for prophylaxis. He went to [**Location (un) **] today for follow up blood work and was found to have Na of 123, and he was transferred here to [**Hospital1 **] as his hepatologist, Dr. [**Last Name (STitle) **], is here. He otherwise denies fever/chills/diarrhea/black or bloody stool/confusion/fatigue. He has not had EtOH for the past month, and is currently abstaining as he is waiting for a transplant. Past Medical History: sbp cirrhosis caogulapathy hypoalbuminemia Social History: Social hx: continues to drink- 6 beers a day and sometimes wine had stopped in 198 then restrated 5 years ago, smokes 1 pack per day had stopped smoking in [**2095**], restarted 3 years ago, lives alone, divorced and has been on temp. disability for 2 years and has been working as a floor refinisher. Family History: family hx: alcoholism in father, h/o emphysema and lung cancer Physical Exam: T 97.5 HR 91 BP 114/57 R 18 sat 98% RA gen alert, NAD, HEENT mmm, mild scleral icterus, no OP lesions , RIJ CDI CV RRR no m/r/g pulm ctab abd s/nt/distended, + fluid wave +BS ext no edema, 2+ pulses Pertinent Results: [**2113-7-21**] 05:37PM GLUCOSE-95 UREA N-7 CREAT-0.5 SODIUM-123* POTASSIUM-4.6 CHLORIDE-89* TOTAL CO2-30 ANION GAP-9 [**2113-7-21**] 05:37PM ALT(SGPT)-42* AST(SGOT)-74* ALK PHOS-189* AMYLASE-79 TOT BILI-1.6* [**2113-7-21**] 05:37PM LIPASE-45 [**2113-7-21**] 05:37PM ALBUMIN-2.7* [**2113-7-21**] 05:37PM OSMOLAL-260* [**2113-7-21**] 05:37PM WBC-10.2 RBC-4.02* HGB-13.7* HCT-39.4* MCV-98 MCH-34.1* MCHC-34.8 RDW-14.2 [**2113-7-21**] 05:37PM NEUTS-76.4* LYMPHS-15.1* MONOS-7.0 EOS-1.3 BASOS-0.3 [**2113-7-21**] 05:37PM PT-15.2* PTT-33.8 INR(PT)-1.5 Abdominal u/s: There is marked ascites seen. The liver itself appears with relatively normal echogenicity and no evidence of mass. Hepatofugal flow is noted within the right, left, and main portal veins. Vasculature appears patent, but with reversed flow. The right kidney measures 11.6 cm. The left kidney measures 10.9 cm. There is no hydronephrosis or stones. The gallbladder appears normal without evidence of stones. The common duct is not dilated. There is splenomegaly. Pancreas is not well visualized secondary to abdominal gas. IMPRESSION: 1. Marked ascites consistent with cirrhosis. 2. Hepatofugal flow within the portal veins consistent with portal hypertension. 3. Splenomegaly. TIPS: 1. Paracentesis with a total of 4.4 liters of ascitic fluid removed. 2. Successful placement of a transjugular intrahepatic portosystemic shunt between the right hepatic vein and main portal vein by way of the right portal vein. A total of 2 10 x 68 mm Wallstents were used in overlap. 3. A 9-French triple-lumen central venous catheter was placed through the right internal jugular venous access with tip at the superior vena cava-right atrial junction. The catheter may be used immediately. A single 3-0 nylon suture was placed at the paracentesis site in the right lower quadrant of the abdomen. This can be removed in 7 days' time. Please note that another suture was in place in the right lower quadrant of the abdomen that was present prior to the beginning of today's procedure. Brief Hospital Course: Mr [**Known lastname 19419**] was admitted to the MICU for one day for monitoring after his TIPS procedure. He remained hemodynamically stable and afebrile throughot his stay. He was to be transferred to the floor the morning following his procedure, but was doing well without acute issue and for this reason was discharged directly from the MICU one day following admission. Medications on Admission: 1. Lasix 80 mg q day 2. Aldactone 200 mg q day 3. Lactulose tid 4. Potassium prn 5. Folic acid, thiamine, and MVI 6. Cipro 500 mg daily Discharge Medications: 1. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a week. Disp:*2 Tablet(s)* Refills:*2* 2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Aldactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:*2700 ML(s)* Refills:*2* 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary 1. Alcoholic Cirrhosis 2. Coagulopathy 3. Hypoalbuminemia Discharge Condition: Good Discharge Instructions: Please continue your home medications. Please call the liver center [**Telephone/Fax (1) 2422**] or go to the ER for increased confusion, fevers, chills, or any other problems. [**Name (NI) **] should not drink more than 6 cups of fluid a day. (1500 cc) Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Where: LM [**Hospital Unit Name 7129**] CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2113-8-11**] 10:40 Do not drink more than 6 cups of fluid (1500 cc) a day

[ "V49.83", "789.5", "428.0", "571.2", "572.3", "276.1", "496" ]

icd9cm

[ [ [] ] ]

[ "54.91", "39.1" ]

icd9pcs

[ [ [] ] ]

5102, 5108

3904, 4283

301, 359

5218, 5225

1829, 3881

5529, 5811

1529, 1594

4470, 5079

5129, 5197

4309, 4447

5249, 5506

1609, 1810

230, 263

387, 1127

1149, 1193

1209, 1513

64,087

188,416

47137

Discharge summary

report

Admission Date: [**2174-3-3**] Discharge Date: [**2174-3-7**] Service: MEDICINE Allergies: Avelox Attending:[**First Name3 (LF) 443**] Chief Complaint: hypotension/weakness Major Surgical or Invasive Procedure: Intubation twice Arterial line placement History of Present Illness: 86 y/o M with hx of CAD s/p CABG, HTN, HL, sCHF and COPD who presents from [**Location (un) **] health via EMS with report of one hour of generalized weakness and borderline hypotension. The weakness began after working with PT today during which he describes his exercise regimen was advanced. On questioning he does endorse mild shortness of breath with exertion over the last few days. At rehab today, his BP was slightly lower with systolics in the 90s and they thought he had crackles on exam. He was recently admitted from [**Date range (1) 82276**] on [**Hospital1 1516**] for an NSTEMI. He had a cardiac cath on [**2174-2-18**] showing diffuse disease, but nothing intervenable. His heparin, integrillin and nitro gtts were stopped and the pain eventually abated. His pain was felt to me multifactorial: recent PNA mid-[**Month (only) 956**] at OSH, his thoracic aortic aneurysm, and some element of angina. He had no ECG changes during episodes of chest pain. He was also noted to have mild hypoxia and was diuresed during this admission. Since his discharge on [**2174-2-23**], he describes a few episodes of mild chest pressure. Each episode was more mild than the chest pain he presented with on his prior admission. The chest discomfort lasts < 30 minutes and is not associated with any diaphoresis, nausea, SOB, or lightheadedness. The episodes were not related to increased activity. . In the ED, initial vitals were T 97.6, HR 112, BP 97/63, R 16 and 100% 6L NC. He was negative for orthostatic hypotension. CXR was consistent with volume overload. Labs were notable for BNP [**Numeric Identifier 26361**], Trop 0.09 (trending down from 0.17 on [**2174-2-18**]), Cr 1.5 (at baseline) He received 40 mg IV lasix prior to being transferred to the cardiology floor. . On review of systems, patient admits to weight gain in the last few days (per record [**3-22**] lbs) and increased shortness of breath with exertion but he is uncertain if this is due to deconditioning or his heart failure. He describes mild increased leg edema. He describes episodes of chest pressure every [**2-18**] days and last for 30 minutes at a time. He admits to new onset diarrhea that he attributes to his increased bowel regimen since his recent discharge. He denies fevers, chills, increased sputum production, black or bloody stools, nausea, vomiting, diaphoresis, lightheadedness, falls, or loss of consciousness. Past Medical History: 1. CARDIAC RISK FACTORS: -Dyslipidemia -Hypertension . 2. CARDIAC HISTORY: AMI x 2 [**2145**] -CABG: s/p CABG x 3 (SVG to LAD, SVG to D1 and SVG to PDA) in [**10/2146**] -PERCUTANEOUS CORONARY INTERVENTIONS: C Cath [**2160-8-28**]: stump occlusion of the SVG to PDA and the SVG to D1. The SVG to LAD had a 20% proximal stenosis and a moderate stenosis prior to touchdown site. 100% mid-LAD and 100% pRCA lesions (lt-rt collaterals from CFX to distal RCA). -PACING/ICD: none . 3. OTHER PAST MEDICAL HISTORY # HTN # Hyperlipidemia # sCHF with EF 30% # Thoracic aortic aneursym 6.5 cm (noted per past discharge summaries to be slowly enlarging, but given age and comorbidities he was not a surgical candidate) # OSA, on CPAP # AAA # Hypertension # Hyperlipidemia # COPD # Prostate cancer diagnosed in [**5-23**] # Renal Insufficiency (baseline Cr 1.5) # Headaches # Multiple episodes of pulmonary infection [**2167**]-[**2168**], which responds well to antibiotics, ? recurrent bouts small vol aspiration # Restrictive lung disease pattern on PFTs # Internal hemorrhoids and diverticulosis of sigmoid and ascending colon on [**3-/2169**] colonoscopy # Hiatal hernia (medium, bx neg), mild gastritis, benign gastric polyp on EGD [**10/2167**] (for dysphagia). # s/p cholecystectomy Social History: -Tobacco history: no cigarettes, but used to smoke a pipe ("I did not inhale") -ETOH: none -Illicit drugs: none -Home: Lives with his wife/HCP in [**Name (NI) 99896**]; although after his recent discharge he went to rehab. He is independent of all ADLs but requires assistance of walker for ambulation. Family History: Father died of MI, Mother had CVA. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T=96.1 BP= 111/55 HR= 104 RR= 16 O2 sat= 98% 2L GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP elevated CARDIAC: borderline tachycardia, RR, diastolic murmur [**1-23**] at R and LUSB. No thrills, lifts. LUNGS: Mild kyphosis, Resp were unlabored, no accessory muscle use. Speaking in full sentences without tachypnea. Decreased bs at bases with bibasilar crackles, ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 1 + pitting edema bilaterally, no cyanosis. SKIN: No rashes R GROIN: prior cath site clean with 3 cm diameter of induration consistent with prior hematoma, 2 + femoral pulse. PULSES: 2 + distal pulses x 4 Discharge exam: Pt deceased. No spontaneous respirations. No pulse or heart rate to auscultation. No corneal reflex. Pertinent Results: Admission Labs: [**2174-3-3**] 04:55PM BLOOD WBC-6.0 RBC-3.41* Hgb-11.4* Hct-33.0* MCV-97 MCH-33.5* MCHC-34.7 RDW-16.2* Plt Ct-228# [**2174-3-3**] 04:55PM BLOOD Neuts-79.4* Lymphs-14.4* Monos-4.2 Eos-1.6 Baso-0.4 [**2174-3-3**] 04:55PM BLOOD Glucose-118* UreaN-41* Creat-1.5* Na-143 K-4.0 Cl-107 HCO3-26 AnGap-14 [**2174-3-3**] 04:55PM BLOOD CK-MB-9 cTropnT-0.09* proBNP-[**Numeric Identifier 26361**]* . Discharge Labs [**2174-3-6**] 03:58AM BLOOD WBC-11.0 RBC-3.62* Hgb-12.0* Hct-34.8* MCV-96 MCH-33.3* MCHC-34.6 RDW-16.6* Plt Ct-215 [**2174-3-6**] 08:02PM BLOOD Glucose-84 UreaN-77* Creat-3.3* Na-144 K-5.8* Cl-101 HCO3-16* AnGap-33* [**2174-3-6**] 08:02PM BLOOD CK-MB-10 MB Indx-3.2 cTropnT-0.70* [**2174-3-6**] 08:02PM BLOOD Calcium-7.3* Phos-9.6* Mg-2.3 [**2174-3-6**] 08:07PM BLOOD Type-ART pO2-177* pCO2-36 pH-7.25* calTCO2-17* Base XS--10 Intubat-INTUBATED [**2174-3-6**] 08:07PM BLOOD Lactate-11.7* K-5.5* . Representative Imaging: CXR [**2174-3-3**] FINDINGS: Frontal and lateral views of the chest were obtained. The cardiac and mediastinal silhouettes are stable, including marked cardiomegaly and severely tortuous aorta, which remains similar in appearance. No focal consolidation, pleural effusion, or pneumothorax is seen. The examination is essentially unchanged as compared to multiple priors, including [**2170-7-12**]. The patient is status post median sternotomy. IMPRESSION: No acute cardiopulmonary process. Stable cardiomegaly and marked aortic tortuosity. . CTA Chest [**2174-3-5**]: IMPRESSION: 1. Mild interval increase in size of a 6.5 cm thoracic aneurysm without evidence of rupture. No evidence of aortic dissection. 2. Mediastinal lymphadenopathy new since [**2167**], concerning for entities such as lymphoma. 3. Extensive atherosclerotic disease. Massive cardiomegaly. 4. Bibasilar atelectasis and small pleural effusions. 5. Liver perfusion abnormalities. 6. Left renal cyst. 7. Tracheal configuration suggestive of tracheomalacia. . RUQ Ultrasound [**2174-3-5**]: IMPRESSION: 1. Small amount of perihepatic and right lower quadrant free fluid. 2. Hyperechoic liver lesions likely representing hemangiomas. 3. Bilateral renal cysts. 4. Assessment for free air is very limited on ultrasound exam and abdominal radiograph or CT is recommended for further workup. . AP CXR [**2174-3-6**]: IMPRESSION: Interval improvement in interstitial pulmonary infiltrates consistent with edema. No other significant change. Brief Hospital Course: 86 y/o M with hx of CAD, HTN, HL, sCHF and COPD who presents today with worsening shortness of breath, intermittent chest pain and weakness, consistent with mild CHF exaccerbation. His presentation was felt to be consistant with a CHF exacerbation. He was on a low-salt diet and 1.5L water restrction. He got 80mg IV Lasix on day 2 of admission. He still had some crackles on exam, but BP was 90s/50s, so further diuresis was held given he was comforable and satting high 90s on 2L. The evening of HD2, he had worsening SOB and was given 40IV lasix. He he then went into aF with RVR in the 120s-140s, and metoprolol was restarted (had been held on admission). Pt has a Hx of AF from prior to transfer last admission, and had opted against anticoagulation. He had an episode of chest and associated back pain, and there was concern for dissection given his known TAA. He went for a stat CTA and was sent to the CCU for closer monitoring. CTA eventually revealed slight increase in size of his AAA (6.5 cm) but no dissection or rupture and new bulk lymphadenopathy. Shortly after arrival to the CCU the patient went into a junctional bradycardia and became unresponsive. Code blue was called with patient in PEA arrest. He was intubated and resuscitated after 5 minutes of CPR. He developed progressive renal failure with oliguria transitioning to anuria in the 24 hours post arrest. LFTs were also elevated, consistent with shock liver. Lactate was also elevated initially above 7. The following day the patient was successfully extubated. In discussion with him and the family at the bedside, he desired to remain full code. He developed progressive electrolyte derrangements over the course of the afternoon. He became hypotensive requiring rapid uptitration of dopamine initiated the prior day and initiation of levophed at maximum dose. He then complained of chest pain and EKG obtained immediately prior to his second cardiac arrest showed ST elevations in the inferior leads. He rapidly became hypotensive and pulseless and code blue was called. He was again intubated and successfully resuscitated. A family meeting was held immediately post-arrest and they decided to make the patient comfort-measures only given his poor prognosis. He was terminally extubated, all pressors were stopped, and morphine was given for comfort. He died shortly thereafter with family at the bedside. Medications on Admission: 1. nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**12-20**] Tablet, Sublinguals Sublingual PRN (as needed) as needed for chest pain. 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 8. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP < 100. 9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP < 100. 10. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily): hold for SBP < 100. 11. Hemorrhoidal Suppository 0.25 % Suppository Sig: One (1) suppository Rectal once a day as needed for rectal pain. 12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for loose stool, > 2 BM/day . 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stool, > 2 BM/day . 15. bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. 16. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. 17. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP < 100. Tablet(s) 18. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day: hold for SBP < 90, HR < 60. Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses: Hypotension ST Elevation MI Liver Failure Oliguric renal failure Cardiac arrest x 2 Secondary Diagnoses: Coronary artery disease Hypertension Hyperlipidemia Obstructive sleep apnea Chronic obstructive pulmonary disease Chronic renal insufficiency Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

[ "785.51", "276.2", "427.5", "584.9", "441.2", "414.01", "496", "272.4", "410.91", "585.9", "V66.7", "403.90", "570", "V45.81", "428.0", "428.23", "327.23", "427.31" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12179, 12188

7919, 10323

232, 274

12499, 12508

5449, 5449

12560, 12566

4354, 4504

12151, 12156

12209, 12313

10349, 12128

12532, 12537

4519, 5311

12334, 12478

2812, 4017

5327, 5430

172, 194

302, 2715

5465, 7896

2737, 2792

4033, 4338

16,732

112,656

7043+7074+55806+55807

Discharge summary

report+report+addendum+addendum

Admission Date: [**2136-12-30**] Discharge Date: [**2137-1-8**] Date of Birth: [**2077-9-6**] Sex: M Service: VASCULAR CHIEF COMPLAINT: Left third toe cellulitis and gangrene. HISTORY OF PRESENT ILLNESS: This is a 59 year-old male who was transferred from [**State 20192**] Center. His past medical history is significant for diabetes, coronary artery disease status post myocardial infarction [**4-7**] and [**6-7**] associated with congestive heart failure, status post coronary artery bypass graft in [**2129**] with a redo in [**2134-6-8**] requiring an AICD implantation for ventricular tachycardia. The patient presented to an outside hospital on [**2136-12-26**] after having "stubbed" his left foot approximately three weeks prior to admission. He presented with cellulitis and gangrene of the left third toe. He had duplex done, which was negative for deep venous thrombosis. He was treated with Unasyn and underwent arterial noninvasives, which revealed inferior popliteal disease on the left. Given the fact that Dr. [**Last Name (STitle) **] had performed the surgery on the other leg he was transferred here for further evaluation and treatment. PAST MEDICAL HISTORY: 1. Diabetes with retinopathy and neuropathy. 2. Coronary artery disease status post myocardial infarction times two [**4-7**] and [**6-7**] associated with congestive heart failure. 3. History of ventricular tachycardia. 4. Status post implantable defibrillator. 5. Status post pacemaker. 6. Orthostatic hypertension secondary to his neuropathy. 7. Chronic obstructive pulmonary disease. 8. Sleep apnea. 9. Hypercholesterolemia. 10. Chronic anemia. 11. Tubulovillous adenoma of the colon. 12. Vitreous hemorrhage of the right eye. 13. Bilateral carotid disease. 14. Right foot osteomyelitis. 15. MRSA. 16. History of depression. PAST SURGICAL HISTORY: 1. Coronary artery bypass graft initial in [**2129**] with redo coronary artery bypass graft times four in [**2134-6-8**]. 2. Status post cholecystectomy, remote. 3. Status post appendectomy remote. 4. Status post right femoral AT bypass graft in [**2132**] with a right ray amputation. 5. Status post right foot flap in [**2132**]. ALLERGIES: Avandia manifestations unknown. MEDICATIONS ON ADMISSION: 1. Lipitor 40 mg q.d. 2. Zoloft 150 mg q.d. 3. Altace 2.5 mg q.d. 4. Hydrochlorothiazide 25 q.d. 5. Glucotrol XL 10 mg b.i.d. 6. Lasix 40 mg q.a.m. and 20 mg q.p.m. 7. Coreg 1.875 mg b.i.d. 8. Humalog sliding scale as follows glucoses greater then 100 3 units, 101 to 180 6 units, greater then 181 9 units. 9. Ferrous sulfate 65 mg b.i.d. 10. Multivitamin tablet q.d. 11. Folic acid 1 mg q.d. 12. Aspirin 325 mg q.d. 13. Elphagen eye drops left eye two q.d. PHYSICAL EXAMINATION: Vital signs 98.1, 62, 137/76, 20, O2 sat 96% on room air. General appearance, this is an alert, cooperative male in no acute distress. HEENT examination without carotid bruits or JVD. Lungs are clear to auscultation bilaterally. Cardiac examination regular rate and rhythm with a normal S1 and S2. Abdominal examination was unremarkable. There were no palpable masses. Vascular examination pulse femorals are 2+ bilaterally. Popliteals were triphasic dopplerable signals bilaterally. The right dorsalis pedis pulse was palpable. The right posterior tibial pulse was dopplerable signal only. The left dorsalis pedis pulse and posterior tibial pulse were dopplerable signals only. There is left lower extremity edema bilaterally with the left great toe with dry gangrene with surrounding erythema. The right lower extremity is warm. The graft is palpable. HOSPITAL COURSE: The patient was admitted to the Vascular Service. He was placed on bed rest. The patient was continued on preadmission medications. He was placed on bed rest. The left toe was dressed with dry gauze b.i.d. with 2 by 2 between the toes and Ace wrap from foot to knee at all times. The patient was placed on Vancomycin 1 gram q 12 hours, Levofloxacin 500 q 24 and Flagyl 500 intravenously q 8 hours. Subq heparin was begun for deep venous thrombosis prophylaxis. The patient was allowed to use his own CPAP from home at bedtime. Admission laboratories, white blood cell count 10.4, hematocrit 34.8, platelets 245. Urinalysis was negative. Electrolyte sodium 136, potassium 5.0, chloride 98, bicarb 30, BUN 32, creatinine 1.4, glucose 141. Admitting chest x-ray showed ill defined opacities within the right upper lobe and within the right lower lobe consistent with an infectious process and/or atelectasis. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2137-1-8**] 11:17 T: [**2137-1-8**] 11:21 JOB#: [**Job Number 26282**] Admission Date: [**2136-12-30**] Discharge Date: [**2137-1-11**] Date of Birth: [**2077-9-6**] Sex: M Service: Vascular ADDENDUM: This is an Addendum to the initial Discharge Summary which was interrupted (work #[**Numeric Identifier 26282**]). CONCISE SUMMARY OF HOSPITAL COURSE (CONTINUED): The patient was admitted to the Vascular Service. He was hydrated with intravenous fluids in anticipation for an arteriogram, and Mucomyst protocol was begun for his creatinine of greater than 1.5. The patient was begun vancomycin, levofloxacin, Flagyl empirically and underwent vein mapping of the upper extremities to determine the adequacy of conduit. A Duplex was done of graft which showed a patent graft femoral dorsalis pedis on the right. The patient had both right and left lesser saphenous veins, and greater saphenous veins were absent. Arm veins (both basilic and cephalic) were patent. The patient underwent an arteriogram on [**2136-12-31**] which demonstrated a patent aorta and bilateral common external and internal iliac arteries. The right lower leg runoff showed patent common femoral artery, superficial femoral artery, and profunda femoris. There was a patent popliteal with mild (less than 50%) stenosis of the above-knee popliteal just above the joint. There were extremely calcified tibial vessels. The patient had a patent anterior tibial and a patent tibial peroneal trunk. There was a focal occlusion at the origin of the peroneal which reconstructed. There was an occlusion at the origin of the posterior tibialis with a diseased vessel distally. The anterior tibial and posterior tibialis were occluded. The anterior tibial reconstructed and occluded at the ankle. The peroneal was with multiple areas of mild stenosis. The dorsalis pedis was calcified which reconstructed at the ankle and bifurcated into the tarsals. Dr. [**Last Name (STitle) **] (a cardiologist) evaluated the patient for perioperative risk assessment. The patient underwent a Persantine MIBI which demonstrated the patient's stress portion of the Persantine MIBI was negative for electrocardiogram or anginal symptoms. The nuclear portion demonstrated the ventricular cavity was dilated both in stress and at rest. Both stress and resting images showed no definite perfusion defects. The ejection fraction was calculated at 37%. There was severe global hypokinesis. The patient was assessed as a class III for surgery; at an increased risk, but there was no obvious ischemia on the Persantine MIBI, and the patient was considered safe to proceed with surgery but to continue all of his current medications. On [**2137-1-2**] the patient underwent a left below-knee popliteal to dorsalis pedis bypass with reversed lesser saphenous vein. The patient tolerated the procedure well. The patient required 200 cc of packed red blood cells intraoperatively. The patient was transferred to the Postanesthesia Care Unit intubated. Postoperatively, there were no significant electrocardiogram changes. An echocardiogram was done which revealed no significant effusions or evidence of tamponade; although there was diminished left ventricular function, but this was unchanged from a preoperative echocardiogram, and the right ventricle did not appear dilated and was normal. Intraoperatively, the patient coded. The patient suffered a transient ischemic attack. Epinephrine was given and continued resuscitation with return of a bounding pulse with good normalization of his end-tidal carbon dioxide. Total cardiopulmonary resuscitation times was estimated to be one minute. The patient was transferred with a systolic blood pressure of 200/110 and a heart rate of 120. The pulmonary artery systolic pressure had been 60 to 80. It was noted to be 100. Esmolol 20 mg times two and nitroglycerin 120 mcg doses reduced the heart rate and blood pressure with a resultant heart rate of 90 and a systolic blood pressure of 170/80; respectively. The patient was transported to the Postanesthesia Care Unit intubated. He required dopamine during transport. On arrival to the Postanesthesia Care Unit, vital signs were recorded. The arterial line showed a blood pressure of 125/55, heart rate 89, and the oxygen saturation was on 100% positive airway pressure was 6925, central venous pressure was 11. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2137-1-11**] 07:31 T: [**2137-1-11**] 07:41 JOB#: [**Job Number 26392**] Name: [**Known lastname 4544**], [**Known firstname **] Unit No: [**Numeric Identifier 4545**] Admission Date: [**2136-12-30**] Discharge Date: [**2137-1-11**] Date of Birth: [**2077-9-6**] Sex: M Service: This is a continuation of the interrupted discharge summary. Patient's diet was advanced as tolerated, and transferred to the VICU on postoperative day #4. Patient's AICD and pacemaker were interrogated on [**2137-1-7**] and this was functioning normally, and there was no AF recorded, no asystole. Patient with an episode of confusion on [**2137-1-7**]. Patient's confusion resolved over the next 24 hours. Etiology was undetermined. He continued to require diuresis. He was seen by Physical Therapy on [**2137-1-8**] for assessment for discharge planning. Psych was consulted on [**2137-1-9**] for episode of acute confusion and expressions of hopelessness. They felt the patient had mild delirium, the etiology was not obvious. Although infection was likely. They doubt that it was secondary to dig toxicity. Dig level was checked and this was the therapeutic range. Sedatives and narcotics were discontinued, and over the next 24 hours, the patient showed significant improvement in his mental status. Zoloft was also held and feels the patient return to baseline, and he will be discharged on Zoloft 150 mg, this is an increase from his preadmission dosing. Haldol was administered 2 mg t.i.d. p.o. until the patient returned to baseline. LFTs were obtained, which were unremarkable. From a cardiology standpoint, the patient was stable, but still had some mild peripheral edema. He had continued diuresis. Patient continued to show improvements and was discharged in stable condition. Patient will require followup in two weeks from discharge. Wounds at discharge were clean, dry, and intact. He had a functioning left leg bypass. DISCHARGE MEDICATIONS: 1. Brimonidine tartrate ophthalmic drops 0.15% drops one O.S. b.i.d. 2. Aspirin 325 mg q.d. 3. Folic acid 1 mg q.d. 4. Ferrous sulfate 325 mg q.d. 5. Atorvastatin 40 mg q.d. 6. Ramipril 25 mg q.d. 7. Carvedilol 18.75 mg b.i.d., hold for systolic blood pressure less than 110, heart rate less than 50. 8. Acetaminophen 325-650 mg q.4-6h. prn for pain. 9. Miconazole powder 2% to groins t.i.d. and prn. 10. Digoxin 0.25 mg q.d. 11. Glipizide 10 mg b.i.d. 12. Lasix 80 mg q.a.m. and 40 mg q.p.m. Levofloxacin and Flagyl postdischarge will be dictated as an addendum prior to patient's actual discharge. DISCHARGE DIAGNOSES: 1. Left great toe gangrene secondary to femoral-tibial disease status post left below knee popliteal to distal anterior tibialis with lesser saphenous vein. 2. Postoperative delirium secondary to narcotics resolved. 3. Intraoperative cardiac arrest, resuscitated. 4. Congestive failure compensated. 5. Type 2 diabetes controlled. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**], M.D. [**MD Number(1) 1549**] Dictated By:[**Last Name (NamePattern1) 145**] MEDQUIST36 D: [**2137-1-11**] 08:54 T: [**2137-1-11**] 08:56 JOB#: [**Job Number 4546**] Name: [**Known lastname 4544**], [**Known firstname **] Unit No: [**Numeric Identifier 4545**] Admission Date: [**2136-12-30**] Discharge Date: [**2137-1-11**] Date of Birth: [**2077-9-6**] Sex: M Service: The patient will be going to rehab. The name of this institution is [**Hospital 4547**] Health Systems. Some of the medications were slightly changed in dosage. Please note: Ramipril 2.5 mg q.d. was changed to ramipril 5 mg p.o. q.d. Patient should also have a digoxin level checked two days post discharge by [**Hospital 4547**] Health Systems. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**], M.D. [**MD Number(1) 1549**] Dictated By:[**Name8 (MD) 4548**] MEDQUIST36 D: [**2137-1-11**] 15:52 T: [**2137-1-12**] 05:26 JOB#: [**Job Number 4549**]

[ "250.60", "496", "293.0", "440.24", "458.29", "428.0", "997.1", "707.15", "357.2" ]

icd9cm

[ [ [] ] ]

[ "93.90", "89.59", "88.42", "88.48", "99.04", "89.64", "39.29", "99.60" ]

icd9pcs

[ [ [] ] ]

12053, 13521

11430, 12032

2290, 2762

3671, 11407

1880, 2264

2785, 3653

158, 199

228, 1189

1211, 1857

71,322

175,149

48074

Discharge summary

report

Admission Date: [**2124-4-28**] Discharge Date: [**2124-5-3**] Date of Birth: [**2075-3-20**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: Enlarging brain mass Major Surgical or Invasive Procedure: Left Craniotomy for Mass resection History of Present Illness: 49 F with a left insular mass that had enlarged on serial imagings. She presents for consideration of surgical resection. The lesion was initially found in [**2120**] as part of a work up for headache. The patient was subsequently diagnosed with migrainous headache, and her headache was subsequently controlled with Verapmil and Midrin. Of note, in recent weeks, the patient complains that her headache is less well controlled with the medical reigmen. The patient denied episodes of nausea, vomiting, visual changes, seizure like activities, difficulty with speech, weakness of arm/legs. The review of system is otherwise unremarkable. Past Medical History: 1. h/o atypical chest pain - [**5-24**] P-MIBI without myocardial perfusion defects 2. last echo [**8-25**]: EF 40-50%, moderate symmetric LVH, mild global LV hypokinesis 3. hypertension 4. cocaine use 5. h/o palpitations 6. Arthritis Social History: No tobacco (past or present); occasional EtOH "several times"/month drinks 2 40-oz containers of beer (denies ever having tremors or seizures with alcohol); smokes cocaine, last use 2 days prior to admission (Friday afternoon). She lives with 4 kids, ages 24, 19, 16, 12, all in good healht. Family History: MGM - died of CHF 78y/o; HTN in mother, siblings, MGM Physical Exam: On discharge: A&0 x 3. Expressive aphasia, improving. Otherwise non focal. Motor and sensory gorssly intact Pertinent Results: MRI brain [**2124-4-28**]:Left temporal meningioma is identified, unchanged in size compared to the prior study. CT head [**2124-4-28**]: S/p left extra-axial mass resection, with expected postsurgical changes, frontal pneumocephalus. There is mild effacement of the sulci and midline shifting towards the right, approximately 4 mm. MRI brain [**4-29**]: Expected post-surgical changes are seen. No acute infarcts, mass effect, or hydrocephalus. No residual nodular enhancement. CT head [**5-1**]: IMPRESSION: 1. Decrease of pneumocephalus and decreased density of blood products posterior to the surgical cavity. 2. Unchanged surgical cavity size, and unchanged 3-4 mm midline shift to the right. 3. No new hemorrhage or infarction. Brief Hospital Course: Ms. [**Known lastname 101385**] was admitted to [**Hospital1 18**] under the care of Dr. [**First Name (STitle) **]. She had MRI imaging and then was taken to the OR. She underwent a craniotomy for mass resection. The procedure went well without complications. She went to the ICU for Q1 hour neuro checks. Her post-op head CT showed some pneumocephalus but no hemorrhage. She was transferred to the neurosurgical floor on [**4-30**]. The patient was stable and a steroid taper was begun. Post-operatively the patient developed expressive aphasia that improved on subsqeuent days. As work up, the patient underwent a head CT in the morning of [**5-1**] The scan showed no hemorrhage or CVA. Post-operative MRI was equally reassuring. Physical therapy evaluated the patient, and they determined that she could go home with PT services. The patient was dicharged home thereafter. Medications on Admission: Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Discharge Medications: 1. Outpatient Speech/Swallowing Therapy Please allow this patient to have outpatient speech therapy for her expressive aphasia. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 5. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 2 weeks. Disp:*56 Tablet(s)* Refills:*0* 8. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day) for 2 weeks. Disp:*84 Tablet(s)* Refills:*0* 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 10. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-22**] Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: Left temporal meningeoma Expressive Aphasia Discharge Condition: Neurologically Stable Mental status:oriented x 3 but has expressive aphasia Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: GENERAL INSTRUCTIONS WOUND CARE: ?????? You or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? Keep your incision clean and dry. ?????? You have dissolvable sutures. They do not need to be removed ?????? Do NOT apply any lotions, ointments or other products to your incision. ?????? DO NOT DRIVE until you are seen at the first follow up appointment. ?????? Do not lift objects over 10 pounds until approved by your physician. DIET Usually no special diet is prescribed after a craniotomy. A normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. Be sure however, to remain well hydrated, and increase your consumption of fiber, as pain medications may cause constipation. MEDICATIONS: ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: -Narcotic pain medication such as Dilaudid (hydromorphone). -An over the counter stool softener for constipation (Colace or Docusate). If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed). Often times, pain medication and anesthesia can cause constipation. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc, as this can increase your chances of bleeding. ?????? You are being sent home on steroid medication. Make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ACTIVITY: The first few weeks after you are discharged you may feel tired or fatigued. This is normal. You should become a little stronger every day. Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. In general: ?????? Follow the activity instructions given to you by your doctor and therapist. ?????? Increase your activity slowly; do not do too much because you are feeling good. ?????? You may resume sexual activity as your tolerance allows. ?????? If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? DO NOT DRIVE until you speak with your physician. ?????? Do not lift objects over 10 pounds until approved by your physician. ?????? Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour, that you are awake. WHEN TO CALL YOUR SURGEON: With any surgery there are risks of complications. Although your surgery is over, there is the possibility of some of these complications developing. These complications include: infection, blood clots, or neurological changes. Call your Physician Immediately if you Experience: ?????? Confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? Double, or blurred vision. Loss of vision, either partial or total. ?????? Hallucinations ?????? Numbness, tingling, or weakness in your extremities or face. ?????? Stiff neck, and/or a fever of 101.5F or more. ?????? Severe sensitivity to light. (Photophobia) ?????? Severe headache or change in headache. ?????? Seizure ?????? Problems controlling your bowels or bladder. ?????? Productive cough with yellow or green sputum. ?????? Swelling, redness, or tenderness in your calf or thigh. Call 911 or go to the Nearest Emergency Room if you Experience: ?????? Sudden difficulty in breathing. ?????? New onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? A seizure that lasts more than 5 minutes. Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. Followup Instructions: FOLLOW UP APPOINTMENT INSTRUCTIONS -Please call Dr.[**Name (NI) 9399**] office to schedule an appointment in 2 weeks with a non-contrast head CT [**Telephone/Fax (1) 1669**]. ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2124-5-29**] at 3:30pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. Completed by:[**2124-5-3**]

[ "225.2", "348.89", "784.3", "305.60", "429.3", "401.9" ]

icd9cm

[ [ [] ] ]

[ "01.51" ]

icd9pcs

[ [ [] ] ]

4824, 4843

2591, 3473

339, 376

4931, 4953

1829, 2568

10161, 10778

1630, 1685

3696, 4801

4864, 4910

3499, 3673

5123, 5144

1700, 1700

1715, 1810

8330, 10138

279, 301

5156, 8303

404, 1046

4967, 5099

1068, 1305

1321, 1614

16,334

168,227

22594

Discharge summary

report

Admission Date: [**2199-8-22**] Discharge Date: [**2199-9-1**] Service: CSURG Allergies: Ciprofloxacin / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 14964**] Chief Complaint: coronary artery disease Major Surgical or Invasive Procedure: CABG x2 LIMA to LAD, RSVG to obtuse MCA History of Present Illness: Mr [**Name13 (STitle) 58586**] is an 80yo male noted to have an abnormal preop EKG for eye surgery, revealing an old inferior MI. An echo ([**2199-7-31**]) revealed an inferoposterior hypokinesis and EF 50%, mild mitral regurgitation, and left atrial enlargement. An [**8-1**] Myoview, exercised 1'[**44**]" with 83% of his age predicted heart rate, +dyspnea, +ST changes, no chest pain. Mr. [**First Name (Titles) 58586**] [**Last Name (Titles) **] any claudication, chest pain, DOE, SOB, PND, or orthopnea. He [**Last Name (Titles) **] any family history of heart disease, hypercholesterolemia, hypertension, or diabetes. He smokes 1/2ppd. Past Medical History: Hypothyroid Macular degeneration High frequency hearing loss status post hernia repair coccygeal removal ('[**56**]) TURP ('[**87**]) Social History: married lives with wife works part time at a storage unit Family History: n/c Physical Exam: Condition on discharge VITALS: Brief Hospital Course: On [**2199-8-22**], Mr. [**Name14 (STitle) 58586**] was admitted to the Cardiac Surgery service under the care of Dr. [**Last Name (STitle) 70**]. He underwent a CABGx2 with LIMA to LAD, SVG to obtuse MCA. Total cardiopulmonary bypass time was 52 minutes. Total cross-clamp time was 31 minutes. Please see Dr.[**Name (NI) 27686**] Operative Note for greater detail. Mr. [**Name14 (STitle) 58586**] was transported to the ICU in stable condition. On POD#0, the patient developed respiratory distress post-extubation and was re-intubated. Mr. [**Name14 (STitle) 58586**] was successfully extubated on POD #1, but went into ventricular rhythm@ rate ~12 beats per minute. Attempts at A-pacing were unsuccessful and pt was V-paced at 70 beats per minute. EPS was consulted for his complete heart block. Telemetry was notable for ventricular failure to capture; threshold 23mA, sometimes also missing at max output. Thus, the team and EPS decided to place temporary ventricular pacing wire transvenously; it was decided that no pacer was immediately needed but Mr. [**Name14 (STitle) 58586**] is scheduled for ICD placement on [**2199-10-8**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**]. Nursing noted that patient had difficulty swallowing, and a swallow evaluation was performed on POD#6. A Video study on POD#7 showed mild oropharyngeal dysphagia, and it was recommended that his diet consist of nectar thick liquids with pureed solids. Swallow therapy recommended that Mr. [**Name14 (STitle) 58586**] maintain this diet consistency and aspiration precautions and follow up with speech therapy at his rehab facility, with a video swallow study prior to upgrading his diet consistency. On POD#7, the epicardial wires were discontinued and patient was transferred to the floor. The remainder of his hospital course was uneventful. At the time of discharge on POD#10 was voiding without difficulty, tolerating his po diet, had minimal pain issues, and will have home PT to help advance gait. Medications on Admission: Toprol 25mg daily Synthroid 50mcg daily Occuvit daily Centrum silver daily ASA 325mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Trazodone HCl 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold HR<60 SBP<100. 9. Synthroid 50 mcg Tablet Sig: One (1) Tablet PO once a day. 10. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 11. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: S?P CABG x2 (LIMA->LAD, SVG->OM) hypothyroid, macular degeneration, HOH, TURP,hernia repair, coccyx surgery Discharge Condition: good Discharge Instructions: keep wounds clean and dry. OK to shower, no bathing or swimming. take all medications as prescribed. call for any fever, redness or drainage from wounds Followup Instructions: Dr [**Last Name (STitle) 11493**] in [**1-29**] weeks Dr [**Last Name (STitle) 70**] in 6 weeks Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] for ICD insertion on [**2199-10-8**] (please call [**Doctor First Name **] for arrangements ([**Telephone/Fax (1) 58587**] Completed by:[**2199-9-1**]

[ "518.5", "276.8", "426.0", "414.01", "997.1", "423.9", "276.2", "427.1", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "36.15", "96.71", "37.78", "36.11", "39.61", "88.72" ]

icd9pcs

[ [ [] ] ]

4559, 4645

1307, 3345

265, 306

4797, 4803

5004, 5326

1231, 1236

3486, 4536

4666, 4776

3371, 3463

4827, 4981

1251, 1284

202, 227

334, 982

1004, 1139

1155, 1215

8,222

113,421

4126

Discharge summary

report

Admission Date: [**2201-5-11**] Discharge Date: [**2201-5-26**] Service: MEDICINE Allergies: Morphine Sulfate / Ciprofloxacin / Demerol Attending:[**First Name3 (LF) 99**] Chief Complaint: Hip fracture Major Surgical or Invasive Procedure: OR [**5-14**]-- L hemi History of Present Illness: 89yoM with h/o CAD s/p 4vCABG, COPD on 2L home O2, CHF (EF 35%), Afib on coumadin, Parkinson's disease, myelodysplastic syndrome with anemia and thrombocytopenia, transferred from OSH with left hip fracture. History obtained from the patient and his daughter. The patient lives alone in an apartment downstairs from his daugther who helps with all ADLs. He walks with a walker. While alone in his apartment, he fell while walking backward from the kitchen with his walker. He called lifeline and was brought to [**Hospital3 1196**]. He reports hitting his head but no LOC. Head CT negative for hemorrhage at [**Hospital1 **]. C-spine cleared. . Per the patient's daughter, over the past week he has been somewhat short of breath. His weight was 170lbs, up from his dry weight of 160lbs. He normally does not wear his home O2 frequently but did so this past week. He was also found to be in ARF with creatinine elevated at 2.8 last week. His lasix dose was increased, and at the OSH today his creatinine was 2.5 (baseline 1.5-1.7). He sleeps with his head elevated in a hospital bed; denies PND. . Pt underwent L hemiarthoplasty of the hip for a L femoral head fx. Pt unable to wean from vent in PACU. Admitted to MICU for VAP, hypotension (briefly on levophed) and ATN thought to be [**3-12**] hypotension. Pt placed on lasix gtt with good u/o to this. Now continues to have altered MS but improved improved creat and treatment of presumed infection. Past Medical History: PMH Myelodysplasia - dx'd 2 [**2-9**] yrs ago Atrial fibrillation CAD s/p CABG/quadruple '[**89**], CHF-EF 40% in [**2198**] AI s/p valvuloplasty Aortic stenosis Melanoma or basal cell ca? - face, dx in '70s s/p radiation Acute pancreatitis - Cholelithiasis "Mild Parkinson's" Internal Hemorrhoids GERD Dyplastic polyps on colonscopy Social History: Lives in the same house as his adult daugher who appears supportive and actively involved in this care. He occupies the apt below hers and uses a baby [**Name (NI) **]-[**Name2 (NI) 18065**] to stay in constant communication with him. Uses a walker to ambulate at home. Family History: Family Hx: Daughter, Crohn's Disease Physical Exam: Pt died 1832 on [**5-26**] Pertinent Results: [**2201-5-11**] 11:00PM GLUCOSE-130* UREA N-57* CREAT-2.7* SODIUM-143 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-21* ANION GAP-20 [**2201-5-11**] 11:00PM CALCIUM-10.2 PHOSPHATE-3.5 MAGNESIUM-2.3 [**2201-5-11**] 11:00PM WBC-7.5 RBC-3.00* HGB-10.7* HCT-33.1* MCV-111*# MCH-35.8*# MCHC-32.4 RDW-18.5* [**2201-5-11**] 11:00PM NEUTS-80.7* LYMPHS-14.1* MONOS-4.8 EOS-0.3 BASOS-0.1 [**2201-5-11**] 11:00PM HYPOCHROM-2+ ANISOCYT-2+ MACROCYT-3+ [**2201-5-11**] 11:00PM PLT COUNT-58* LPLT-2+ [**2201-5-11**] 11:00PM PT-22.8* PTT-32.9 INR(PT)-2.2* Brief Hospital Course: A/P: 89 yo M with h/o CAD s/p CABG, AS s/p valvuloplasty, CHF EF 35%, COPD, AF, CRI, Parkinson's Disease presenting with failure to extubate secondary to poor mental status after left hip hemiarthroplasty transferred to the MICU with hypoxic respiratory failure, hypotension. . # Respiratory/PEA arrest: Pt self-extubated [**5-23**]. CXR with mild vascular congestion, LLL collapse. s/p treatment w/ 8 day course of Vanco/Zosyn for VAP completed on [**5-22**]. Lasix gtt d/c'd [**5-24**] d/t hypotension. US did not show a large enough LLL effusion to tap. After transferred to the medical floor on [**5-26**], pt complained of acute shortness of breath. He became hypoxic and then had a PEA arrest. He was resuscitated with EPI and atropine. He was shocked x 3 for probable VT and bolused with amiodarone 300 mg IV x 1. On tranfer to the MICU, again had a PEA arrest with bradycardic rhythm x 2 unresponsive to multiple doses of Epi, atropine, bicarbonate, calcium chloride, transcutaneous pacing and maximum pressor support on Levophed, Dopamine and Neosynephrine. Laboratory results were significant for severe metabolic lactic acidosis. Discussions were made with the family regarding pt's poor prognosis despite maximal medical efforts. Time of death was 1832 on [**5-26**]. Possible etiology may have been acute PE, though patient had been anticoagulated x 2 weeks for his atrial fibrillation. CXR did not show signs of fluid overload/PNA/PTX. Pt's family declined a post-mortem. . # ID: Pt treated for VAP s/p 8 day Vanco and 7 day Zosyn on [**5-22**], MRSA in sputum. . # Acute on Chronic renal failure: Cr elevated from baseline of 1.5, peaked at 4.1, trending down to 2.9 likely from ATN. Renal had been following, HD had not been started. . # CV: > CAD: increased enzymes earlier in admission were c/w demand ischemia [**3-12**] hypotension. Was on ASA, statin, BB > Rhythm: atrial fibrillation- rate controlled, anticoagulated on heparin gtt. . # Anemia: s/p 1u PRBC [**5-17**]. Hct remained stable. . # Mental Status: Initial somnolence likely secondary to narcotics administered in the PACU. Slow improvement in MS likely from uremia. . # s/p Left hip hemiarthroplasty: Ortho had been following along with PT for mobilization. . # MDS: Anemia/thrombocytopenia at baseline. Had been on EPO/Iron. . # Parkinson's Disease: was on Sinemet . # Conjunctivitis: was on erythromycin ointment Medications on Admission: Outpt meds: Epogen 20,000/ml 1 ml SQ qwk Sinemet 25/100 1 tab [**Hospital1 **] Lasix 40mg 2 tabs qd Aldactone 25mg 1 tab qd Toprol XL 50mg tab qd Protonix 40mg 1 tab qd Lipitor 10mg 1 tab qd Paxil CR 12.5 mg qd Pepcid AC 10mg 2 tabs qd Coumadin 1.0 mg qd Alphagan 10ml one drop to left eye [**Hospital1 **] Xalatan 0.005% one frop to left eye qhs IC Erythromycin ointment tid prn Discharge Medications: Pt died [**5-26**] at 1832 Discharge Disposition: Expired Discharge Diagnosis: Time of death 1832, [**2200-5-26**] Discharge Condition: death Discharge Instructions: none Followup Instructions: none Completed by:[**2201-5-27**]

[ "238.7", "496", "E888.9", "585.9", "584.9", "038.9", "518.5", "287.5", "997.5", "785.51", "332.0", "995.92", "285.9", "428.0", "V45.81", "427.31", "820.8", "998.59", "276.51", "414.00" ]

icd9cm

[ [ [] ] ]

[ "96.72", "81.52", "96.6" ]

icd9pcs

[ [ [] ] ]

5980, 5989

3097, 5113

261, 285

6068, 6075

2528, 3074

6128, 6163

2428, 2466

5929, 5957

6010, 6047

5524, 5906

6099, 6105

2481, 2509

209, 223

313, 1765

5128, 5498

1787, 2123

2139, 2412

14,002

173,178

53012

Discharge summary

report

Admission Date: [**2194-7-8**] Discharge Date: [**2194-7-17**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 974**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Open cholecystectomy with common bile duct exploration History of Present Illness: 83 yo male with a history of Afib, hypertension, constipation and lung cancer presented to the [**Hospital1 18**] with severe abdominal pain, vomitting and diarrhea. The patient has had an approximately 3 month history of vague abdominal pain presents with ~12hrs of gradual onset, intermittent, steady, [**5-1**], diffuse R paraumbilical/RUQ pain radiating to his R back and which is worse on palpation. Pain lasts ~1-2hrs then resolves without intervention only to return again ~2hrs later. Unassociated with food or position, but is somewhat pleuritic in character resulting in some SOB but no SSCP.No fevers, chills, rigors, jaundice, dark urine, [**Male First Name (un) 1658**]-colored stool, diarrhea, steatorrhea, melena or hematochezia Past Medical History: Chronic atrial fibrillation (on Coumadin terapy; followed by Dr. [**Last Name (STitle) 24717**] COPD/Emphysema LLL adenoCA s/p LLL lobectomy [**9-23**] Mediastinal mass, stable since [**2188**] Left thyroid lobe nodule GI bleeding x 2 HTN Temporal arteritis (on Prednisone 5mg daily) BPH Anemia Peripheral neuropathy Social History: He is from the [**Location (un) 86**] area. Employment history includes working as a police officer in [**Location (un) 4628**], health director, and state representative for 10 years until he retired at the age of 54. He is married and lives with wife, has children, grandchildren and great-grandchildren, all whom are in close and consistent contact with him. History of 35pk-yr smoker, quit in [**2160**]. History of heavy ETOH use, currently drinks [**12-24**]/night, and does not use illicit substances. Family History: Both parents died in their mid 80s. Father had heart disease. His mother had memory problems, but was never formally diagnosed with a neurologic disorder. Physical Exam: Gen: No acute distress V: T: HR: 80 BP: 196/94 RR: 17 O2 Sat: 98%RA HEENT: PERRLA EOMI supple neck, no CAD PULM: CTAB CV: RRR No MGR GI/GU: diffuse TTP in RLQ, no CVA tenderness stool guaiac + MSK: 5/5 strength all ext. Skin: W, WN Neuro: AOx3 Psych: Calm Pertinent Results: CBC: [**2194-7-8**] 03:07AM BLOOD WBC-13.6*# RBC-4.71 Hgb-15.7 Hct-43.8 MCV-93 MCH-33.3* MCHC-35.8* RDW-14.2 Plt Ct-228 [**2194-7-9**] 06:30AM BLOOD WBC-13.4* RBC-4.34* Hgb-14.0 Hct-42.1 MCV-97 MCH-32.3* MCHC-33.3 RDW-13.9 Plt Ct-202 [**2194-7-10**] 04:56AM BLOOD WBC-14.9* RBC-4.02* Hgb-13.2* Hct-37.4* MCV-93 MCH-32.8* MCHC-35.3* RDW-14.3 Plt Ct-177 [**2194-7-10**] 04:59PM BLOOD WBC-11.6* RBC-3.66* Hgb-12.3* Hct-33.9* MCV-93 MCH-33.7* MCHC-36.4* RDW-14.1 Plt Ct-142* [**2194-7-11**] 03:58AM BLOOD WBC-15.4* RBC-4.01* Hgb-13.1* Hct-38.9* MCV-97 MCH-32.6* MCHC-33.6 RDW-13.9 Plt Ct-223# [**2194-7-11**] 10:29AM BLOOD WBC-18.4* RBC-4.12* Hgb-13.6* Hct-40.2 MCV-98 MCH-33.0* MCHC-33.9 RDW-13.9 Plt Ct-286 [**2194-7-12**] 02:29AM BLOOD WBC-11.6* RBC-3.70* Hgb-12.2* Hct-36.1* MCV-98 MCH-32.9* MCHC-33.7 RDW-14.3 Plt Ct-230 [**2194-7-13**] 03:28AM BLOOD WBC-11.7* RBC-3.70* Hgb-12.2* Hct-36.0* MCV-97 MCH-32.8* MCHC-33.8 RDW-14.4 Plt Ct-273 [**2194-7-13**] 10:10AM BLOOD WBC-10.8 RBC-3.66* Hgb-12.0* Hct-35.5* MCV-97 MCH-32.8* MCHC-33.8 RDW-14.4 Plt Ct-278 [**2194-7-14**] 04:14AM BLOOD WBC-8.9 RBC-3.68* Hgb-12.0* Hct-35.8* MCV-97 MCH-32.7* MCHC-33.6 RDW-14.6 Plt Ct-291 [**2194-7-15**] 02:45AM BLOOD WBC-7.2 RBC-3.76* Hgb-11.9* Hct-36.4* MCV-97 MCH-31.6 MCHC-32.6 RDW-14.1 Plt Ct-316 [**2194-7-16**] 04:50AM BLOOD WBC-11.1*# RBC-4.04* Hgb-13.3* Hct-39.7* MCV-98 MCH-32.9* MCHC-33.5 RDW-14.2 Plt Ct-387 Differential: [**2194-7-8**] 03:07AM BLOOD Neuts-85* Bands-2 Lymphs-6* Monos-4 Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-1* [**2194-7-10**] 04:59PM BLOOD Neuts-94.2* Lymphs-3.1* Monos-2.5 Eos-0.1 Baso-0.1 [**2194-7-12**] 02:29AM BLOOD Neuts-91.1* Lymphs-4.5* Monos-4.3 Eos-0.1 Baso-0 [**2194-7-13**] 03:28AM BLOOD Neuts-92.3* Lymphs-4.4* Monos-3.0 Eos-0.1 Baso-0.1 [**2194-7-13**] 10:10AM BLOOD Neuts-92.0* Lymphs-4.1* Monos-3.7 Eos-0.1 Baso-0.1 [**2194-7-15**] 02:45AM BLOOD Neuts-79* Bands-4 Lymphs-7* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 Coagulation: [**2194-7-8**] 03:07AM BLOOD Plt Smr-NORMAL Plt Ct-228 [**2194-7-8**] 08:41AM BLOOD PT-26.3* PTT-32.1 INR(PT)-2.7* [**2194-7-9**] 06:30AM BLOOD PT-35.2* PTT-38.3* INR(PT)-3.8* [**2194-7-9**] 06:30AM BLOOD Plt Ct-202 [**2194-7-9**] 04:17PM BLOOD PT-22.0* PTT-32.8 INR(PT)-2.2* [**2194-7-9**] 09:03PM BLOOD PT-18.4* PTT-31.6 INR(PT)-1.7* [**2194-7-10**] 04:56AM BLOOD PT-15.9* PTT-29.9 INR(PT)-1.4* [**2194-7-10**] 04:56AM BLOOD Plt Ct-177 [**2194-7-10**] 04:59PM BLOOD PT-14.5* PTT-29.8 INR(PT)-1.3* [**2194-7-10**] 04:59PM BLOOD Plt Ct-142* [**2194-7-11**] 03:58AM BLOOD PT-14.0* PTT-28.3 INR(PT)-1.2* [**2194-7-11**] 03:58AM BLOOD Plt Ct-223# [**2194-7-11**] 10:29AM BLOOD Plt Ct-286 [**2194-7-12**] 02:29AM BLOOD PT-17.0* INR(PT)-1.6* [**2194-7-12**] 02:29AM BLOOD Plt Ct-230 [**2194-7-13**] 03:28AM BLOOD PT-18.4* PTT-29.8 INR(PT)-1.7* [**2194-7-13**] 03:28AM BLOOD Plt Ct-273 [**2194-7-13**] 10:10AM BLOOD Plt Ct-278 [**2194-7-14**] 04:14AM BLOOD PT-22.2* PTT-30.2 INR(PT)-2.2* [**2194-7-14**] 04:14AM BLOOD Plt Ct-291 [**2194-7-15**] 02:45AM BLOOD PT-25.5* PTT-31.6 INR(PT)-2.6* [**2194-7-15**] 02:45AM BLOOD Plt Ct-316 [**2194-7-16**] 04:40AM BLOOD PT-33.4* PTT-32.1 INR(PT)-3.6* [**2194-7-16**] 04:50AM BLOOD Plt Ct-387 [**2194-7-16**] 01:20PM BLOOD PT-38.3* PTT-31.7 INR(PT)-4.3* [**2194-7-17**] 11:57AM BLOOD PT-26.9* PTT-32.4 INR(PT)-2.8* Renal/Glucose: [**2194-7-8**] 03:07AM BLOOD Glucose-117* UreaN-24* Creat-1.2 Na-137 K-4.0 Cl-103 HCO3-24 AnGap-14 [**2194-7-9**] 06:30AM BLOOD Glucose-106* UreaN-19 Creat-1.0 Na-139 K-4.8 Cl-104 HCO3-27 AnGap-13 [**2194-7-10**] 04:56AM BLOOD Glucose-111* UreaN-15 Creat-0.9 Na-136 K-3.4 Cl-104 HCO3-21* AnGap-14 [**2194-7-10**] 04:59PM BLOOD Glucose-111* UreaN-20 Creat-0.8 Na-135 K-3.6 Cl-105 HCO3-22 AnGap-12 [**2194-7-11**] 03:58AM BLOOD Glucose-99 UreaN-21* Creat-0.9 Na-140 K-4.6 Cl-107 HCO3-22 AnGap-16 [**2194-7-11**] 10:29AM BLOOD Glucose-103 UreaN-24* Creat-1.0 Na-135 K-5.0 Cl-109* HCO3-21* AnGap-10 [**2194-7-12**] 02:29AM BLOOD Glucose-110* UreaN-31* Creat-1.0 Na-143 K-3.8 Cl-109* HCO3-23 AnGap-15 [**2194-7-12**] 04:47PM BLOOD Glucose-113* UreaN-33* Creat-0.9 Na-143 K-3.6 Cl-109* HCO3-22 AnGap-16 [**2194-7-13**] 03:28AM BLOOD Glucose-114* UreaN-38* Creat-1.0 Na-146* K-3.8 Cl-111* HCO3-23 AnGap-16 [**2194-7-14**] 04:14AM BLOOD Glucose-122* UreaN-36* Creat-0.9 Na-150* K-3.4 Cl-113* HCO3-26 AnGap-14 [**2194-7-14**] 11:18AM BLOOD Glucose-110* UreaN-39* Creat-1.0 Na-147* K-3.7 Cl-110* HCO3-27 AnGap-14 [**2194-7-15**] 02:45AM BLOOD Glucose-105 UreaN-37* Creat-0.8 Na-144 K-3.1* Cl-110* HCO3-26 AnGap-11 [**2194-7-15**] 11:48AM BLOOD Glucose-132* UreaN-35* Creat-0.9 Na-143 K-3.4 Cl-108 HCO3-29 AnGap-9 [**2194-7-16**] 04:40AM BLOOD Glucose-104 UreaN-32* Creat-0.9 Na-140 K-4.3 Cl-107 HCO3-24 AnGap-13 [**2194-7-17**] 12:00AM BLOOD Glucose-99 UreaN-29* Creat-1.0 Na-139 K-4.3 Cl-105 HCO3-24 AnGap-14 Enzymes: [**2194-7-8**] 03:07AM BLOOD ALT-34 AST-35 AlkPhos-41 Amylase-71 TotBili-0.5 [**2194-7-9**] 04:36AM BLOOD ALT-327* AST-174* AlkPhos-55 Amylase-38 TotBili-4.5* [**2194-7-9**] 06:30AM BLOOD ALT-311* AST-159* AlkPhos-55 Amylase-37 TotBili-4.3* [**2194-7-10**] 04:56AM BLOOD ALT-177* AST-67* AlkPhos-70 Amylase-25 TotBili-3.9* [**2194-7-11**] 10:29AM BLOOD ALT-153* AST-80* AlkPhos-73 Amylase-32 TotBili-1.8* [**2194-7-12**] 02:29AM BLOOD ALT-122* AST-48* AlkPhos-55 Amylase-33 TotBili-1.6* [**2194-7-14**] 11:18AM BLOOD ALT-99* AST-48* LD(LDH)-406* AlkPhos-50 TotBili-1.4 [**2194-7-15**] 02:45AM BLOOD ALT-86* AST-41* LD(LDH)-356* AlkPhos-44 TotBili-1.2 [**2194-7-9**] 04:36AM BLOOD Lipase-18 [**2194-7-9**] 06:30AM BLOOD Lipase-18 [**2194-7-10**] 04:56AM BLOOD Lipase-17 [**2194-7-11**] 10:29AM BLOOD Lipase-20 [**2194-7-12**] 02:29AM BLOOD Lipase-22 Chemistry: [**2194-7-8**] 03:07AM BLOOD Albumin-4.2 [**2194-7-9**] 06:30AM BLOOD Calcium-7.9* Phos-2.4* Mg-2.3 [**2194-7-10**] 04:56AM BLOOD Calcium-8.1* Phos-1.7* Mg-2.2 [**2194-7-10**] 04:59PM BLOOD Calcium-8.1* Phos-2.8 Mg-2.2 [**2194-7-11**] 03:58AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.4 [**2194-7-11**] 10:29AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.5 [**2194-7-12**] 02:29AM BLOOD Calcium-8.4 Phos-2.1* Mg-2.6 [**2194-7-12**] 04:47PM BLOOD Calcium-8.3* Phos-2.1* Mg-3.0* [**2194-7-13**] 03:28AM BLOOD Calcium-8.4 Phos-2.3* Mg-3.1* [**2194-7-14**] 04:14AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.9* [**2194-7-14**] 11:18AM BLOOD Calcium-8.1* Phos-2.1* Mg-2.9* [**2194-7-15**] 02:45AM BLOOD Calcium-7.7* Phos-2.3* Mg-2.6 [**2194-7-15**] 11:48AM BLOOD Calcium-8.6 Phos-2.1* Mg-2.6 [**2194-7-16**] 04:40AM BLOOD Albumin-2.9* Calcium-8.2* Phos-2.3* Mg-2.3 [**2194-7-17**] 12:00AM BLOOD Calcium-8.4 Phos-2.2* Mg-2.1 [**2194-7-8**] 11:36AM BLOOD Lactate-1.8 [**2194-7-9**] 09:43AM BLOOD Lactate-1.7 [**2194-7-10**] 02:57PM BLOOD Glucose-100 Lactate-1.1 Na-136 K-3.2* Cl-107 [**2194-7-10**] 07:27PM BLOOD Glucose-100 Lactate-1.0 Na-135 K-3.6 Cl-108 [**2194-7-10**] 02:57PM BLOOD Hgb-13.0* calcHCT-39 [**2194-7-10**] 07:27PM BLOOD O2 Sat-98 [**2194-7-10**] 02:57PM BLOOD freeCa-1.04* [**2194-7-10**] 07:27PM BLOOD freeCa-1.10* Blood Gas: [**2194-7-10**] 02:57PM BLOOD Type-ART pO2-396* pCO2-41 pH-7.35 calTCO2-24 Base XS--2 Intubat-INTUBATED [**2194-7-10**] 05:23PM BLOOD Rates-12/0 Tidal V-600 PEEP-5 FiO2-100 pO2-169* pCO2-46* pH-7.33* calTCO2-25 Base XS--1 AADO2-500 REQ O2-84 Intubat-INTUBATED Vent-IMV [**2194-7-10**] 07:27PM BLOOD Type-ART pO2-217* pCO2-41 pH-7.35 calTCO2-24 Base XS--2 Microbiology: [**2194-7-8**] 11:30 am BLOOD CULTURE AEROBIC BOTTLE (Final [**2194-7-14**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2194-7-11**]): REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], R.N. ON [**2194-7-9**] AT 0345. ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. PRELIMINARY RESISTANCE TO LEVOFLOXACIN IS NOT CONFIRMER BY FINAL SENSITIVITY. SENSITIVITIES: MIC expressed in MCG/ML ENTEROCOCCUS FAECIUM AMPICILLIN------------ <=2 S LEVOFLOXACIN---------- 2 S PENICILLIN------------ 4 S VANCOMYCIN------------ <=1 S [**2194-7-8**] 1:40 pm BLOOD CULTURE #2 RT HAND. AEROBIC BOTTLE (Final [**2194-7-14**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2194-7-14**]): NO GROWTH. [**2194-7-10**] 2:15 pm SWAB Site: GALLBLADDER GRAM STAIN (Final [**2194-7-10**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. WOUND CULTURE (Final [**2194-7-12**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). PROBABLE ENTEROCOCCUS. SPARSE GROWTH. GRAM NEGATIVE ROD(S). RARE GROWTH. OF TWO COLONIAL MORPHOLOGIES. [**2194-7-11**] 8:54 pm MRSA SCREEN Source: Rectal swab. MRSA SCREEN (Final [**2194-7-15**]): No MRSA isolated. [**2194-7-11**] 8:55 pm MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Final [**2194-7-15**]): No MRSA isolated. [**2194-7-14**] 4:14 am MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Final [**2194-7-16**]): No MRSA isolated. [**2194-7-14**] 4:14 am MRSA SCREEN Source: Rectal swab. MRSA SCREEN (Final [**2194-7-16**]): No MRSA isolated. Radiology Report CHEST (PORTABLE AP) [**2194-7-8**] 5:23 AM IMPRESSION: 1. No free intraperitoneal air. 2. No acute intrathoracic pathology. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Name (STitle) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**] Approved: TUE [**2194-7-8**] 8:59 AM Radiology Report CT PELVIS [**2194-7-8**] 6:05 AM IMPRESSION: 1. Findings are suggestive of early cholecystitis. If further imaging is required, HIDA scan could be performed. 2. Small bilateral renal hypodensities, too small to be fully characterized. 3. Diverticulosis without evidence of diverticulitis. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17726**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**] Approved: TUE [**2194-7-8**] 2:11 PM Radiology Report LIVER OR GALLBLADDER [**2194-7-8**] 8:59 AM IMPRESSION: 1) Distended gallbladder with mild gallbladder wall edema. [**Doctor Last Name 515**] sign is not present. These findings could represent early cholecystitis, as seen on recent CT. If further imaging is required, HIDA scan could be obtained. 2) 9 mm hyperechoic focus lower pole right kidney. Stone is felt less likely, but not excluded. [**Month (only) 116**] be related to recent iodinated contrast administration. 3) No evidence of intra or extrahepatic biliary ductal dilatation. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17726**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**] Approved: WED [**2194-7-9**] 12:33 AM Pathology Examination [**Known lastname **],[**Known firstname 412**] E. [**2110-12-15**] 83 Male [**-6/2838**] [**Numeric Identifier 109276**] Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **] Gross Description by: DR. [**Last Name (STitle) **]. HARDY/cofc SPECIMEN SUBMITTED: GALLBLADDER. Procedure date Tissue received Report Date Diagnosed by [**2194-7-10**] [**2194-7-10**] [**2194-7-15**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/nbh Previous biopsies: [**-5/4154**] SKIN EXCISION, LEFT UPPER CHEST (1). [**-5/3857**] L. UPPER CHEST. [**-3/3418**] SKIN RIGHT NOSE. [**-3/3114**] EGD. BX'S 2. DIAGNOSIS: Gallbladder: Acute cholecystitis. Radiology Report ABD [**2194-7-10**] 4:12 PM IMPRESSION: Catheter in the right upper quadrant and NG tube in the stomach. No evidence of other foreign bodies. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**] Approved: SAT [**2194-7-12**] 8:10 AM Radiology Report ABDOMINAL FLUORO [**2194-7-10**] 4:41 PM IMPRESSION: Tiny filling defects at the distal end of CBD were visualized which could be representative of bubbles, sludge/stones. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**] Approved: SAT [**2194-7-12**] 8:11 AM Radiology Report -76 [**2194-7-10**] 4:41 PM IMPRESSION: Tiny filling defects at the distal end of CBD were visualized which could be representative of bubbles, sludge/stones. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**] Approved: SAT [**2194-7-12**] 8:11 AM Radiology Report CHEST (PORTABLE AP) [**2194-7-11**] 10:13 AM Final Report REASON FOR EXAMINATION: Followup of a patient with coarse lung sounds. Portable AP chest radiograph compared to [**2194-7-10**]. The patient is extubated in the meantime interval. The NG tube tip terminates in the stomach. The moderate cardiomegaly and mediastinal contours are unchanged. Slight improvement in interstitial pulmonary edema is demonstrated. Small bilateral pleural effusion are unchanged. Improvement of left lower lobe opacity is likely due to resolving atelectasis. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: FRI [**2194-7-11**] 4:08 PM Radiology Report CHEST (PORTABLE AP) [**2194-7-13**] 8:17 AM Final Report CLINICAL HISTORY: Diffuse abdominal pain, hypertension. IMPRESSION: Persistence of mild failure. DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**] Approved: SUN [**2194-7-13**] 10:53 AM Radiology Report CHEST (PORTABLE AP) [**2194-7-14**] 9:50 AM IMPRESSION: Interval removal of a NG tube with associated mild gastric distention; otherwise essentially unchanged radiographic chest showing mild failure. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 5206**] [**Name (STitle) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: MON [**2194-7-14**] 3:43 PM Radiology Report CHEST (PORTABLE AP) [**2194-7-15**] 3:40 PM IMPRESSION: Interval removal of a right IJ line. Decreased gastric distention. Otherwise, essentially unchanged radiograph showing mild failure. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 5206**] [**Name (STitle) **] DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Approved: TUE [**2194-7-15**] 11:40 PM Radiology Report CHEST (PORTABLE AP) [**2194-7-16**] 7:58 AM IMPRESSION: 1. Possible slight improvement in mild pulmonary vascular congestion without overt pulmonary edema. 2. Left basilar atelectasis. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**] Approved: WED [**2194-7-16**] 5:00 PM Radiology Report CHEST (PORTABLE AP) [**2194-7-17**] 7:33 AM FINDINGS: Bedside AP examination labeled "upright at 0740" is compared with semi-erect examination obtained from the preceding day; the overall appearance is not much changed. There is left ventricular enlargement and evidence of mild interstitial edema involving the right more than left lung, with no overt edema or significant pleural effusion. There is bibasilar linear atelectasis or scarring, but no focal consolidation. There are atherosclerotic changes involving the thoracic aorta and surgical staples in the upper abdomen. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**] Brief Hospital Course: 83 yo male with a history of Afib, hypertension, constipation and lung cancer presented to the [**Hospital1 18**] on [**2194-7-8**] with severe abdominal pain, vomitting, iarrhea and an elevated white count. He was placed on Zosyn and given Morphine and Zofran the day of admission. Blood cultures were also sent to assess possible sepsis. One of the samples sent was positive for Enterococcus, thus the patient was placed on Flagyl/Zosyn. The patient also received an CXR to evaluate the mediastinum for free air and it too was negative. What's more, he received a CT scan which demonstrated early cholecystitis. Upon evaluation, he appeared to be worse. He was getting disoriented. Although his labs were improved, his abdomen was clearly problem[**Name (NI) 115**]. [**Name2 (NI) **] had a large palpable gallbladder. He was, therefore, taken to surgery on [**2194-7-10**] after he was appropriately resuscitated. At surgery, he was found to have a necrotizing cholecystitis with hemorrhage into the wall as well as necrotic gallbladder. Moreover, even though the ultrasound said there were no gallstones, he had multiple small stones, one of which was impacted into the cystic duct. The cystic duct actually had a very small stricture at its junction with the common bile duct which precluded completion of choledochoscopy as noted in the procedure below. Intraoperative cholangiograms which were done revealed free flow into the duodenum. There was no evidence of any ductal injury. He was hemodynamically stable after surgery. POD1: Patient extubated - tolerated it well. Later on, he became disoriented and began pulling lines. Haldol was given by housestaff to calm him. Patient was transfered from PACU to T-SICU. An NG tube was placed and serous and bilious drainage was obtained. There was also leakage of similary fluid from the wound. Patient also has a CVP of 12. POD2: Patient CXR demonstrated congested lungs. Moreover, crackles and rhonchi were ausculated. They were worse on the left side. Thus, the patient was put on Lasix for diuresis to try to improve lung function. Haldol was continued for the agitation and steroid administration was tapered off to avoid possible consequences associated with long term steroid use. Patient's blood pressure was also elevated and was thus, placed on Lopressor and Hydralazine. Fluid balance for the day was -800cc. POD3: Patient's blood pressure was better controlled, his respiratory status improved and he appeared less agitated than in previous days, though his agitation was not entirely gone. His abdomen was less distended and his CVP ranged from [**10-6**]. His WBC dropped to 11.7 from a high of ~15 a couple of days prior due to the administration of steroids, which will continue to be tapered off. POD4: Patient doing much better - AOx2. Lungs were much clearer. Central line and foley discontinued. Patient put on clear liquids. POD5: Patient doing well. No issues today - AOx2. Lungs mostly clear with scattered rhonchi. Abdomen soft and wound clean and dry. Patient transfered to floor. Patient reports that legs are weak. Patient tolerating clear liquids well and moved to full liquids. Patient had bowel movement and denied n/v. POD6: Patient tolerating diet well, so diet was advanced to low fat solids. Patient is ambulating on walker. Half of the staples were removed. Patient AOx3. Abdomen still slightly distended and patient is having loose bowel movements. Physical therapy evaluated patient. POD7: Wound clear and dry; staples removed with steri strips placed. 1050++ from Lasix last night. Lungs clear. Physical therapy will evaluate patient prior to discharge. Patient was then evaluated by physical therapy as ready for discharge the following day; he was able to climb stairs very well and was mobile. He could void independently without difficulty, tolerate appropriate po diet, demonstrated markedly reduced dyspnea on exertion with no pain and a healing wound Medications on Admission: Prednisone 5'(temporal arteritis), Atenolol 25', Coumadin 2.5', Simvastatin 10', Tamsulosin 0.4 SR', Clonazepam 1 hs, Protonix 40', Albuterol, Atrovent, Salmeterol 100' Discharge Medications: 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours). 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 4. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 5. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 6. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*10 Capsule(s)* Refills:*2* 10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* 12. Ampicillin 250 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 4 days. Disp:*16 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: acute cholecystitis/ gangrenous Discharge Condition: Doing well, afebrile and hemodynamically stable, able to void independently without difficulty, tolerating po intake well, pain under good control. Examined by attending physician and has met all discharge criteria. Discharge Instructions: You are to follow up with Dr.[**Name (NI) 18535**] office in two weeks at his surgery clinic. You are to follow up with your PCP at the following appt: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Location (un) 453**] in Atrium suite) [**Telephone/Fax (1) 250**] tomorrow [**7-18**] @300pm. PCP is not in office tomorrow Dr. [**Last Name (STitle) **] is covering. You are to follow up with your [**Hospital 197**] clinic as follows: Patient is to go to [**Location (un) **] [**Hospital1 **] on [**Hospital1 766**] before noon and have his blood drawn. A member of the ACMS staff will contact patient with [**Name (NI) 766**] dose. [**Doctor First Name **] in the ACMS staff [**Telephone/Fax (1) 2173**] is your contact person. Please return or contact for * fever >101F or chills * continued abdominal pain * persistent nausea or vomiting * inability to pass gas or stool * redness or drainage from incision sites * misplacement of tubes * any other concerns You may shower with your dress. please pat dry and no soaking of the dressing Followup Instructions: You are to follow up with Dr.[**Name (NI) 18535**] office in two weeks at his surgery clinic. You are to follow up with your PCP at the following appt: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Location (un) 453**] in Atrium suite) [**Telephone/Fax (1) 250**] tomorrow [**7-18**] @300pm. PCP is not in office tomorrow Dr. [**Last Name (STitle) **] is covering. You are to follow up with your [**Hospital 197**] clinic as follows: Patient is to go to [**Location (un) **] [**Hospital1 **] on [**Hospital1 766**] before noon and have his blood drawn. A member of the ACMS staff will contact patient with [**Name (NI) 766**] dose. [**Doctor First Name **] in the ACMS staff [**Telephone/Fax (1) 2173**] is your contact person.

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Discharge summary

report

Admission Date: [**2202-10-17**] Discharge Date: [**2202-10-22**] Date of Birth: [**2143-12-3**] Sex: M Service: NEUROLOGY Allergies: Vicodin / Roxicet / Sirolimus Attending:[**First Name3 (LF) 1032**] Chief Complaint: Mental status changes Major Surgical or Invasive Procedure: Endotracheal intubation Lumbar puncture with moderate sedation Radial arterial line insertion History of Present Illness: 58y/o RHM with history of liver transplant, Hepatitis C, chronic renal disease and multiple asymptomatic strokes, presented with sudden decline in his mental status. His wife witnessed him be struggling get out from bed, decline in his awareness. His wife spoke to him with appropriate condition around 6:05PM. Around 6:25PM, she heard that the patient started to say non-sence, act inappropriately, unable to exchange conversation. His wife recalled some "shaking" at the right arm. He was brought into [**Hospital1 18**] ED above time and Neurology was consulted for code stroke. In ED, while Neurology was examining patient, he developed right arm, leg clonic seizure with head deviation and gaze deviation toward to left. He responded with moan when his name was called, then developed left arm clonic seizure (secondary generalization) and became unresponsive. Ativan 2mg IV was given to stop. Patient was intubated subsequently to have further neuroradiological evaluation. HPI ADDENDUM: Further history was obtained from the patient's wife the morning following his admission. She reports the patient was well until returning from a same-day-surgical procedure on [**10-14**] for repair of left eye retinal detachment. The patient was vague with his reported symptoms, but complained of "feeling lousy" with poor appetite and fatigue. He did not eat or drink very much Friday or Saturday following. On Saturday evening he began to vomit quite frequently. They had a small breakfast Sunday morning and the patient was still feeling unwell, but altogether normal per his wife. She left for a few hours during the day, returned home and heard him yelling out of frustration after having dropped something in his room, however the yelling continued and she went to see him and noted that he had a great amount of difficulty getting himself upright to the edge of his bed. She then noted his right arm was shaking. He was brought to [**Hospital1 18**] ED where the above described event occurred. Past Medical History: - ETOH/HCV cirrhosis s/p Liver Transplant [**2195**] on immunosuppression. Course c/b recurrent hep C viremia, CRI, LFT abnl, acute rejection and hepatic artery thrombosis ([**2196**]) - Polymyositis - diagnosed in [**2196**] after hepatic artery thrombosis, Bx showed inflammatory myositis - HTN - CRI (baseline 2.0) - DM on insulin - post-transplant, related to steroid treatment - IVDU - Multiple strokes - [**2195**] prior to transplant left corona radiata and posterior putaminal infarct, periventricular white matter disease. [**8-12**] MRI with evidence of chronic cerebellar infarcts. - Seizure - single event 3 days prior to transplant while in hospital. However chart review reveals pt may have had seizures associated with prior infarcts in [**2195**]. Social History: Lives with his wife. Does not smoke. Quit ETOH use several years prior to transplant. Family History: No FH of stroke or neurological disease Physical Exam: Vitals: T ? HR 64, reg BP 243/123 RR 17 SO2 97% r/a Gen:NAD. HEENT:MMM. Sclera clear. OP clear. Extra ear canals, ear drums clear. Neck: No Carotid bruits CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: Horizontal surgical scar. Soft, flat, no tenderness Ext: No arthralgia, no deformities, no edema Neurologic examination: MS- Opening eyes to voice. Non-verbal. Vocalize non identifiable sound. No following command. CN- Pupils left sclera injected, surgical. Right pupil also surgical. Left gaze preference. Left head turning. No facial droop with grimacing. Gag+. Cough+. Motor/Sensory- Normal bulk. R foot clonus x7-9 beats. Left negative. No withdrawal at R arm, leg, L leg. Withdrawal at R arm. Response to the noxious stimuli at left arm. None at right arm, leg and left leg. Reflexes: B T Br Pa Ankle Right 2 2 2 3 3 Left 2 2 2 2 2 Toes were upgoing at the right, down at the left. Coordination:Unable to examine due to inattention. Meningeal sign: Negative Brudzinski sign. No nuchal rigidity. Pertinent Results: ADMISSION LABS: 138 99 42 AGap=18 ------------<140 3.9 25 2.3 estGFR: 29/36 (click for details) 11.2 >15.9/46.6< 127 N:64.7 L:24.7 M:9.9 E:0.6 Bas:0.2 PT: 11.7 PTT: 31.0 INR: 1.0 Head CT: No hemorrhage. Head MRI/MRA: MRA: The intracranial vertebral and internal carotid arteries and their major branches appear normal with no evidence of significant stenosis, occlusion, or aneurysms. MRI: Unchanged appearance of punctate hemorrhagic areas in bilateral cerebral hemispheres and brainstem suggestive of chronic process. Amyloid angiopathy is one of the conditions that can predispose to tiny punctate hemorrhages. No acute hemorrhage, masses, infarct. Brief Hospital Course: Mr. [**Known lastname 2809**] is a 58 year old gentleman s/p liver transplant related to chronic HCV infection, myopathy (? steroid induced), history of prior multiple asymptomatic embolic infarcts prior to transplantation, who presents with three day prodrome of general malaise, poor appetite, nausea/vomiting, followed by acute change in mental status with witnessed partial complex seizure in the [**Hospital1 18**] ED. 1) Neuro: * SEIZURE - Initially a code stroke was called in the ED, but CT imaging and later, MRI, showed no evidence of acute infarction. Initial labs notable for presence of only serum benzodiazepines on tox screening and acute on chronic renal failure. Etiology of seizure was thought to be areas of prior cortical infarcts in setting of gastrointestinal illness. The patient was intubated in the emergency department and promptly extubated at 2am in the Neuro ICU the same evening. The morning following admission the patient's examination was notable for marked encephalopathy. He was changed from phenytoin to oxcarbazepine (Trileptal) given multiple long term side effects of phenytoin, and with normal hepatic function, but renal impairment and keppra did not seem a wise choice. Lumbar puncture was attempted with light sedation without success. It was re-attempted with fentanyl and midazolam for monitored conscious sedation and revealed 1 WBC, 0 RBC, normal protein and glucose. He was transferred to the floor after an EEG done on the [**7-18**] revealed no abnormalities and showed a normal background. * ENCEPHALOPATHY - On the floor, the patient's exam was notable for continued encephalopathy, but he was evidently not delerious. His main abnormalities were frontal dysfunction (as exhibited by impulsiveness, stimulus-bound behaviors, desinhibition, bilateral grasp and palmomental reflexes, a marked inability to switch mindset) and memory (as exhibited by anososgnosia, orientation to place and time, as well as not imprinting new information, and working memory (the patient stayed in-task, and had sufficent attention to perform, but couldn't complete the tasks). Clinically he continued to improve slowly but surely, an EEG done on [**10-21**] showed 7 Hz background, but otherwise normal. Per his wife, his level of cognitive functioning at home was high, as for example he was able to discuss politics. 2) Cardio: * NSTEMI - Patient was noted to have elevated troponin enzymes to 0.31 with EKG without ischemic changes. He was started on aspirin, beta blocker, atorvastatin. Cardiology consultation was obtained and additionally recommended echocardiogram which revealed moderate symmetric left ventricular hypertrophy, no focal wall motion abnormalities (poor data quality though), LVEF>55%, mild aortic valve stenosis. His NSTEMI was thought related to demand related ischemia in the setting of catecholamine surge associated with seizure. He should be scheduled for an exercise stress test as an outpatient. 3) FEN * Acute Renal Failure - Patient's has prior hepato-renal syndrome now with baseline creatinine of 1.9-2. Admission creatinine notable for 2.4. He was noted to have low urine output. He received vigorous IV hydration with improved Cr to 1.6, however this was likely a sampling error because all the lines of his cellcount were down on this blooddraw as well, repeat labs showed a creat of 2.0 and his [**Hospital1 **] back to the old values. His medications were renally dosed. He was started on Thiamine, Folate and MVI. 4) Liver transplantation Transaminase levels on admission were WNL. Hepatology consultation was obtained and recommended continuing with his prior regimen of immunosuppressive agents. No changes were made. 5) ID A broad spectrum of CSF studies were sent despite the normal cell count. Varicella PCR and CMV PCR negative, remainder pending. MRSA isolation negative. VRE swab negative. Cryptococcal antigen GRAM STAIN, FLUID CULTURE, FUNGAL CULTURE-PRELIMINARY,ACID FAST CULTURE, VIRAL CULTURE were all (preliminary) negative. 6) PPx, reactivation and reconditioning For prophylaxis, he was put on Heparin, pneumoboots, TEDs, and PT and OT were consulted to evaluate and treat him. Medications on Admission: Prograf 1mg [**Hospital1 **] Imuran 50mg [**Hospital1 **] Cellcept (mycophenidate mofetil) 1000mg [**Hospital1 **] bactrim metoprolol 50mg [**Hospital1 **] Clindagel asa 81mg daily fosamax 35mg q fri marinol 5mg qpm and qhs simethicone 80mg [**Hospital1 **] calcum 500mg + D [**Hospital1 **] Ambien (zolpidem) 5mg qhs doxazosin 1.5mg qhs hydroxyzine hcl 50mg [**Hospital1 **] ritalin 15mg qam remeron 7.5 qhs prilosec 20mg daily Effexor 37.5mg daily Florinef 0.1mg daily Lasix 20mg daily Kayexylate Lipitor 10mg daily Lisinopril 5mg daily Percocet one tab qid prn Cosopt one drop to left eye [**Hospital1 **] Alphagan 0.15% to left eye [**Hospital1 **] Ofloxacin 0.3% eye drop to left eye qid Prednisolone 1% eye drop to left eye qid Homatropine 5% eye drop to left eye [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO twice a day. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Alendronate 35 mg Tablet Sig: One (1) Tablet PO QFRI (every Friday). 7. Doxazosin 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 8. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 10. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday) as needed for ppx. 13. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 15. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q 12H (Every 12 Hours). 16. Ofloxacin 0.3 % Drops Sig: One (1) Ophthalmic four times daily (). 17. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID (4 times a day). 18. Homatropine HBr 5 % Drops Sig: One (1) Ophthalmic twice daily (). 19. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 20. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 21. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 23. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Complex partial seizure with secondary generalization. Discharge Condition: Stable, improving cognitively. Discharge Instructions: You have been admitted with an epileptic seizure, most likely related to small scars in your brain from old small strokes, possibly in the setting mild dehydration. After this you have been confused for a while, which is not unusual with a fragile brain, a post-seizure state and a lot of medications on board. Your medications such as Remeron and Methylphenidate have been temporarily discontinued - please follow up with your doctor to perhaps reverse these changes when you are back to your baseline. Please take all medications as directed, and attend all your follow-up appointments. If you experience any signs or symptoms of concern, please contact your doctor immediately, or in case of urgency go directly to the emergency room - for example in case of recurrence of seizures. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2202-11-17**] 8:40 Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2202-12-14**] 4:10 Provider: [**Name10 (NameIs) 8741**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2202-12-14**] 4:30 Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**] MD Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2202-11-17**] 2:30 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 1041**]

[ "V58.67", "V58.66", "V12.59", "070.70", "V42.7", "403.90", "E932.0", "345.50", "V15.82", "710.4", "410.71", "V12.51", "348.39", "787.29", "276.51", "585.9", "584.9", "251.8" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.04", "03.31", "96.71" ]

icd9pcs

[ [ [] ] ]

12163, 12308

5190, 9366

315, 410

12406, 12438

4498, 4498

13273, 13916

3350, 3391

10204, 12140

12329, 12385

9392, 10181

12462, 13250

3406, 3754

254, 277

438, 2441

4700, 5167

4514, 4691

3778, 4479

2463, 3231

3247, 3334

9,296

189,994

52687

Discharge summary

report

Admission Date: [**2151-11-1**] Discharge Date: [**2151-11-4**] Date of Birth: [**2094-6-15**] Sex: M Service: MEDICINE Allergies: Nifedipine / Tetracyclines / Zoloft / Paxil Attending:[**First Name3 (LF) 8487**] Chief Complaint: Transferred from OSH for care of worsening hepatic/renal failure Major Surgical or Invasive Procedure: Paracentesis Placement of Right IJ line History of Present Illness: 57 year old male with h/o alcoholic cirrhosis, presented as transfer from outside hospital with sepsis from E. Coli bacteremia and SBP, with Acute liver failure and worsening renal failure. Past Medical History: Alcoholic Hepatitis Hypertension Social History: History of heavy alcohol use. Family History: Unknown Physical Exam: Intubated and sedated, not reactive to voice or sternal rub. Extremely jaundiced, with scleral icterus. Left IJ line in place. Intubated with clear breath sounds. Heart with regular rate and rhythm. No M/G/R. Abdomen extremely distended, with spider angiomata, caput medusa, positive fluid wave. Right Femoral vein groin line. Extremities with pitting edema. Pertinent Results: ADMISSION LABS: [**2151-11-1**] 09:59PM WBC-22.7*# RBC-3.10*# HGB-10.3*# HCT-29.5*# MCV-95# MCH-33.2* MCHC-34.9 RDW-20.3* [**2151-11-1**] 09:59PM PLT SMR-VERY LOW PLT COUNT-52*# [**2151-11-1**] 09:59PM PT-23.5* PTT-35.8* INR(PT)-4.0 [**2151-11-1**] 09:59PM GLUCOSE-84 UREA N-102* CREAT-2.4*# SODIUM-147* POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-22 ANION GAP-21* [**2151-11-1**] 08:59PM TYPE-ART TEMP-36.5 RATES-/28 PEEP-15 O2-50 PO2-61* PCO2-26* PH-7.58* TOTAL CO2-25 BASE XS-3 INTUBATED-INTUBATED [**2151-11-1**] 08:59PM LACTATE-5.4* . [**2151-11-2**] 2:40 am BLOOD CULTURE **FINAL REPORT [**2151-11-8**]** AEROBIC BOTTLE (Final [**2151-11-8**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2151-11-8**]): NO GROWTH. . [**2151-11-2**] 2:40 am PERITONEAL FLUID **FINAL REPORT [**2151-11-2**]** GRAM STAIN (Final [**2151-11-2**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. . [**2151-11-2**] 12:12 am SPUTUM Site: EXPECTORATED **FINAL REPORT [**2151-11-4**]** GRAM STAIN (Final [**2151-11-2**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final [**2151-11-4**]): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 2 S IMIPENEM-------------- 2 S MEROPENEM------------- 1 S PIPERACILLIN---------- 8 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S . [**2151-11-2**] 9:56 am CATHETER TIP-IV Source: right fem line tip. **FINAL REPORT [**2151-11-4**]** WOUND CULTURE (Final [**2151-11-4**]): PSEUDOMONAS AERUGINOSA. >15 colonies OF THREE COLONIAL MORPHOLOGIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 2 S IMIPENEM-------------- 2 S MEROPENEM------------- 1 S PIPERACILLIN---------- 8 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S . RENAL U.S. PORT [**2151-11-2**] 8:21 AM: No hydronephrosis. . CHEST (PORTABLE AP) [**2151-11-2**] 3:48 AM CHEST (PORTABLE AP) Reason: please eval tubes/lines [**Hospital 93**] MEDICAL CONDITION: 57 year old man s/p intubation, transferred for OSH REASON FOR THIS EXAMINATION: please eval tubes/lines HISTORY: Transferred for OSH. Status post intubation. Evaluate tubes and lines. FINDINGS: An AP supine portable chest radiograph shows an endotracheal tube in place with the tip ending 4.5 cm above the carina. Catheter projected over the right internal jugular vein seen with the tip projecting at the level of the mid to distal SVC. Central venous catheter on the left and at the distal brachiocephalic veins, not reaching the SVC. No pneumothorax seen on this side. A nasogastric tube is seen with the tip and side hole both well below the left hemidiaphragm, with the tip off the view of the film. Lung volumes are small, crowding the central pulmonary vasculature which is probably not congested. Bilateral pleural effusions, however present and probably some subsegmental atelectasis at the left lung base. CONCLUSION: Supporting tubes and lines positioned as described. Bilateral pleural effusions and small lung volumes. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: TUE [**2151-11-2**] 11:37 AM . CT HEAD W/O CONTRAST [**2151-11-3**] 11:01 AM CT HEAD W/O CONTRAST Reason: evaluate for head bleed [**Hospital 93**] MEDICAL CONDITION: 57 year old man with ESLD, hepatic encephalopathy, hypercoagulable state. (Already on the schedule) REASON FOR THIS EXAMINATION: evaluate for head bleed CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: End stage liver disease, hepatic encephalopathy, hypercoagulable state, evaluate for head bleed. COMPARISON: Report from non-contrast head CT of [**2149-8-27**], as images are not available on PACS at the time of interpretation. TECHNIQUE: Non-contrast head CT. FINDINGS: No intra or extra-axial hemorrhage is identified. There is no mass effect or shift of normally midline structures. Again seen is age inappropriate prominence of the sulci and ventricles consistent with severe brain atrophy. Chronic acunar infarcts are seen in the left basal ganglia. The remainder of the brain parenchyma is normal in density, with preservation of the [**Doctor Last Name 352**] white matter differentiation. Again seen is a punctate calcification in the approximate region of the anterior communicating artery, left of midline, which is likely atherosclerotic in nature. Mucosal thickening of the left maxillary and ethmoid sinuses is identified. The surrounding soft tissues demonstrate some punctate calcifications, which are likely atherosclerotic in nature. The orbits appear unremarkable. IMPRESSION: No evidence of intracranial hemorrhage or mass effect. Marked brain atrophy. Brief Hospital Course: 57 year old male with h/o alcoholic cirrhosis, presented from OSH with sepsis from SBP and bacteremia, who expired after worsening liver and renal failure. . 1. ID: Presented after treatment started for SBP and bacteremia. Had paracentesis on admission which never grew any microorganisms. WBC count was stable, but he was hypothermic. Cultures of removed right groin catheter tip grew Gram neg rods (pseudomonas). Sputum with Pseudomonas as well. Treated with antibiotics (vanco and zosyn). . 2. Hypotension: Originally required pressors to MAP >60mmHg, likely secondary to sepsis from bacteremia/SBP. Was weaned off pressors and was able to maintatin MAP's greater than 60mmHg. . 3. Respiratory Alkalosis: Originally intubated at OSH for airway protection given worsenign clinincal picture. He was sedated on admission to decrease respiratory rate as he was overbreathing vent to point of resp alkalosis. His respiratory alkolosis improved while sedated and mechanicallyu ventilated on AC mode. . 4. Metabolic acidosis: He had an anion gap acidosis which remained unchanged throughout his admission, likely from uremia and/or lactic acid from sepsis. . 5. Altered mental status: Remained altered throughout. Unable to make his own healthcare decisions. Thought to be likely secondary to hepatic encephalopathy. Head CT was negative for bleed, but showed evidence of cerebral atrophy. He was treated with lactulose. . 6. ARF: Renal function worsened throughout his stay. Thought originally to be contributed to by abddominal compartment syndrome. He had paracentesis twice to reduce pressure, but renal failure progressed despite this treatment. Possibly due to heptorenal syndrome. . 7. GIB: He had an episode of active bleed from NG tube. It was thought to be due to portal gastrophathy. He was transfused 2 units PRBC, and treated with octreotide, midodrine, and IV PPI twice a day. . 8. Abdominal compartment syndrome: He had peritoneal tap twice, with bladder pressures of around 20. . 9. Cirrhosis: Likely alcholic cirrhosis. He was Hep B and Hep C negative in the past. His liver enzymes trended down but his T bili continued to rise. . 10.Anemia: His baseline Hct was in 40's. His drop was likely due to prior GI bleed given portal gastropathy. He received two units of PRBC without appropriate increase in HCT. . Dr. [**Last Name (STitle) 4427**] and Dr. [**Last Name (STitle) **] of Hepatology discussed his poor prognosis with both his sister and his partner, [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 108700**] (who was his health care proxy), who decided to withdraw care given the poor prognosis and the patient's wishes not to have prolonged aggressive treatment. Medications on Admission: HOME MEDS: ERYTHROMYCIN 333MG TID FOR GASTROPARESIS FUROSEMIDE 20MG QD LACTULOSE 10G/15ML Syrup 15-30ML/DAY TITRATE TO [**2-5**] LOOSE STOOLS DAILY LORAZEPAM 1MG Tablet ONE-HALF TO ONE TID PRN SPIRONOLACTONE 50MG QD TAMOXIFEN CITRATE 20MG QD Discharge Medications: None. Patient Expired. Discharge Disposition: Expired Discharge Diagnosis: Alcoholic Hepatitis with Hepatic Failure Acute Renal Failure HTN Sepsis with Pseudomonas Line Infection Sputum with Pseudomonas Cardiorespiratory Failure Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[**2151-12-21**]

[ "567.23", "584.9", "443.0", "578.9", "571.2", "537.89", "518.81", "038.42", "572.2", "276.3", "401.9", "995.92", "585.9", "570", "276.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "99.07", "96.04", "96.6", "99.05", "54.91", "96.71" ]

icd9pcs

[ [ [] ] ]

9818, 9827

6782, 7948

369, 410

10024, 10033

1151, 1151

10086, 10122

748, 757

9771, 9795

5373, 5473

9848, 10003

9502, 9748

10057, 10063

772, 1132

265, 331

5502, 6759

438, 629

1167, 4016

7963, 9476

651, 685

701, 732

42,396

157,330

42795

Discharge summary

report

Admission Date: [**2130-5-31**] Discharge Date: [**2130-6-1**] Date of Birth: [**2082-8-13**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2712**] Chief Complaint: liver failure Major Surgical or Invasive Procedure: none History of Present Illness: This is a 47 year old male with history of alcohol abuse who presents to us with liver failure, transferred from [**Hospital3 60734**] this evening. He has liver failure with multi-organ failure requiring intubation and pressor support. He initially presented to [**Hospital3 **] in the early morning of [**5-30**] with abdominal pain, diarrhea, and chest pain. He stated he had felt unwell for the past week. He called an ambulance; EMS found him hypotensive with systolic blood pressures in the 70s, jaundiced, increased respiratory rate into the 40s, but mentating and able to give a brief history. Upon arrival to the hospital, he was resuscitaed with 5 L of fluid; IJ was placed and shortly after placement of line, Mr [**Known lastname **] became unresponsive; he was emergently intubated and ventilated. Upon review of his labs, he was noted to have profound anion gap lactic acidosis with acute kidney injury and a creatinine of 7.8, and an ABG with pH of 7.11/31/39/9.5/54. He was found to be in fulminant hepatic failure with elevated bilirubins of 35, transaminitis in the 100s, as well as a lipase of 7000 and amylase of 500. He was encephalopathic. He received vancomycin, Cipro and Flagyl. His blood glucose was found to be 43 and he was given an amp of D50. He was started on a Levophed drip. A head CT and abdominal pelvic CT were obtained which revealed peripancreatic fluid and mild ascites on imaging. A bicarbonate drip was initiated given acidosis. Thiamine, folate, and vitamins were given. Dextrose drip was started. FFP and cryoprecipitate were given. Tylenol level was negative; EtOH level was 11. Bicarb continued to be low; potassium started to rise, lactate peaked at 11. GI and nephrology were consulted, and given potential need for CVVH in the setting of hypotension - he was transferred to [**Hospital1 18**] for further management. On route a third pressor was started (neosynephrine, vasopressin and levophed at this point). Upon arrival, he was able to open his eyes to voice and able to follow simple instructions (squeezing hands on command). His vitals on transfer were HR 101, BP 92/50, RR 12, 98% on pressure support of 15 with 10 of PEEP. His family arrived at bedside - they stated that most of them have not been in contact with the patient, although they feel that he has been hiding his health status over the past few weeks. His alcohol history dates back to the past three years in the setting of his divorce and associated depression. He may have been drinking [**6-30**] heavy drinks per day over the past three years; prior to this time period, he was not actively drinking. Family states no prior history of jaundice or abdominal swelling; however last year he had an episode of bright red blood from above in the setting of alcohol use. Per the family, he also donated one of his kidneys to his father who has end-stage renal disease. Past Medical History: alcohol abuse Social History: Per the family, he has a history of alcohol abuse, drinks 3-5 drinks of vodka daily for the last 3 years. Brother informs he has failed multiple detox programs. ETOH level at [**Last Name (un) 1724**] was 11. Denies Tylenol use, drug use, IVDA, sexual activity, or new food exposures or recent travel. He denies ever having liver problems in the past. Family History: nc Physical Exam: VS: temp 96.4, RR 15, SaO2 98% on 10 PEEP and 50% FiO2, HR 85, BP 100/70 (on 3 pressors) GEN: jaundiced, somnolent HEENT: icteric CV: RRR, No M/G/R PULM: rhonchorous breath sounds bilaterally ABD: mildly distended Ext: 2+ lower extremity edema Pertinent Results: [**2130-5-31**] 10:57PM TYPE-ART TEMP-37.2 RATES-/20 PEEP-10 PO2-114* PCO2-26* PH-7.35 TOTAL CO2-15* BASE XS--9 VENT-SPONTANEOU [**2130-5-31**] 09:41PM HBsAg-NEGATIVE HBs Ab-BORDERLINE HBc Ab-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2130-5-31**] 09:16PM TYPE-ART PO2-148* PCO2-29* PH-7.32* TOTAL CO2-16* BASE XS--9 [**2130-5-31**] 09:10PM GLUCOSE-134* UREA N-52* CREAT-7.5*# SODIUM-126* POTASSIUM-4.2 CHLORIDE-81* TOTAL CO2-13* ANION GAP-36* [**2130-5-31**] 09:10PM ALT(SGPT)-173* AST(SGOT)-914* LD(LDH)-1107* ALK PHOS-285* AMYLASE-170* TOT BILI-31.8* [**2130-5-31**] 09:10PM ALBUMIN-2.9* CALCIUM-6.7* PHOSPHATE-5.1* MAGNESIUM-2.6 CHOLEST-252* [**2130-5-31**] 09:10PM TRIGLYCER-258* HDL CHOL-LESS THAN [**2130-5-31**] 09:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2130-5-31**] 09:10PM WBC-15.4*# RBC-2.33*# HGB-8.7*# HCT-25.4*# MCV-109*# MCH-37.2*# MCHC-34.2 RDW-17.9* [**2130-5-31**] 09:10PM NEUTS-83* BANDS-5 LYMPHS-11* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-8* [**2130-5-31**] 09:10PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ TARGET-1+ STIPPLED-1+ HOW-JOL-1+ Brief Hospital Course: This 47 year old male with potential underlying history of liver disease presented with worsening hepatic failure likely secondary to acute on chronic liver disease, acute episode possibly precipitated by alcoholic pancreatitis/hepatitis or sepsis from unclear etiology. Full serologic work up was obtained. Abdominal ultrasound was performed to evaluate vasculature and biliary tree; no clear obstruction was identified. Blood was transfused. Pressors were run to keep MAP > 55. Transplant surgery was consulted who deemed him not a candidate given his alcohol history (active drinking). Renal was consulted for consideration of dialysis. Lactulose was started. Broad spectrum antibiotics were continued. However, given increasing pressor requirements and progressive difficulty with ventilation, a decision was made to escalate care. Family was in agreement with this plan. The patient was extubated; pressors were weaned and transition to comfort care was initiated. The patient expired on [**2130-6-1**]. Medications on Admission: Home Medications: Prilosec Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: decompensated liver failure Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "572.8", "038.9", "995.92", "305.01", "577.0", "570", "V45.73", "276.2", "785.52", "276.69", "275.41", "571.1", "789.59", "584.5", "572.2" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

6309, 6318

5175, 6199

317, 323

6389, 6398

3947, 5152

6454, 6464

3664, 3668

6277, 6286

6339, 6368

6225, 6225

6422, 6431

3683, 3928

6244, 6254

264, 279

351, 3240

3262, 3277

3293, 3648

18,846

174,494

6088

Discharge summary

report

Admission Date: [**2140-4-16**] Discharge Date: [**2140-5-12**] Date of Birth: [**2074-2-1**] Sex: F Service: SURGERY Allergies: Penicillins / Ceftriaxone / Strawberry / Bleach Attending:[**First Name3 (LF) 2777**] Chief Complaint: 66 year old female presents to the ER on [**2140-4-16**] with bleeding from a recent right groin abscess that had been incised and drained. Major Surgical or Invasive Procedure: [**2140-4-26**]:Right groin exploration with take down of right common femoral and right profunda artery arteriovenous fistulas. History of Present Illness: Ms [**Known lastname **] was at dialysis when her groin wound spontaneously started oozing blood on [**2140-4-16**]. She was sent to the emergency department, where her hematocrit was 30, from a baseline of 36, and she was hypotensive into the 80s. The bleeding was successfully stopped with lidocaine with epi and surgifoam. Her INR was 3.0 at the time. Her wound was examined by ACS who repacked the wound and recommended admission for further evaluation. Past Medical History: - h/o bilateral lower extremity DVT's - atrial tachycardia: seen by Dr. [**Last Name (STitle) **] in [**10-24**] and felt to be atrial tachy [**2-18**] illness, no indication for ablation - hemorrhagic pericardial effusion - Bilateral internal jugular thromboses, restarted on coumadin [**8-24**] - ESRD on HD T, Th, Sat [**Doctor First Name 12074**] Dialysis [**Telephone/Fax (5) 23864**] [**Numeric Identifier 23865**] - IDDM - Diastolic heart failure - Pulmonary hypertension - Hypercholesterolemia - OSA, noncompliant with CPAP as outpatient (on 2L home O2) - OA - h/o C. Diff - GERD - Depression - Morbid obesity - Fibroid uterus; vaginal bleeding - h/o Osteomyelitis at the T9 Vertebrae [**5-24**]; tx with Vanc - h/o Multiple line infections Social History: Patient denies tobacco, alcohol or illicit drug use. She lives in a nursing home ([**Hospital3 2558**]) since the last 10 years. She is separated from her husband. She has 5 children in [**Location (un) 86**] [**Doctor Last Name **] area. Uses electric wheelchair. Family History: Two children with asthma. Strong family hx of cancer (many uncles/aunts with lung cancer, father had prostate cancer, mother has HCC [**2-18**] alcoholic hepatitis) Physical Exam: Alert and oriented x 3 VS:BP 108/40 HR 68 Resp: Lungs clear Abd: Soft, non tender Right groin wound: wound bed partially granulated, 50% slough. Scant serosang drainage. Measures 6cm long x 9 cm wide x 4 cm deep. Pertinent Results: CTA pelvis [**2140-4-18**]: 1. Bilateral common femoral DVT's. Atretic left SFA indicating prior thrombosis. 2. Right AV fistula. No evidence of pseudoaneurysm. 3. Fibroid uterus. 4. New discrete enhancing rounded hyperdensity within the right labia adjacent to the skin defect site. This could represent a small hematoma or lesion. Clinical correlation is recommended. [**2140-5-12**] 06:35AM BLOOD WBC-6.5 RBC-3.02* Hgb-9.2* Hct-30.3* MCV-100* MCH-30.4 MCHC-30.4* [**Month/Day/Year 23866**]-17.2* Plt Ct-356 [**2140-5-12**] 06:35AM BLOOD PT-17.6* PTT-36.1 INR(PT)-1.7* [**2140-5-12**] 06:35AM BLOOD Glucose-117* UreaN-45* Creat-5.7*# Na-134 K-5.2* Cl-96 HCO3-29 AnGap-14 [**2140-5-12**] 06:35AM BLOOD Calcium-9.7 Phos-4.3 Mg-2.3 [**2140-5-9**] 06:00AM BLOOD PTH-491* [**2140-5-2**]: Right groin culture _________________________________________________________ PROTEUS MIRABILIS | KLEBSIELLA PNEUMONIAE | | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R =>32 R CEFAZOLIN------------- 8 R =>64 R CEFEPIME-------------- <=1 S 2 S CEFTAZIDIME----------- <=1 S =>64 R CEFTRIAXONE----------- <=1 S 16 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 8 I 8 I MEROPENEM-------------<=0.25 S <=0.25 S TOBRAMYCIN------------ 4 S 8 I TRIMETHOPRIM/SULFA---- =>16 R =>16 R Brief Hospital Course: Ms [**Known lastname **] is a 66 year old woman who was recented hospitalized for an abscess incision and drainage in the right groin from [**Date range (3) 23867**]. On [**2140-4-16**], she was at dialysis when her groin wound spontaneously started oozing blood. She was sent to the emergency department, where her hematocrit was 30 from a baseline of 36 and she was hypotensive into the 80s systolic. The bleeding was successfully stopped with lidocaine with epi and surgifoam. Her INR was 3.0 at the time. Her wound was examined by ACS who repacked the wound and recommended admission for further evaluation. A duplex ultrasound demonstrated a small 1.4 x 1.2 cm pseudoaneurysm likely originating from an epigastric arterial branch. Over the course of the next week, she developed recurrent bleeding into her right thigh with associated anemia and hypotension. A CT was performed confirming a the fistula emanating from the femoral profunda and possibly from branches off the common femoral with distended femoral vein and multiple dilated venous branches extending into her pannus and into her vulvar region consistent with her presentation of bleeding episodes from her groin wounds. She therefore underwent a right groin exploration with take down of right common femoral and right profunda artery arteriovenous fistulas on [**2140-4-26**]. The procedure was without complications although she did have a 4500cc blood loss requiring 6 liters crystalloid, 6 units packed red blood cells, 2 units FFP, 1150 cc Cell [**Doctor Last Name **]. She was closely monitored in the ICU and then was ready for transfer to the floor on POD 1. On POD 6, she developed erythema and drainage from her groin incision. She was started on vancomycin, cipro and flagyl. The incision was opened and packed with NS w>d. The wound culture eventually grew klebsiella and proteus. Her antibiotic was changed to IV meopeneum. The wound was assessed daily and debided as needed. A wound VAC was placed on [**2140-5-6**]. As she no longer needs debridement, and the wound has started to granulate, she is ready for discharge. She is now on her regular Tuesday, Thursday and Saturday dialysis schedule. Her blood sugars have consistently been less well controlled. Her coumadin has been restarted. She is tolerating a regular diet. She has remained hemodynamically stable since surgery. Follow-up has been arranged with Dr. [**Last Name (STitle) **] in 2 weeks. Medications on Admission: Vanc with HD x 1 more day (End [**4-17**]) fleet enema 19g - 7g / 118 mL daily prn constipation glucagon 1 mg IM for FSBS < 60 cepacol 4.5 mg lozenge 1 tab PO q4h prn sorethroat calcium 600 with vitamin D3 1 tab PO BID senna 8.6 mg tab PO daily NPH insulin 10 units sc qAM duoneb 0.5mg-2.5mg/3ml neb solution IH q6h prn dyspnea Sevalemer 1600 TID with [**Month/Day (4) 16429**] Neprocaps 1 tab PO daily bactrim DS 800 mg - 160 mg 1 tab PO before hemodialysis, 1 tab PO after hemodialysis acetaminophen 500 mg PO q6h PRN pain or fever ex-lax milk of magnesia 400mg/5ml 5 ml PO q6h prn constipation albuterol sulfate 2.5 mg / 3 ml IH q6h prn dyspnea simvastatin 10 mg PO daily omeprazole 40 mg PO daily amiodarone 200 mg PO daily paroxetine 20 mg PO daily docusate 100 mg PO BID bisacodyl 10 mg PR daily warfarin 5 mg PO daily vitamin B-100 complex 1 tab PO daily folic acid 1 mg PO daily Discharge Medications: 1. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily). 6. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. meropenem 500 mg Recon Soln Sig: One (1) Intravenous once a day for 14 days days. 8. B complex vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. 11. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/[**Month/Day (4) **] (3 TIMES A DAY WITH [**Month/Day (4) **]). 12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: PRIMARY DIAGNOSIS: Groin abscess, AV fistula. SECONDARY DIAGNOSES: Diabetes Mellitus 2 End stage renal disease Chronic Diastolic Heart Failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital for low blood pressures, concern for bacteria in your blood and bleeding from you groin. You were found to have an infection in your groin and a arterial/venous fistula which we resected on [**2140-4-26**]. We are discharge you with a special wound VAC to the right groin and an PICC line for IV antibiotics. Followup Instructions: Department: VASCULAR SURGERY When: WEDNESDAY [**2140-5-25**] at 2:00 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 Completed by:[**2140-5-12**]

[ "996.73", "V58.61", "530.81", "486", "416.8", "327.23", "682.2", "285.1", "041.12", "E879.8", "428.0", "V12.51", "V85.41", "428.32", "998.59", "998.11", "V45.11", "278.01", "442.3", "997.2", "585.6", "250.00", "272.0" ]

icd9cm

[ [ [] ] ]

[ "39.43", "39.95" ]

icd9pcs

[ [ [] ] ]

8635, 8705

4091, 6552

446, 577

8893, 8893

2557, 4068

9438, 9776

2139, 2306

7490, 8612

8726, 8726

6578, 7467

9069, 9415

2321, 2538

8794, 8872

267, 408

605, 1066

8745, 8773

8908, 9045

1088, 1840

1856, 2123

64,178

111,605

32603

Discharge summary

report

Admission Date: [**2188-2-22**] Discharge Date: [**2188-2-28**] Date of Birth: [**2133-5-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Blurry vision Major Surgical or Invasive Procedure: None. History of Present Illness: Mr [**Known lastname **] is a 54 year old man who presented with a 1 week history of polyuria, polydipsia, blurred vision, nausea, emesis, abdominal pain and was admitted to the MICU for treatment of presumed DKA. He had no prior history of [**Known lastname **] and had never been told he had a high blood sugar. He reports that since [**2188-2-15**] he had had polyuria, polydipsia and severe "gastritis" which prevented him from eating. He reports that the day prior to that he had an episode of vomiting. He acknowledges that he has a history of gastritis that he takes ranitidine for, but since [**2188-2-15**] he has been unable to tolerate oral intake. On [**2188-2-19**] he had an endoscopy at [**Hospital1 18**] that showed mild gastritis. On admission on [**2188-2-21**] the pt denied any fever, chills, dysuria, diarrhea, chest pain, dyspnea, diaphoresis or any localizing signs of infection. . Review of systems is otherwise negative other than HPI. . In the emergency department the pt was noted to have a BG of 865. At that time he was started on an insulin gtt at 7 units/hr, 7 unit regular insulin bolus, morphine 4mg, and zofran 4mg. ECG showed TWI III, SR, nml axis and intervals. CXR was normal. . Past Medical History: Gastritis- EGD [**2-19**] Hypothyroidism Dyslipidemia Social History: Originally from El [**Country 19118**], emigrated 4 yr ago. Lives with 30 yr old daughter. [**Name (NI) **] worked as a car mechanic since he was young. 10 pack year tobacco history but quit 25 years ago. Also was a heavy drinker but quit 25 years ago. Family History: Mother is alive. His father died of alcohol related disease. Sisters have [**Name (NI) **]. No h/o cardiac disease, htn or hypercholesterolemia that he is aware of. Physical Exam: GENERAL: Pleasant, well appearing in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**11-23**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately Pertinent Results: [**2188-2-22**] 06:40PM WBC-10.1 RBC-5.04 HGB-14.9 HCT-45.0 MCV-89 MCH-29.5 MCHC-33.1 RDW-13.0 [**2188-2-22**] 06:40PM PLT COUNT-259 [**2188-2-22**] 06:40PM GLUCOSE-865* UREA N-32* CREAT-1.6* SODIUM-141 POTASSIUM-5.7* CHLORIDE-94* TOTAL CO2-22 ANION GAP-31* [**2188-2-22**] 06:40PM ALT(SGPT)-58* AST(SGOT)-30 CK(CPK)-1224* ALK PHOS-165* TOT BILI-0.4 [**2188-2-22**] 06:40PM LIPASE-54 [**2188-2-22**] 06:40PM cTropnT-<0.01 [**2188-2-22**] 06:40PM CK-MB-13* MB INDX-1.1 [**2188-2-22**] CXR: No acute cardiopulmonary process. Limited study due to patient positioning. Possible granuloma at right lung base. Brief Hospital Course: Mr. [**Known lastname **] is a 54 year old man with new onset [**Known lastname **] who presented with abdominal pain, polyuria, polydipsia and blurred vision for 7 days prior to admission and was found to have diabetic ketoacidosis (DKA). . Hospital course by problem: . # [**Name (NI) 75996**] The pt had no prior diagnosis of [**Name (NI) **] mellitus to his knowledge, and did not have a history of elevated blood glucose that he knew of. The trigger of the DKA remains unknown, as the pt never had any evidence of infection, chest pain or other possible trigger. The pt was initially maintained on an insulin gtt given anion gap of 31 and ketonuria. His gap closed by the morning following admission and he was transitioned to NPH 10 units [**Hospital1 **] and HISS. He was volume resuscitated with 4L NS in the ED and another 2-3L in the ICU. On the floor the pt's insulin regimen was titrated with the help of [**Last Name (un) **] consultation service, and the pt was discharged on insulin glargine and humalog sliding scale, with plans to follow up in [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] Clinic with diabetic teaching and plans to be seen by [**Last Name (un) **] when they travel to the clinic in [**Month (only) 116**]. Of note, the pt's GAD antibody was negative during this admission, and his hemoglobin A1C was noted to be 13. He likely has type II [**Month (only) **]. . # Hypernatremia- This resolved with managment of serum glucose and half-normal saline. On discharge the pt's sodium was in a normal range. . # Hypothyroidism- During this hospitalization the pt was continued on his home levothyroxine. . # [**Name (NI) 75997**] The pt was noted to have an elevated CK on admission, which trended down during the hospitalization. The pt's home atorvastatin was held, and on discharge the pt was instructed to continue to hold his statin until he saw his primary care physician. . # Gastritis- During this admission the pt complained of burning epigastric pain, which was likely due to a combination of the pt's chronic mild gastritis (visualized just prior to admission on EGD) and DKA. The pt's ranitidine was switched to pantoprazole, with which the pt had symptomatic improvement. H. pylori from recent EGD returned negative, and the pt was discharged on pantoprazole. . Medications on Admission: Levothyroxine 25 mcg daily Lipitor 40mg daily MVI Ranitidine 150mg daily Discharge Medications: 1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Insulin Glargine 100 unit/mL Cartridge Sig: Thirty Five (35) u Subcutaneous at bedtime. Disp:*10 cartridges* Refills:*2* 4. Humalog 100 unit/mL Cartridge Sig: Per sliding scale Subcutaneous four times a day: See attached sliding scale. Disp:*20 cartridges* Refills:*2* 5. Insulin Syringe 1 mL 30 x 1 Syringe Sig: One (1) syringe Miscellaneous four times a day. Disp:*120 syringes* Refills:*2* 6. One Touch UltraSoft Lancets Misc Sig: One (1) syringe Miscellaneous four times a day. Disp:*120 lancets* Refills:*2* 7. One Touch Ultra Test Strip Sig: One (1) strip In [**Last Name (un) 5153**] four times a day. Disp:*120 strips* Refills:*2* 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Primary: diabetic ketoacidosis [**Last Name (un) 982**] mellitus, likely type II Secondary: gastritis Gastroesophageal Reflux Disease hyperlipidemia Discharge Condition: Good, breathing comfortably on room air. Discharge Instructions: Mr [**Known lastname **]: You were admitted with a new diagnosis of [**Known lastname **]. You presented with a condition called Diabetic Ketoacidosis, which is sometimes provoked by an infection. We did not find any evidence of infection. You had a CT scan of your abdomen that showed fatty liver, a condition that had been noted on prior abdominal radiology images. . You also had some pain after the nurse removed your IV on your final day of the hospital stay. You were found to have a superficial blood clot on ultrasound, and you should continue to place hot pads and use tylenol for the pain. . You have been started on insulin for [**Known lastname **]. Your ranitidine has been changed to pantoprazole. Please ONLY take pantoprazole. Your lipitor has been STOPPED. Please do not start taking this medication until you see your primary care doctor. . If you develop chest pain, shortness of breath or worsening stomach burning, please call your doctor or return to the emergency room. Followup Instructions: Appointment #1 MD: Dr [**Last Name (STitle) **] Specialty: Primary Care Date and time: [**Last Name (LF) 2974**], [**2-29**] @2:15pm Location: [**Hospital3 33953**] Community Center,[**Street Address(2) 34193**], [**Hospital1 **], Ma Phone number: [**Telephone/Fax (1) 17826**] Special instructions if applicable: this appt has been moved up. disregard old form . Appointment #2 MD: Nurse [**First Name (Titles) 982**] [**Last Name (Titles) **] Specialty: [**Last Name (Titles) 982**] Date and time: [**3-6**] at 8pm Location: [**Hospital3 33953**] Community Health Center, [**Street Address(2) 34193**], [**Hospital1 **] Ma Phone number: [**Telephone/Fax (1) 17826**] Special instructions if applicable: Appt with [**Doctor First Name 440**] the nurse [**Doctor First Name 30484**] . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18307**], MD Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2188-3-4**] 8:00 . [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "276.0", "584.9", "530.81", "728.88", "275.41", "276.8", "244.9", "272.4", "250.12", "535.50" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6973, 6979

3514, 3756

328, 336

7173, 7216

2870, 3491

8257, 9320

1947, 2113

5969, 6950

7000, 7152

5871, 5946

7240, 8234

2128, 2851

275, 290

3784, 5845

364, 1583

1605, 1661

1677, 1931

15,220

194,710

2647+2739

Discharge summary

report+report

Admission Date: [**2180-6-8**] Discharge Date: [**2180-6-17**] Date of Birth: [**2110-7-20**] Sex: F Service: PRINCIPAL DIAGNOSIS: Bladder carcinoma. HISTORY OF PRESENT ILLNESS: The patient is a 69 year old female who was recently hospitalized at [**Hospital6 649**] with acute renal failure. She was taken to the Operating Room and found to have bilateral ureteral obstruction at the base of her bladder from presumably a bladder primary carcinoma. This was biopsied and it was a little indecisive as to wether this was a bladder primary or a gynecologic primary cancer. Either way, the recommendations were to proceed to the Operating Room for an anterior exenteration. This is what she did and this is what this admission is for. PAST MEDICAL HISTORY: Multiple sclerosis; hypertension; noninsulin dependent diabetes mellitus; breast cancer, status post lumpectomy and radiation in [**2174**] with Tamoxifen therapy; chronic renal insufficiency; history of an upper gastrointestinal bleed with gastritis; history of recent aspiration pneumonia. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Celexa 40 mg p.o. q. day; Tamoxifen 20 mg p.o. q. day; Prevacid 30 mg p.o. q. day; calcium carbonate 500 mg p.o. t.i.d.; subcutaneous heparin 5000 units subcutaneously b.i.d.; regular insulin sliding scale, Baclofen 30 mg p.o. q.h.s.; Colace 100 mg p.o. b.i.d.; Compazine 5 mg p.o. t.i.d.; Miconazole powder as needed; Zonata 5 mg p.o. q. day. HOSPITAL COURSE: The patient was admitted to the [**Hospital6 1760**] preoperatively on [**2180-6-8**]. She received consultation from the enterostomal nurse in preparation for going to the Operating Room the following day. She was taken to the Operating Room on [**2180-6-9**] where she underwent anterior exenteration with ileal loop urinary diversion. She did well in the Operating Room and was taken to the Intensive Care Unit intubated postoperatively. She had a vaginal pack in place along with the [**Location (un) 1661**]-[**Location (un) 1662**] drain, two nephroureteral stents, bilateral nephrostomy tubes which were present preoperatively, a pulmonary arterial line, an arterial line, an nasogastric tube and peripheral intravenous lines. In the Intensive Care Unit she did quite well and she was kept on Ancef and Flagyl antibiotics for 72 hours. Her pain was controlled with intermittent Morphine pulses and she remained intubated for two days postoperatively. Her x-rays that were performed postoperatively revealed both ureteral stents to be in the mid to proximal ureters. Her bilateral nephrostomy tubes were left to gravity and were draining urine. On postoperative day #2 the patient was extubated and she was oxygenating and ventilating well. She received aggressive chest physiotherapy and continued to improve from a respiratory standpoint. She was still kept without eating with an nasogastric tube in place. She was on Zantac prophylaxis. Her vaginal packing was removed on postoperative day #2. At this point her right internal jugular catheter was changed to a triple lumen with a port saved for parenteral nutrition should she need it. On postoperative day #4, the patient was transferred to the Intensive Care Unit to the floor in stable condition. She continued to receive intravenous fluids and was not eating as she had not passed gas yet. On postoperative day #5, she had had a small bowel movement and her diet was advanced to sips of clear liquids. She continued to do well and was continued on her subcutaneous heparin. Physical therapy saw her and began to mobilize her. On postoperative day #6 the patient underwent bilateral antegrade nephrostograms and she was found to have prompt drainage from the right kidney through the dilated right ureter into her ileal loop. The left side, which is her better-functioning kidney did drain but at a slower rate when compared to the right side. With this knowledge and the nephrostograms, both percutaneous nephrostomy tubes were clamped on postoperative day #6. The patient developed no pain in the upcoming 12 hours, and on postoperative day #7, the right nephrostomy tube was removed. There was no leakage from this site and a dressing was applied. The left nephrostomy tube remained capped and the patient was tolerating this quite well. The decision was made to leave this tube in place as this is her healthier kidney and providing most of her renal function. In the event that she should develop left flank pain it could easily be uncapped and placed to gravity drainage. By postoperative day #7 the patient was out of bed, and working with the physical therapist. By postoperative day #8 her rehabilitation bed was ready at [**Hospital1 **] Facility in [**Location (un) 246**] and she was transferred to rehabilitation in stable condition. The morning of postoperative day #8 her [**Location (un) 1661**]-[**Location (un) 1662**] drain was removed as it was draining small amounts of fluid and the creatinine from this fluid revealed it was consistent with peritoneal fluid and not urine. DISCHARGE PHYSICAL EXAMINATION: Temperature 98.9, heartrate 84, blood pressure 136/74, respiratory rate 18 breaths per minute, oxygen saturation 98% on room air. She is in no acute distress. Her heart is regular rate and rhythm. Her lungs are clear to auscultation bilaterally with decreased effort. Her abdomen is soft, nontender and slightly obese. Her midline incision is clean, dry and intact with staples. Her right lower quadrant urostomy stoma is pink with clear yellow urine draining. Her left flank nephrostomy tube is capped and the site is clean, dry and intact. Her previous [**Location (un) 1661**]-[**Location (un) 1662**] drain site is covered with a dressing and intact. Her extremities are warm and well perfused with trace edema bilaterally. DISCHARGE MEDICATIONS: All of her preoperative medications without change as well as stoma supplies. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: [**Hospital3 13268**] in [**Location (un) 246**]. DISCHARGE INSTRUCTIONS: The patient's midline abdominal staples can be removed on postoperative day #14 and Steri-Strips applied. 1. Nutrition - The patient is advanced to a house diet, but her intake has been somewhat questionable, secondary to decreased appetite. When the patient was transferred here from her rehabilitation facility she was receiving peripheral parenteral nutrition. There may be need for this in the future if she does not continue to improve with her oral intake. 2. Genitourinary - The patient's left nephrostomy tube should remain capped at all times. Should the patient develop left flank pain or have minimal output from her loop for an extended period of time, the left nephrostomy could be placed back to gravity drainage but we would like to keep this capped in an effort to have it removed at the postoperative visit. The patient's ileal loop urostomy appliance was changed on [**2180-6-16**] and extensive instructions have been left in her chart for additional changes on her Page 2 summary completed by the enterostomal therapy nurse. 3. Follow up - The patient should follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**] in two weeks time for possible left nephrostomy tube removal in the office. This is scheduled through his office at [**Telephone/Fax (1) 6445**]. LABORATORY DATA: All laboratory data from [**2180-6-14**] - White blood cell count 11,000, hematocrit 29, platelets 305,000. PT 15.5, PTT 33.6, INR 1.6, sodium 136, potassium 3.7, chloride 105, bicarbonate 20, BUN 11, creatinine 0.9, glucose 66, magnesium 1.8. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 13269**] Dictated By:[**Last Name (NamePattern1) 13270**] MEDQUIST36 D: [**2180-6-17**] 10:29 T: [**2180-6-17**] 10:38 JOB#: [**Job Number 13271**] Admission Date: [**2180-6-8**] Discharge Date: [**2180-6-17**] Date of Birth: [**2110-7-20**] Sex: F Service: ADDENDUM: Addendum to her discharge medications. Please add Lopressor 25 mg p.o. three times per day. Addendum to her hospital course. Number 3 would be cardiovascular. The patient was found to be hypertensive and tachycardic postoperatively and was begun on intravenous Lopressor. This was converted to Lopressor orally 25 mg p.o. three times per day, and she did well from this standpoint. She was borderline hypertensive on admission and was continued on this Lopressor at the time of discharge. Number 5 on hospital course will be non-insulin-dependent diabetes mellitus issues. The patient's fingersticks remained in the 110 to 150 range she was in house, and she received subcutaneous insulin according to the sliding-scale as needed. Please continue her on the sliding-scale at rehabilitation. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 13269**] Dictated By:[**Name8 (MD) 13538**] MEDQUIST36 D: [**2180-6-17**] 10:34 T: [**2180-6-17**] 10:39 JOB#: [**Job Number 13539**]

[ "196.6", "591", "340", "401.9", "250.00", "188.8", "582.9", "593.4", "198.82" ]

icd9cm

[ [ [] ] ]

[ "57.71", "45.93", "70.4", "59.11", "87.72", "65.61", "40.3", "68.4", "47.19", "56.51" ]

icd9pcs

[ [ [] ] ]

6025, 6076

5888, 5967

1142, 1487

1505, 5105

6101, 9230

5128, 5864

201, 761

784, 1115

5992, 6001

80,658

164,961

27457

Discharge summary

report

Admission Date: [**2112-1-30**] Discharge Date: [**2112-3-11**] Date of Birth: [**2053-12-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Weakness, shortness of breath Major Surgical or Invasive Procedure: [**2-5**], CT-guided drainage of sigmoid fluid collection Right Internal Jugular Central line placement Arterial Line placement Intubation with mechanical ventilation x 2 Extubation x 1 Dobhoff placement Oral-gastric tube placement History of Present Illness: Mr. [**Known lastname 67176**] is a 58 year old man with ANCA-negative vasculitis with a history of pulmonary hemorrhages, on chronic supplemental oxygen, high dose prednisone therapy s/p recent admission earlier this month ([**Date range (1) 67187**]) for perforated diverticular disease managed conservatively with bowel rest and antibiotics, now admitted with worsening weakness. Patient reports that since he first received the Rituxan in early [**Month (only) 404**], his weakness has worsened. He feels tired all the time, has no energy and decreased exercise tolerance. He can no longer walk from his wheelchair (motorized) to the bathroom (a matter of a few steps) due to dyspnea. He denies fevers, chills, change in his cough or hemoptysis. He has daily hemoptysis that is no different from baseline. He has had some pain in his mouth that he attributes to thrush. He started on Nystatin swish and swallow a few days ago and that has helped considerably. His abdominal discomfort is much improved. He is tolerating a normal diet and taking in POs. He has been on 6L of oxygen for the past month or so, but adds a face mask with additional oxygen when ambulating to the BR. This is a significant worsening for him per his report, in the not too distant past, he reports, he could at times go without supplemental oxygen. He does not wear CPAP or BiPAP. ROS is negative for chest pain, edema, rash, fevers/chills, nausea, no urinary frequency or dysuria. Positive for: diarrhea - loose stools since diverticulitis flare. Also with some chronic visual changes limiting his ability to read easily. Says he saw a ophthamologist for this and was told it was due to ischemic damage. Past Medical History: Alveolar hemorrhage/anca negative vasculitis. Never had a biopsy. presented as DAD in [**4-8**]. Several hospitalizations for same since then. Atrial fibrillation status post ablation. Type 2 diabetes mellitus. DVT with PE s/p filter [**7-8**] CAD status post stenting to the LAD in [**2101**]. Mild pulmonary hypertension. Obesity. Sleep apnea. NASH. Hyperlipidemia. Hypertension. Bilateral torn rotator cuff. BPH. GERD, consistent with Barrett's esophagus. Anxiety. Spinal stenosis. Social History: Mr. [**Known lastname 67176**] lives with his wife and has 2 children that live in [**Location (un) 86**]. He has a history of smoking 2-3pk per day x 25 yrs and quit 5 yrs ago. He also has a history of alcohol use but no illicits. Per OMR, prior job in Auto-body repair. At baseline, he uses an electric wheelchair to get around. Family History: No known family history of blood clots or bleeding. Physical Exam: ADMISSION EXAM GEN: Obese, [**Location (un) **]-oid appearing man, appears comfortable at rest, with dyspnea with full-sentences VS: T 96.5 po, 156/91 85 22 100% on 6L NC Gen: NAD. Oriented x3. HEENT: NCAT. Sclera anicteric. Right pupil 4--> 3 mm, Left pupil 3--> 2 mm. EOMI. OP with upper and lower dentures in place, + white exudate on tongue and posterior o/p. Neck: Supple, JVP not seen due to habitus. CV: RRR distant Chest:No accessory muscle use. CTAB, no rales, wheezes or rhonchi. Diminished breath sounds throughout Abd: Obese, Soft, NTND. unable to appreciate HSM Ext: No c/c/edema. Skin: No stasis dermatitis, ulcers, scars NEURO: alert and appropriate Pertinent Results: ADMISSION LABS ============================================= [**2112-1-30**] 01:09AM LACTATE-1.9 [**2112-1-30**] 01:00AM GLUCOSE-67* UREA N-25* CREAT-0.6 SODIUM-138 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-30 ANION GAP-11 [**2112-1-30**] 01:00AM ALT(SGPT)-46* AST(SGOT)-23 CK(CPK)-27* ALK PHOS-47 TOT BILI-0.8 [**2112-1-30**] 01:00AM cTropnT-<0.01 [**2112-1-30**] 01:00AM LIPASE-28 [**2112-1-30**] 01:00AM WBC-4.8 RBC-2.98* HGB-9.8* HCT-29.4* MCV-99* MCH-33.0* MCHC-33.5 RDW-15.8* [**2112-1-30**] 01:00AM PT-11.3 PTT-19.9* INR(PT)-0.9 REPORTS ============================================= CT ABDOMEN W/CONTRAST Study Date of [**2112-2-2**] 1. Feculent collection adjacent to loop of sigmoid colon at site of previous episode of diverticultis consistent with perforated diverticulitis. This has progressed in size from the prior examination and is localized to the perisigmoid region although there is not a well defined wall about this gas and stool containing collection. 2. Extensive colonic diverticulosis. 3. Paraumbilical hernia containing nonobstructed, nondilated loops of small bowel. 4. Stable scarring at bilateral lung bases with fibrotic changes. 5. Stable hypodensity in the pancreas, which could represent an IMPN or pancreatic cyst. MRCP would be recommended for further evaluation. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2112-2-28**] 1. Persistent diffuse ground-glass opacities superimposed on interstitial abnormality. As previously described, this may be due to pulmonary hemorrhage, exacerbation of underlying interstitial disease, or infection. No pleural effusions. 2. No pulmonary embolus. 3. Sigmoid colon abscess drainage catheter in place. No reaccumulation of fluid or new abdominal collections. CHEST (PORTABLE AP) Study Date of [**2112-3-11**] In comparison with the study of [**3-10**], there are lower lung volumes and increasing pulmonary vascular congestion. The possibility of supervening pneumonia must be considered. Monitoring and support devices remain in place with the metallic portion of the Dobbhoff tube just below the esophagogastric junction. [**2112-2-2**] 4:55 pm BLOOD CULTURE **FINAL REPORT [**2112-2-16**]** Blood Culture, Routine (Final [**2112-2-10**]): MORGANELLA MORGANII. FINAL SENSITIVITIES. VIRIDANS STREPTOCOCCI. ISOLATED FROM ONE SET ONLY FINAL SENSITIVITIES. Susceptibility testing requested by DR. [**First Name (STitle) 815**] [**Numeric Identifier 67188**] [**2112-2-7**]. Sensitivity testing performed by Sensititre. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ MORGANELLA MORGANII | VIRIDANS STREPTOCOCCI | | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S CLINDAMYCIN----------- <=0.25 S ERYTHROMYCIN---------- 0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PENICILLIN G---------- 0.06 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R VANCOMYCIN------------ 1 S Anaerobic Bottle Gram Stain (Final [**2112-2-3**]): GRAM NEGATIVE ROD(S). GRAM POSITIVE COCCI IN PAIRS AND CHAINS. REPORTED BY PHONE TO [**Doctor First Name 1730**] [**Doctor Last Name **] [**2112-2-3**] AT 1415. Aerobic Bottle Gram Stain (Final [**2112-2-3**]): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Brief Hospital Course: Upon admission the weekend of [**1-30**], patient's Cellcept and Rituxan were halted. CT scan of abdomen and pelvis showed enlarging sigmoid fluid collection consistent with an abscess. Pulmonary, surgery (Dr. [**Last Name (STitle) **], ID and IR were all consulted. Additional blood cultures were drawn and Zosyn started. Surgery was felt to be high-risk given his 450 mg-per-day Prednisone dosing. A plan was made for IR drainage of the fluid collection after a platelet transfusion -- after a platelet transfusion for his thrombocytopenia -- while simultaneously changing his steroids over to Hydrocortisone 200 mg TID and attempting to wean that down to 80 mg TID. On [**2-2**], his blood cultures were reported positive for Strep Viridans and Morganella. Linezolid was d/discontinued. On [**2-5**], he was intubated, a central line was placed, and IR placed a drain in the abscess that post-procedure was returning brown feculent material. Post-procedure his vent and sedation were weaned, and he received IV Ig. He had a Foley placed prior the procedure that was traumatic in placement, and urology came to place a Coudet. Urology recommended the Foley until [**2-12**] when he could have a voiding trial. On [**2-6**], a TTE was ordered given Strep Viridans-positive cultures. His steroids were tapered from 200 TID to 180 TID. He was extubated. He had some minimal bleeding in his tracheal secretions and a hematocrit of 19, for which he was transfused 1 unit of blood with a good response. On [**2-7**], attempts to wean him to Hydrocortisone 160 mg TID led to him reporting an increase in his chronic hemoptysis, so his steroid dose was pushed back up to 180 mg TID. He was called out of the ICU to the floor at this point. The patient developed increasing oxygen requirement on the floor and frank blood on suctioning. He was transferred back to the ICU and shortly re-intubated. Patient's rebleed was felt likely due to attempted decreasing of his steroids so per rheumatology, hydrocortisone was increased to 500 mg three times daily. Patient also briefly developed neutropenia. His ETT tube also tended to migrate above carina, have cuff leaks requiring repositioning by anesthesia. Patient developed thrombocytopenia (20-30s) requiring transfusions; in consultation with Heme/Onc, it was felt this was not due to HIT but acute disease and patient's large body habitus. He was transfused platelets and bumped appropriately. CMV/EBV/Parvovirus viral loads were negative. Peripheral blood smear negative for DIC. Ultimately, patient underwent plasmapheresis (5 sessions) and another round of IVIG (5 days) to optimize his healing potential and immunological status. His hydrocortisone was slowly weaned down and then transitioned to Solumedrol (60mg IV three times daily). In the meantime, [**Last Name (un) **] continued to monitor patient's insulin sliding scale and fixed dose regimens on steroids. Repeat CT abdomen/pelvis showed dramatically improving/shrinking abscess and good drainage. He did require one replacement of his drain when it fell out overnight on [**2-16**]. Infectious disease continued to follow patient and recommended Meropenem (Cipro/Linezolid felt redundant given sensitivity/speciation of abscess microbes). There was brief concern of SIRS in the setting of relative hypotension. Patient was initially kept NPO with parenteral feedings to provide bowel rest for his known sigmoid abscess and perforated diverticulitis. Eventually, a Dobhoff was placed and his diet slowly advanced. Intermittently he had ileus and tube feeds were held. Throughout patient's remaining hospital course, his pulmonary ventilation status was difficult to manage until he was started on Airway Pressure Release Ventilation. Patient was also found to have anasarca with +14 L length of stay. He was started on active Lasix diuresis which he responded well to (~-6 L daily on occasion). He was also briefly on Acetazolamide for metabolic acidosis. Patient was gradually transitioned to pressure support and then weaned/extubated. Once extubated the second time, patient complained of significant back and left shoulder pain. He has chronic back pain from spinal stenosis and known left rotator cuff tear. His baseline pain level is [**7-9**] from these two issues. During his hospitalization, however, shortly after extubation, he was also noted to be hyperalgesic likely in setting of prolonged benzodiazepine/narcotic use for sedation/intubation. Patient was trialed on standing Tylenol, lidocaine patches and fentanyl boluses. The patient unfortunately did not tolerate extubation and was re-intubated 1 week later after becoming agitated, tachypneic and acidotic. He remained intubated for the remainder of his hospital course. Over the final week of hospitalization, all efforts were made to optimize Mr. [**Known lastname 67189**] nutritional and respiratory status. On [**2112-3-7**] a final burst of high dose steroids with rapid taper was trialed in an effort to improve his respiratory status. Other ongoing issues included sigmoid abscess with external drain that ultimately resulted in an enterocutaneous fistula. Fistula output was mostly feces but intermittently with maroon stools concerning for GI hemorrhage. Despite this, he did improve from an infectious stand point with several days of being afebrile. Additionally, his renal function worsened until he was anuric with worsening metabolic acidosis. On [**2112-3-9**], patient had an episode of rapid decompensation with hypotension, fever and respiratory distress. This resolved with fluid bolus and broadening antibiotics. After multiple family meetings to discuss Mr. [**Known lastname 67189**] grim prognosis and prolonged hospital course, his family opted to not pursue further interventions which the patient would not have wanted. Thus, tracheostomy, feeding tube placement and hemodialysis were not pursued. On [**2112-3-11**], Mr. [**Known lastname 67176**] was terminally extubated with his family at his side. He expired soon after. An limited autopsy of his lungs was planned upon his death. Medications on Admission: Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Sotalol 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Prednisone 20 mg Tablet Sig: 3 Tablets PO TID (2 times a day). Paroxetine HCl 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF ([**Known lastname 766**]-Wednesday-Friday). Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Alendronate 70 mg Tablet Sig: 0.5 Tablet PO QMON (every [**Known lastname 766**]). Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Insulin Metformin 1000 mg po qam, 500 mg po qpm Rituxan [**1-2**], [**802-1-7**] mg per treatment Nystatin swish and swallow bactroban nasal ointment [**Hospital1 **] Discharge Medications: Patient expired. Discharge Disposition: Expired Discharge Diagnosis: ANCA-negative vasculitis with pulmonary vascular involvement Intra-abdominal abscess, recent h/o diverticulitis managed conservatively with antibiotics Type 2 DM, uncontrolled Anemia Thrombocytopenia Renal failure Discharge Condition: Expired. Discharge Instructions: Expired. Followup Instructions: Expired.

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icd9cm

[ [ [] ] ]

[ "96.71", "57.94", "33.23", "96.04", "97.29", "96.72", "99.71", "33.24", "99.14", "99.15", "38.93", "38.91", "54.91", "57.32", "96.6" ]

icd9pcs

[ [ [] ] ]

15113, 15122

7627, 13743

346, 579

15379, 15389

3940, 7604

15446, 15457

3183, 3236

15072, 15090

15143, 15358

13769, 15049

15413, 15423

3251, 3921

277, 308

607, 2306

2328, 2814

2830, 3167

64,677

176,087

7096

Discharge summary

report

Admission Date: [**2105-7-23**] Discharge Date: [**2105-7-26**] Date of Birth: [**2040-5-10**] Sex: F Service: MEDICINE Allergies: Prednisone Attending:[**Doctor First Name 13737**] Chief Complaint: Hyponatremia Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 65 yo woman with h/o DM2, CHF, chronic renal insufficiency, and HTN, who presented to the ED with Na of 113. She was in her usual state of health until last week, when she developed a UTI and was placed on Cipro 10 days ago. On [**7-17**], she had a basal cell cancer removed from her face. The procedure was performed under general anesthesia, and she tolerated the procedure well. Upon arriving home, she attempted to eat, and became immediatedly nauseated. For the next six day, the patient had persisent nausea, vomiting, and diarrhea. She states that the vomit was predominantly bile, and she had multiple episodes of diarrhea each day. She believes that drank approximately 4 glasses of water and Gatorade each day. She presented to her PCP yesterday afternoon for evaluation of fatigue, dysuria, and diarrhea. She was prescribed Cipro for a UTI, and BMP demonstrated a Na of 117. Of note, the patient's Lasix dose was increased two weeks ago to 80 mg daily. This morning, she was called by her PCP and presented to the ED for further evaluation. . In the ED, the patient's VS were T 97.8, BP 199/72, P 58, R 20, O2 94% on RA. Initial labs demonstrated Na of 113. She recieved 1L of NS, and repeat Na at 6 PM was 113 as well. She was given Metoprolol 25 mg in the ED for SBP of 180s, and she was started on HISS for FSBG of 327. . On the floor, she states that she feels fatigued and endorses dysuria. She denies confusion, seizures, headaches, altered sensorium, chest pain, and shortness of breath. Otherwise, she has no new complaints. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied constipation or abdominal pain. No recent change in bowel or bladder habits. Denied arthralgias or myalgias. Past Medical History: Acute on chronic diastolic CHF (EF 50-55% in [**8-/2104**]) Acute on chronic renal insufficiency, stage IV (baseline 2.9-3.1) Diabetes mellitus Type II Hypertension Hyperlipidemia Chronic anemia Social History: Works as kindergarten teacher in [**University/College **]. Lives with husband in [**Name (NI) 5176**]. Has 2 cats, with immunizations up to date. No other known animal exposures. Has two children, son [**Location (un) **] and daughter ([**Name (NI) 26454**]). Has received both flu vaccine and pneumovax. Non smoker, no EtOH or illicit drug use. Family History: Mother with [**Name (NI) **]+ breast cancer Father with CVA Physical Exam: Admission physical exam: Vitals: T: 97.7, BP: 199/73, P: 68 R: 16 O2: 96% on RA General: Middle aged woman, pleasant, but anxious with depressed affect, in NAD HEENT: PERRL, EOMI, Oropharynx clear and without exudate. Ecchymoses over maxillary sinus on right. Dry mucous membranes Neck: Supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: 3/6 systolic murmur. Regular rate and rhythm, normal S1 + S2. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on admission: CBC: WBC 11.0, Hct 26.9, Plt 238 BMP: Na 113, K 4.7, Cl 80, HCO3 23, BUN 46, Cr 2.9, Glucose 327 Urine: - Cr 22 - Na 22 . Micro on admission: U/A: 100 Protein, 1000 glucose, Trace blood Discharge labs: Sodium on discharge: 127 Urine lytes: [**2105-7-26**] Na-23, URINE Osmolal-304 . EKG: Sinus rhythm. The Q-T interval is prolonged. ST-T wave changes which are most consistent with underlying left ventricular hypertrophy, although ischemia or myocardial infarction cannot be excluded. Compared to the previous tracing the Q-T interval is longer. Rate PR QRS QT/QTc P QRS T 61 164 96 490/491 -9 25 161 Imaging: CXR ([**7-26**]): In comparison with study of [**7-23**], there is further enlargement of the cardiac silhouette with bilateral pleural effusions and increasing pulmonary venous pressure. Findings are consistent with the clinical impression of overhydration. Brief Hospital Course: 65 year-old woman with h/o CHF, chronic renal insufficiency, DM2, who presents with hyponatremia. # Hyponatremia: The patient was admitted to the ICU. She with hyponatremia with a nadir of 113 meq in the setting of nausea, vomiting, diarrhea, and an increase in her lasix dose. Nephrology was consulted and she was started on hypertonic saline, a high protein diet to increase osmoles, and a 1.2L fluid restriction, with improvement in her serum sodium. Hypertonic saline was stopped on [**2105-7-24**]. Her hyponatremia was thought to be a combination of a tea and toast diet, with decreased solute intake; fluid loses from vomiting and diarrhea; and increased lasix dosing. Her sodium climbed to 123 and she was transferred to the general medicine floors where she continued a fluid restriction and a high protein diet. On [**7-25**], she was given 20 cc/hr of hypertonic saline for 10 hr. Her sodium corrected to 127 on discharge. She will have renal followup. . # Hypertension: The patient has a history of HTN, for which she takes Metoprolol, Enalapril, and Furosemide at home. Her BP remained elevated as high as SBP~200. She was started on her home dose of Enalapril and Metoprolol and her blood pressures continued to be high. On discharge, she was given no further BP medications and will have followup with renal and her PCP for BP management. . #UTI: The patient presented with UTI on [**7-16**] and was prescribed 3 days of Cipro. She presented once again with UTI symptoms on [**7-22**] and was put on a 7 day course of Cipro 500, however, it was stopped on [**7-25**] because it has been linked to hyponatremia. On discharge, she had no symptoms of dysuria. . # DM2: The patient was switched from Januvia to a humalog insulin sliding scale. Her glucoses were high ranging from ~170-220. On discharge, she was switched back to her Januvia. #ANEMIA: The patient's crit was 27.6 on admission [**7-22**] and dropped as low as 22.5 [**7-24**] but has generally stayed in the mid to high 20s. She has had chronic low crits for the past year likely due to low EPO levels as a result of her CKD. Her latest iron studies showed normal iron and transferrin levels and an elevated ferritin. . #DIASTOLIC HF: EF 50-55% in 9/[**2103**]. No active symptoms. Medications on Admission: Enalapril 10 mg [**Hospital1 **] Furosemide 80 mg daily Glipizide 10 mg daily Th, Fr, [**Last Name (LF) **], [**First Name3 (LF) **] Metoprolol XR 200 mg daily Pravastatin 80 mg daily Januvia 50 mg daily Triamcinolone 0.1% cream [**Hospital1 **] prn ASA 325 mg daily Colace 100 mg daily Ferrous Sulfate 325 mg daily Cipro 500 mg daily Discharge Medications: 1. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 3. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for itching. 4. Aspirin 325 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. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day. 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 8. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital3 3765**] Homecare Program Discharge Diagnosis: Primary: 1. Hyponatremia 2. Urinary tract infection . Secondary 1. Hypertension 2. Chronic kidney disease 3. chronic diastolic CHF Discharge Condition: Stable. On room air. Patient ambulating. Discharge Instructions: You were found to have a low sodium level and were admitted to the ICU. Hypertonic saline was infused and your sodium levels rose. On the general medicine floors, you were restricted to 1.2L of fluid a day and also given some hypertonic saline. . Your low sodium might have been related to your use of furosemide, lasix. You should stop taking furosemide until you have followup outside of the hospital. You should also restrict your fluid intake to 1.2 liters a day and follow a high protein diet. . While in the hospital you finished your course of Cipro for your UTI. You felt pain on urination on [**7-24**], but a test revealed that you did not have an infection. . You had low oxygen levels with walking, and your chest x-ray showed fluid in your lungs. You should continue to walk short distances at home, refrain from strenuous exercise. You will follow-up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 9533**] a diuretic. . You should come back to the hospital or call your doctor if you have pain on urination, feel lightheaded or dizzy, cannot think clearly, or have any seizure-like activity. Followup Instructions: You should followup with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 26455**], this week, Wednesday. She will repeat blood tests, check your blood pressure, and decide about [**Last Name (STitle) 9533**] Lasix or another diuretic. Please call tomorrow for an appointment. . [**2105-8-3**] 02:30p [**Last Name (LF) **],[**First Name3 (LF) **] (nephrology) [**Hospital6 29**], [**Location (un) **] . [**2105-8-12**] 09:40a [**Last Name (LF) **],[**First Name3 (LF) **] H. [**Hospital6 29**], [**Location (un) **] [**Hospital 191**] MEDICAL UNIT

[ "428.0", "428.32", "250.00", "599.0", "403.90", "272.4", "285.21", "276.1", "585.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7834, 7902

4504, 6767

286, 293

8077, 8120

3587, 3592

9306, 9904

2840, 2901

7152, 7811

7923, 8056

6793, 7129

8144, 9283

3809, 3816

2941, 3568

3830, 4481

234, 248

1903, 2242

321, 1885

3748, 3793

2264, 2460

2476, 2824

31,956

118,021

22913

Discharge summary

report

Admission Date: [**2103-10-22**] Discharge Date: [**2103-11-3**] Date of Birth: [**2047-9-14**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Tetanus / Iodine; Iodine Containing / Peanut Oil / Demerol / Lidocaine Attending:[**First Name3 (LF) 2969**] Chief Complaint: Recurrent desmoid tumor of the left chest wall. Major Surgical or Invasive Procedure: Radical resection of recurrent left desmoid tumor with [**Doctor Last Name 4726**]-Tex chest wall and flank reconstruction with concurrent omental flap and primary closure with the assistance of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of plastic surgery. History of Present Illness: Mr. [**Known lastname 59199**] is a 56-year-old gentleman with a previous enucleated desmoid tumor that was referred to me 2-1/2 years ago at which time I performed a wide excision of this and a [**Doctor Last Name 4726**]-Tex chest wall reconstruction. He has been followed radiographically and was found to have 2 enlarging soft tissue masses, one at the superior aspect of the excision below the latissimus muscle involving the 6th rib and one inferiorly growing lateral to the [**Doctor Last Name 4726**]-Tex patch into the subcutaneous fat and dermis. After preoperative consultation with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], we planned a radical excision of this. Dr. [**First Name (STitle) **] placed tissue expanders up behind the scapula and over the buttock to recruit additional soft tissue for closure as there would be a substantial amount of skin resected. The patient agreed to proceed. Past Medical History: Hypertension, asthma, hypercalcemia, pneumothorax s/p talc pleurodiesis [**2094**] Social History: non-contributory Family History: non- contributory Physical Exam: NAD, alert Neck: soft, supple, no bruits, no cervical lymphadenopathy RRR, no murmurs CTAB, no R/R Abd: soft, NT, ND, +BS Ext: warm, well-perfused Pertinent Results: [**2103-10-25**] 07:25AM BLOOD WBC-12.3* RBC-3.63* Hgb-11.3* Hct-32.6* MCV-90 MCH-31.2 MCHC-34.7 RDW-13.2 Plt Ct-217 [**2103-10-24**] 04:44AM BLOOD PT-15.9* PTT-35.4* INR(PT)-1.4* [**2103-10-25**] 07:25AM BLOOD Glucose-124* UreaN-25* Creat-1.2 Na-136 K-5.1 Cl-100 HCO3-28 AnGap-13 [**2103-10-25**] 07:25AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.4 Brief Hospital Course: Pt was admitted on [**2103-10-22**]. Post-operatively, the pt had an intrathoracic chest tube and [**Doctor Last Name 406**] drain on the left side, as well as three [**Doctor Last Name 406**] drains placed by plastic surgery. The pt had an uncomplicated hospital course as was discharged home with VNA services on POD#7. The pt was extubated overnight in the SICU on the evening of POD#0. Pain was well controlled with an epidural catheter. On POD#2 the pt was transferred out of the SICU to a regular floor bed on [**Hospital Ward Name 121**] 2. The chest tube was removed on POD#2 and the intrathoracic [**Doctor Last Name 406**] was left to bulb suction. [**Last Name (un) 1372**]-gastric tube was removed on POD#3. On POD#4 Epidural and Foley catheter were removed and diet was advanced as tolerated to a regular diet and antibiotics were switched from Kefzol IV to Keflex PO for prophylaxis while drains remain in place. On POD#5 the chest [**Doctor Last Name 406**] was removed, the three JP drains placed by plastics remained to bulb suction. On POD#6 pt was ambulating, tolerating a regular diet, and pain was well controlled with oral pain medication. There was still a significant amount of drainage from the wound site and over the remainder of the hospital course the patient was closely monitored for signs of wound dehiscence, infection and breakdown. One of the 3 JP drains was removed on POD#12. The pt was discharged home on POD#12 with 2 JP drains to bulb suction with VNA services to empty drains and check wounds daily. Upon discharge the wound was clean, dry and intact with no signs of infection. Pt will follow-up with Plastic Surgery in one week and with Thoracic Surgery in one week as well. Medications on Admission: accolate, albuterol, lipitor, norvasc Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): this medication will be tapered by Dr. [**Last Name (STitle) **]. Do not take your norvasc while taking this medication. Disp:*60 Tablet(s)* Refills:*2* 4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*75 Tablet(s)* Refills:*0* 5. Zafirlukast 20 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-12**] Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 mdi* Refills:*1* 8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. Disp:*28 Capsule(s)* Refills:*1* Discharge Disposition: Home With Service Facility: TBA Discharge Diagnosis: re-excision of left chest wall Desmoid tumor with en bloc portions of left ribs [**4-21**] and placement of gortex graft to reconstruct left chest wall. s/p resection L chest wall desmoid tumor [**2-15**], HTN, asthma, hypercalcemia, ptx s/p talc pleurodiesis 6 years ago Discharge Condition: good Discharge Instructions: call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you develop chest pain, shortness of breath, fever, chills, redness or drainage from your incision site. You cannot shower until you have had your Plastic Surgery follow up appointment. keep your drain sites clean and dry. Empty the drains daily and keep a log of the output- bring this log to your follow up appointment. Keep a clean tegaderm dressing daily on your incision site. Followup Instructions: You have a follow up appointment with Dr. [**Last Name (STitle) **] on [**11-8**] in the [**Hospital **] Medical office building [**Hospital Unit Name **] [**Doctor First Name **] [**Telephone/Fax (1) 170**]. Please arrive 30 minutes prior to your appointment for a CXR on the [**Hospital Ward Name **] [**Location (un) 470**] radiology. and a follow up appointment with Dr. [**First Name (STitle) **] on [**11-8**] at [**Street Address(2) **], [**Apartment Address(1) **], [**Location (un) **]- [**Telephone/Fax (1) 59200**] Please call the clinic on Monday to schedule a time for these appointments.

[ "560.1", "493.90", "238.1", "238.0", "338.18", "401.9" ]

icd9cm

[ [ [] ] ]

[ "34.79", "34.4", "83.39", "86.74", "03.90" ]

icd9pcs

[ [ [] ] ]

5121, 5155

2375, 4094

401, 687

5472, 5479

2010, 2352

5983, 6590

1808, 1827

4182, 5098

5176, 5451

4120, 4159

5503, 5960

1842, 1991

313, 363

715, 1652

1674, 1758

1774, 1792

77,484

125,750

717

Discharge summary

report

Admission Date: [**2163-10-6**] Discharge Date: [**2163-10-13**] Date of Birth: [**2086-4-12**] Sex: F Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 64**] Chief Complaint: left hip pain [**2-14**] protusion, failed left THR Major Surgical or Invasive Procedure: left revision THR History of Present Illness: Patient is a 77F who had a primary left total hip replacement in [**2152**] by another surgeon that sustained progressive protrusio early, ultimately failing with loss of fixation of the acetabulum. I brought [**Known firstname 5321**] to surgery a little over a year ago at which time we felt that her best treatment option intraoperatively would be allograft packing of the acetabulum defect and a hemiarthroplasty head. Also considered at the time was a Restoration GAP prosthesis. She did well for probably 10 or 12 months and then started developing pain and x-rays demonstrated progressive protrusio with the femoral head at risk for pushing through the remnant of the acetabulum. We have also seen insufficiency fractures developing on the pubic ramus and in the posterior wall of the acetabulum. The patient is developing progressive pain, unrelenting, and sciatic symptoms. She has been made nonweightbearing a couple months ago in preparation for the surgery. She understands this is very much a salvage operation. She is developing progressive fracturing from osteoporosis and there is very little bone stock remaining. She is really not a candidate for major allograft pelvic reconstruction as fixation would be limited. Best treatment course, cemented GAP cage and avoidance of further allograft. Past Medical History: history lymphoma in [**2160**], history of ovarian cancer, splenectomy [**2160**] for lymphoma; L THA [**2152**], hysterctomy, THRs per above Social History: born in [**Country 2559**]; denies ETOH use, does not smoke Family History: non-contributory Physical Exam: At the time of discharge: AVSS NAD wound c/d/i without erythema [**Last Name (un) 938**]/FHL/TA/GS intact SILT distally Pertinent Results: Labs on admission: [**2163-10-6**] 01:12PM BLOOD WBC-15.4*# RBC-2.86*# Hgb-8.6*# Hct-25.1*# MCV-88 MCH-30.0 MCHC-34.2 RDW-13.8 Plt Ct-198# [**2163-10-6**] 01:12PM BLOOD Glucose-140* UreaN-19 Creat-0.6 Na-143 K-3.9 Cl-115* HCO3-21* AnGap-11 [**2163-10-6**] 01:12PM BLOOD Mg-1.5* labs prior to discharge: [**2163-10-13**] 09:40AM BLOOD WBC-14.3* RBC-3.17* Hgb-9.2* Hct-27.4* MCV-86 MCH-28.9 MCHC-33.4 RDW-14.8 Plt Ct-411 [**2163-10-12**] 06:45AM BLOOD WBC-9.7 RBC-3.16* Hgb-8.8* Hct-27.7* MCV-88 MCH-27.9 MCHC-31.8 RDW-14.9 Plt Ct-357 [**2163-10-12**] 06:45AM BLOOD Glucose-98 UreaN-16 Creat-0.5 Na-136 K-4.1 Brief Hospital Course: The patient was admitted on [**2163-10-6**] and, later that day, was taken to the operating room by Dr. [**Last Name (STitle) **] for revision left THR without complication. Please see operative report for details. Postoperatively the patient did well. She received 2upRBCs in OR and then 2upRBCs in PACU. The patient was initially treated with a PCA followed by PO pain medications on POD#1. The patient received IV antibiotics for 24 hours postoperatively, as well as lovenox for DVT prophylaxis starting on the morning of POD#1. The drain was removed without incident on POD#1. The Foley catheter was removed without incident. The surgical dressing was removed on POD#2 and the surgical incision was found to be clean, dry, and intact without erythema or purulent drainage. On POD3 patient developed nausea and vomiting with a WBC of 25. Urine and blood cultures were negative. CXR showed no evidence of PNA. An NGT was placed for peristent N/V and a distended abdomen. She was made NPO with maintenance IVFs. Her electrolytes were repleted. Her urine output was closely monitored. A general surgery consult was placed for ?high grade SBO (h/o splenectomy). Patient was transferred to the SICU and later received an abdominal CT which showed dilated loops with a ?transition point at the distal ileum c/w with an early low grade SBO. No evidence of perforation or diverticulitis. Bilateral LENIs were negative for a DVT. On POD4 her NGT output decreased and she had a bowel movement. Her neasea and abominal pain resolved. Bowel sounds returned. She passed a clamping trial and NGT was pulled on POD5, and later was transferred to the floor. On POD7 she was noted to have 1+ pitting edema in BLE. She was given 20mg PO lasix for likely mild vol overload. While in the hospital, the patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was stable, and the patient's pain was adequately controlled on a PO regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient was discharged to home with services or rehabilitation in a stable condition. The patient's weight-bearing status was touch down weight bearing of the LLE with post hip precautions. Medications on Admission: atenolol Discharge Medications: 1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) daily Subcutaneous DAILY (Daily) for 3 weeks. daily 2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-14**] Drops Ophthalmic PRN (as needed) as needed for itchy eyes. 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: left hip OA/protusio from failed THR Discharge Condition: good Discharge Instructions: experience severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your PCP 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 operate heavy machinery or drink alcohol when taking these medications. As your pain improves, please decrease the amount of pain medication. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (e.g., colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may get the wound wet or take a shower starting 5 days after surgery, but no baths or swimming for at least 4 weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by a visiting nurse at 2 weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment at 4 weeks. 8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen, advil, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg twice daily for an additional three weeks. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower after POD#5 but do not take a tub-bath or submerge your incision until 4 weeks after surgery. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by VNA in 2 weeks. The rehab facility can remove the staples at 2 weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at 2 weeks after surgery. 12. ACTIVITY: Touch down weight bearing on the operative leg with posterior hip precautions. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: Touch down weight bearing of LLE. Post hip precautions. Treatments Frequency: wound checks, lovenox. Staples out by VNA 2 weeks from surgery. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2163-11-4**] 12:40 Completed by:[**2163-10-13**]

[ "560.1", "727.09", "V10.43", "997.4", "733.19", "733.00", "996.43", "696.1", "V10.79", "276.6", "401.9", "285.9", "338.28", "788.5", "718.65" ]

icd9cm

[ [ [] ] ]

[ "78.65", "00.71" ]

icd9pcs

[ [ [] ] ]

6161, 6231

2793, 5231

370, 390

6312, 6319

2162, 2167

8880, 9113

1989, 2007

5290, 6138

6252, 6291

5257, 5267

6343, 7942

2022, 2143

8712, 8769

8791, 8857

279, 332

7954, 8694

418, 1730

2181, 2770

1752, 1895

1911, 1973

4,328

188,261

2515+2535

Discharge summary

report+report

Admission Date: [**2138-4-30**] Discharge Date: [**2138-5-13**] Date of Birth: [**2078-7-3**] Sex: F Service: NEUROMEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old woman with a history of hypertension, diabetes, hypercholesterolemia, and obesity, who presented with the sudden onset of difficulty speaking. She had been known to be speaking normally at approximately 6:05 p.m. on the day of admission. At 6:30 p.m., she was seen by her family and was noted to have difficulty speaking. The sounds that were coming out did not sound like actual words. It was unclear if she understood what was being said to her. There may have been some right-sided facial weakness. She was brought to the [**Hospital6 256**] Emergency Department. In the Emergency Department, she was noted by the Neurology resident and Stroke fellow to have Wernicke's type aphasia. Head CT was negative for bleed. Blood sugar on arrival was 468, and this improved to 288 after Insulin. Blood pressure was as high as the 200s, and this improved with Labetalol. Given the fact that she had multiple vascular risk factors and presented within the thrombolytic window, she was given intravenous TPA. She was then admitted to the Intensive Care Unit for monitoring, status post TPA. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes. 3. Obesity. 4. Asthma. 5. Hidradenitis suppurativa. 6. Osteoarthritis. MEDICATIONS ON ADMISSION: According to CCC, the family was not aware of her medications: Albuterol q.i.d., Combivent 2 puffs q.i.d., Diovan 320 mg q.d., Doxycycline 100 mg b.i.d., Duricef 500 mg b.i.d., Flovent 110 mcg 2 puffs b.i.d., Glyburide 10 mg q.a.m., 5 mg q.p.m., Lipitor 10 mg q.d., Metformin 850 mg q.a.m., 1700 mg q.p.m., Zantac 150 mg b.i.d., Rhinocort nasal spray, Aspirin 325 q.d., Naproxen 500 mg b.i.d. p.r.n. pain. ALLERGIES: AVANDIA CAUSES SHORTNESS OF BREATH, ACE INHIBITOR UNKNOWN REACTION. SOCIAL HISTORY: The patient is divorced. She has three children. She is a retired librarian. She has a 15 pack-year history; she quit ten years ago. She rarely drinks alcohol. There is no other drug use. PHYSICAL EXAMINATION: Vital signs: On admission temperature was 97.8??????, blood pressure 165/66, pulse 88, respirations 18, oxygen saturation 99%. General: This was an obese African-American woman in no acute distress. Neck: Supple. No carotid bruits. Lungs: Normal. Cardiovascular: Normal. Abdomen: Normal. There was a superficial nodule in the right groin area oozing some pus and blood. MENTAL STATUS EXAM: Exam showed her to be awake and alert. She was oriented to person but not to place or date. She attended to the examiner but was difficult to formally assess attention due to her language deficit. She was intermittently fluent with her best phrase length greater than five words, but she spoke in [**1-24**] word phrases. She was unable to repeat. She was able open and close her eyes, but no other commands. On cranial nerve testing, she had decreased blink to threat on the right. Her pupils were equal, round and reactive to light. Her extraocular movements were intact. Her face was symmetric. Her tongue was midline. On motor testing, there was at least 4+ strength throughout. Sensation was intact to pain in all four extremities. Reflexes were symmetric. Toes were downgoing. LABORATORY DATA: On admission white blood cell count was 11.6, hospital course 39.1, platelet count 197; sodium 134, potassium 4.1, chloride 96, bicarb 28, BUN 19, creatinine 1, glucose 425; calcium 9.2, magnesium 1.4, phosphorus 4.2; PT 13.2, PTT 21.7; urinalysis showed [**12-13**] white blood cells. Head CT was negative. Electrocardiogram showed normal sinus rhythm. In summary this was a 59-year-old woman with multiple vascular risk factors who presented with a Wernicke type aphasia. Although the differential diagnosis included stroke versus seizure versus metabolic derangement, given her vascular risk factors, stroke was felt to be most likely. She was therefore given intravenous TPA. HOSPITAL COURSE: The patient was monitored in the Neurology Intensive Care Unit with close neurologic checks. She was unable to go to MRI due to her size. Repeat head CT showed no signs of stroke. CTA showed an area of stenosis at the origin of the superior division of the left middle cerebral artery. Carotid ultrasound showed no evidence of carotid stenosis bilaterally. A transthoracic echocardiogram was suboptimal due to poor echo windows. She therefore went for transesophageal echocardiogram which showed a patent foramen ovale with an interatrial septum which was aneurysmal. There was a bidirectional shunt across the interatrial septum at rest. There was mild symmetric left ventricular hypertrophy. Left ventricular ejection fraction was greater than 55%. There was mild tricuspid regurgitation and mild mitral regurgitation. Electroencephalogram was normal. Given this data, it was felt that the most likely diagnosis was still transient ischemic attack or stroke possibly due to her paradoxical embolism across the PFO. She was therefore started on Heparin with a goal PTT between 45 and 65. She was very refractory to Heparin and required very large doses in order to maintain this goal. She was transitioned to Coumadin, and again was very refractory, requiring doses as high as 15 mg. Her goal INR is between 2 and 3. INR at the time of this dictation is 1.7. Prior to starting Coumadin, a full hypercoagulation panel was sent. This was notable for an elevated factor 8 level of 342. Lupus anticoagulant was negative. Antithrombin III was normal. Protein C was normal. Homocystine was normal. Prothrombin gene mutation is pending. Factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12843**] is pending. Protein S was normal. Anticardiolipin antibodies were negative. Hemoglobin A1C was elevated at 10.6. Over the course of the first several days, the patient showed significant improvement. She essentially regained small speech and language function and had a normal exam at the time of this dictation. Cardiovascular: Echocardiogram revealed a PFO with an interatrial septal aneurysm as above. Fluids, electrolytes, and nutrition: The patient's sugars were followed closely. The [**Last Name (un) **] Service assisted with the management. Sugars came under much better control using a single daily dose of Glargine, as well as oral agents. Heme: As above in infectious disease, the patient had a urinary tract infection on admission with Klebsiella pneumonia which was treated with Levofloxacin. She had one blood culture positive for coagulase-negative staph, which was likely contaminant. She grew yeast from urine culture, but this cleared after removal of the Foley. In summary, the patient is a 59-year-old woman with hypertension, hypercholesterolemia, and diabetes, who presented with the sudden onset of language disturbance thought most likely to be a transient ischemic attack. She has improved significantly. She has been found to have a PFO and will have anticoagulation. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Home. DISCHARGE DIAGNOSIS: 1. Left MCA territory transient ischemic attack status post intravenous TPA. 2. Hypertension. 3. Hypercholesterolemia. 4. Diabetes mellitus. DISCHARGE MEDICATIONS: Coumadin dose to be determined, Glargine 20 U q.h.s., Glyburide 10 mg p.o. q.a.m., 5 mg p.o. q.p.m., Metformin 500 mg p.o. b.i.d., Pantoprazole 40 mg p.o. q.d., Albuterol 1 nebulizer q.6 hours p.r.n. wheezing, Atorvastatin 10 mg p.o. q.d., Colace 100 mg p.o. b.i.d. [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6125**] Dictated By:[**Name8 (MD) 12844**] MEDQUIST36 D: [**2138-5-13**] 03:04 T: [**2138-5-13**] 09:56 JOB#: [**Job Number 12845**] Admission Date: [**2138-4-30**] Discharge Date: [**2138-5-13**] Date of Birth: [**2078-7-3**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old woman with a history of hypertension, diabetes, hypercholesterolemia, and obesity, who presented with the sudden onset of difficulty speaking. The patient had been speaking normally at approximately 6:05 p.m. At 6:30 p.m., she was seen by her family and had slurred speech, and the words that were coming out did not sound like actual words. It was unclear is she understood what was being said to her. There may have been some right-sided facial weakness. Her family brought her to the [**Hospital1 **] Emergency Department. Her initial evaluation by the Neurology Team in the Emergency Department and Stroke fellow found her to have aphasia, more consistent with a Wernicke's. Head CT was negative. [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) **], M.D. Dictated By:[**Name8 (MD) 12893**] MEDQUIST36 D: [**2138-5-13**] 02:42 T: [**2138-5-13**] 09:52 JOB#: [**Job Number 12894**]

[ "745.5", "401.9", "286.0", "435.8", "729.89", "680.2", "599.0", "784.3", "414.10" ]

icd9cm

[ [ [] ] ]

[ "88.72", "38.93", "99.10" ]

icd9pcs

[ [ [] ] ]

7394, 8057

7224, 7370

1456, 1945

4100, 7143

2179, 4082

8086, 9063

1319, 1429

1962, 2156

7168, 7203

10,950

161,915

20991+20992+57212

Discharge summary

report+report+addendum

Admission Date: [**2159-2-27**] Discharge Date: [**2159-3-5**] Date of Birth: [**2105-8-8**] Sex: M Service: OTOLARYNGOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8480**] Chief Complaint: Left Vocal Cord SCCA now w increased dyspnea Major Surgical or Invasive Procedure: Tracheotomy Esophagoscopy Laryngoscopy and Bx History of Present Illness: Pt is a 53 yM w Left vocal cords SCCA (T2N0M0) extending into the subglottic area, s/p radiotherapy ending [**11-13**], who presented with increased dyspnea and upper airway obstruction. The CT scan of the neck did not show any obvious recurrences. Pt underwent a tracheotomy, direct laryngoscopy with biopsy of left subglottis and true vocal cord and right superior surface of true vocal cord, rigid cervical esophagoscopy as well as a flexible bronchoscopy. The case was switched from IVCS to General ET anesthesiae. Past Medical History: As above, type 1 diabetes for 19 years, hypertension, history of positive PPD, and recent diagnosis of chest nodules likely stated to be granulations. Social History: The patient is married, with two children. Currently, he lives with his wife. His son is 31 years old and daughter is 22 years old. Alcohol History: The patient used to drink one pint of hard liquid a day, quit seven months ago. The patient also has a remote history of drug abuse. Smoking: He smoked about two packs per day for greater than 40 years. He quit about one-and-a-half month ago. The patient denies any history of being abused. Family History: Father deceased at age 56 with stomach cancer. Mother deceased at 60 with lung cancer. Physical Exam: NAD RRR CTA B; no wheezing or crackles + BS/S/NT/ND Neck exam: Trach in place with minimal oozing around it; cuff is down; No stridor. Neuro: CNI, MP [**6-14**], SILT, No Babinski or Pronator Drift Pertinent Results: [**2159-2-27**] 05:47PM PT-12.6 PTT-34.3 INR(PT)-1.0 [**2159-2-27**] 05:47PM PLT COUNT-108* [**2159-2-27**] 05:47PM WBC-3.5*# RBC-4.38* HGB-12.4*# HCT-36.7* MCV-84 MCH-28.4 MCHC-33.9 RDW-14.2 [**2159-2-27**] 05:47PM CALCIUM-8.6 MAGNESIUM-1.5* [**2159-2-27**] 05:47PM GLUCOSE-182* UREA N-16 CREAT-0.9 SODIUM-139 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-32* ANION GAP-8 Brief Hospital Course: Patient did well postoperatively with no complications. He was weaned to tracheal collar oxygen on the same operation day and tolerated it well. The tracheotomy cuff was down on POD1. Routine trach care was provided with deep suctioning q3h+PRN, humidified air and trach care teaching. Pt had a strong cough and was able to expel secretions on his own as well. His pain was well controlled on a combination of percocet and oxycontin. He was ambulating, tolerating PO and breathing comfortably before discharge. Tracheotomy was changed on POD 5. Medications on Admission: PO oxycontin 20 mg [**Hospital1 **] SC insulin 75/25 60 units in am, 40 units in pm PO norvasc 5 mg [**Hospital1 **] PO omeprazole 20 mg qd Discharge Medications: PO Protonix 40 mg qd PO Norvasc 5 mg qd PO Keflex 500 mg PO x7 days PO Colace 100 mg [**Hospital1 **] SC Insulin 75/25 60 units in am, 40 units in pm PO Oxycodone 5-10 mg q4h PRN pain PO Tylenol 650 mg q6h PRN pain Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: Laryngeal Squamous cell Carcinoma, upper airway obstruction status post tracheotomy Discharge Condition: Stable Discharge Instructions: 1- Please inform physician if fever>101, wound redness or discharge are noted. 2- Please inform physician if shortness of breath, significantly increased tracheotomy secretions or abnormal breathing sounds are noted. 3- Do not drive while taking oxycodone or percocet. 4- Routine trach care as per the trach teaching during hospital stay. Followup Instructions: 1- Follow up with Dr. [**First Name (STitle) **] within 1-2 weeks; call [**Telephone/Fax (1) 41**] for appointment 2- Follow up with primary care physician with regard to Diabetes and hypertension management Completed by:[**2159-3-2**] Admission Date: [**2159-2-27**] Discharge Date: [**2159-3-5**] Date of Birth: [**2105-8-8**] Sex: M Service: ENT CHIEF COMPLAINT: Left vocal cord squamous cell carcinoma now with increased dyspnea. Major surgical invasive procedures. The patient is status post tracheostomy, esophagoscopy, laryngoscopy and biopsies. HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old male with left vocal cords squamous cell carcinoma T2-N0-M0 extending in the subglottic area, status post radial therapy ending [**11/2158**] who had presented with increased dyspnea and upper airway obstruction. CAT scan of the neck did not show any obvious recurrence. The patient underwent a tracheostomy, direct laryngoscopy with biopsy of the left subglottis and true vocal cords and right superior surface of the true vocal cord, rigid cervical esophagoscopy as well as flexible bronchoscopy. The case was switched to IVCS to general endotracheal anesthesia. ALLERGIES: The patient has no known drug allergies. PAST MEDICAL HISTORY: 1. As above as well as type 1 diabetes for 19 years. 2. Hypertension. 3. History of ______ PPD. 4. Recent diagnosis of chest nodules slightly stated to be granulomas. SOCIAL HISTORY: The patient is married with two children. He lives with his wife. [**Name (NI) **] used to drink a pint of hard liquor a day, but quit seven months ago. The patient also has a remote history of drug abuse. He smoked two packs a day for greater than 40 years. He quit about one and a half months ago. FAMILY HISTORY: Father deceased at 56 with stomach cancer. Mother deceased at 60 with lung cancer. PHYSICAL EXAMINATION: No acute distress. Regular rate and rhythm. Lungs are clear bilaterally. Abdomen is benign. Neck examination trachea in place with minimal oozing around it, cuffed down, no stridor. Neuro examination is unremarkable. LABORATORY DATA: Pertinent laboratory results on admission [**2159-2-27**]: Coags are 12.6, 34.1 and 1.0. Complete blood count is 3.5, 36.7 and 108. Chem-7 is 139, 4.1, 103, 32, 16 and 0.9. Other pertinent laboratory results on [**2159-3-4**]: Complete blood count, white blood cell count is 5.0. BRIEF HOSPITAL COURSE: The patient did well postoperatively with no complications. He was weaned to trach collar oxygen on the same operative day and tolerated it well. The tracheostomy path was taken down on postoperative day one without complication. Routine trach care was provided with deep suctioning every three hours p.r.n. humidified air and trach teaching. The patient had a strong cough and was able to expel secretions on his own and was able to begin to phonate. His pain was well controlled on a combination of Percocet and OxyContin. Of note, the patient did spike a fever on postoperative day [**4-13**] of 102. A full workup for this was negative including a negative urinalysis, negative chest x-ray for any consolidations or pneumonia and white blood cell count of 5.0. By postoperative day six, the patient was felt ready to be discharged home with services. He is ambulating and tolerating a diabetic diet as well as breathing comfortably before discharge. His trach was changed on postoperative day six to a 7 Portex. He was given strict instructions to follow up with Dr. [**First Name (STitle) **] within one week. MEDICATIONS ON ADMISSION: 1. OxyContin 20 mg p.o. b.i.d. 2. Humalog subcutaneous insulin 75/25 16 units in the morning and 40 units in the evening. 3. Norvasc 5 mg p.o. b.i.d. 4. Omeprazole 20 mg p.o. once daily. DISCHARGE MEDICATIONS: 1. Norvasc 5 mg p.o. once daily. 2. Omeprazole 20 mg p.o. once daily. 3. Insulin 75/25 16 units in the morning and 40 units in the evening. 4. OxyContin 20 mg b.i.d. 5. Levaquin 500 mg once daily. The patient is to continue to take this for 10 days. 6. Oxycodone 5-10 mg p.o. every 4-6 hours p.r.n. pain. He is discharged home with services for routine trach care management. DISCHARGE DIAGNOSES: 1. Laryngeal squamous cell carcinoma. 2. Upper airway obstruction status post tracheotomy. DISCHARGE CONDITION: Stable. DISCHARGE INSTRUCTIONS: Informing physician of fevers, wound erythema or discharge, shortness of breath or abnormal breathing as well as counseling regarding routine trach care as well as proper pain medication use. He is to followup with Dr. [**First Name (STitle) **] in one week, calling the number [**Telephone/Fax (1) 41**] for an appointment. He is also to followup with his primary care physician regarding his diabetes and hypertension management. [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 46108**] Dictated By:[**Last Name (NamePattern1) 55770**] MEDQUIST36 D: [**2159-3-5**] 10:20:55 T: [**2159-3-5**] 10:54:18 Job#: [**Job Number 55771**] Name: [**Known lastname 10456**],[**Known firstname **] Unit No: [**Numeric Identifier 10457**] Admission Date: [**2159-2-27**] Discharge Date: [**2159-3-5**] Date of Birth: [**2105-8-8**] Sex: M Service: OTOLARYNGOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 10032**] Addendum: Of note, on POD4-5 pt. did spike a fever of 102 which was worked up as negetive; WBC was 5, UA negetive and CXR did not reveal a PNA. Pt. defervesced and was afebrile for the rest of his hospital course. Major Surgical or Invasive Procedure: Tracheotomy esophagoscopy, laryngoscopy + Biopsy Past Medical History: As above, type 1 diabetes for 19 years, hypertension, history of positive PPD, and recent diagnosis of chest nodules likely stated to be granulations. Social History: The patient is married, with two children. Currently, he lives with his wife. His son is 31 years old and daughter is 22 years old.Alcohol History: The patient used to drink one pint of hard liquid a day, quit seven months ago. The patient also has a remote history of drug abuse. Smoking: He smoked about two packs per day for greater than 40 years. He quit about one-and-a-half month ago. The patient denies any history of being abused. Family History: Father deceased at age 56 with stomach cancer. Mother deceased at 60 with lung cancer. Father deceased at age 56 with stomach cancer. Mother deceased at 60 with lung cancer. Brief Hospital Course: Addendum: Pt's trach was changed to 7 Portex on POD6, the day of his discharge. Uncomplicated. Pt. was dc'd home with services for routine trach care management that day, afebrile, HD stable, tolerating diabetic diet and ambulating. Given strict instructions to f/u with Dr. [**First Name (STitle) **] in 1 week. Discharge Medications: 1. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*2* 3. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: One (1) 60U q AM, 40U q PM Subcutaneous once a day. Disp:*20 1000* Refills:*2* 4. Norvasc 5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 5. Omeprazole 20 mg Packet Sig: One (1) tablet PO once a day. Disp:*60 * Refills:*2* 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital6 313**], [**Location (un) 42**] Discharge Diagnosis: s/p tracheotomy Discharge Condition: Stable Discharge Instructions: 1- Please inform physician if fever>101, wound redness or discharge are noted. 2- Please inform physician if shortness of breath, significantly increased tracheotomy secretions or abnormal breathing sounds are noted. 3- Do not drive while taking oxycodone or percocet. 4- Routine trach care as per the trach teaching during hospital stay. Followup Instructions: Follow up with Dr. [**First Name (STitle) **] within 1 weeks; call [**Telephone/Fax (1) 1848**] for appointment [**Name6 (MD) 3228**] [**Last Name (NamePattern4) 4849**] MD [**MD Number(1) 4850**] Completed by:[**2159-3-5**]

[ "161.8", "519.8", "V58.67", "780.6", "250.00", "401.9", "998.89" ]

icd9cm

[ [ [] ] ]

[ "31.43", "42.23", "31.1", "33.23" ]

icd9pcs

[ [ [] ] ]

11571, 11645

10489, 10803

9591, 9642

11705, 11713

1930, 2305

12102, 12358

10291, 10466

8123, 8216

10826, 11548

11666, 11684

7502, 7694

11737, 12079

1712, 1911

5801, 6326

4291, 4480

4509, 5161

9664, 9817

9833, 10275

42,028

153,004

55075

Discharge summary

report

Admission Date: [**2129-6-28**] Discharge Date: [**2129-7-1**] Date of Birth: [**2085-2-13**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4327**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: CARDIAC CATHETERIZATION: Selective coronary angiography of this left-dominant system demonstrated significant single-vessel coronary artery disease. The LMCA had no angiographically-apparent flow-limiting stenoses. The LAD had a 100% mid-vessel occlusion, with diffuse disease throughout and a 50-60% stenosis in the distal segment. The large LCx had luminal irregularities up to 30%; there was a large first OMB with a superior and inferior branch, a large first and second posterolateral branch, and a large dominant PDA. These vessels were free of angiographically-apparent disease. The non-dominant RCA was small and diffusely diseased. 1. Anterior STEMI. 2. Single vessel coronary artery disease with LAD occlusion. 3. Successful drug-eluting stents to the mid-LAD. History of Present Illness: 44 yo M with history of HTN and HL (untreated), obesity, former tobacco abuse had acute onset [**9-7**] CP after eating dinner. He reports that the pain was sudden onset, substernal, radiation to the arms, he was diaphoretic and vomited x2. He reports that he had never had any chest pain before. He initially presented to OSH got ASA, plavix, NTG (which dropped his pressure), morphine. He was then transfered to [**Hospital1 18**]. His EKG had ST elevations in V2-5. He was evaluated in the ED and a STEMI was called amd he was taken urgently to the Cardiac Cath Lab. Found to have complete occulsion of LAD. Reopened and 3 DES were placed with good result. Transfered to the CCU in stable condition. On arrival to the floor, patient was stable with a TR band in place on right wrist. Denies chest pain or SOB. Past Medical History: Dyslipidemia, Hypertension Social History: Married, lives with his wife and baby son. [**Name2 (NI) 1403**] as a recruiter. Does not exercise. -Tobacco history: Former smoker. Quit 1.5 years ago. -ETOH: 1-2 beers/day -Illicit drugs: denies Family History: Father had MI in late 50's and died in late 60's of cardiac complications. Physical Exam: VS: T=97.5 BP=163/57 HR=64 RR=17 O2 sat= 95% RA GENERAL: Young male lying in bed in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 7 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. TR band on right wrist with no oozing SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [**2129-6-27**] Chest X-Ray: The mediastinal silhouette and hilar contours are normal. No large pleural effusion or pneumothorax is present. Mild pulmonary vascular congestion. [**2129-6-27**] Cardiac Cath: Selective coronary angiography of this left-dominant system demonstrated significant single-vessel coronary artery disease. The LMCA had no angiographically-apparent flow-limiting stenoses. The LAD had a 100% mid-vessel occlusion, with diffuse disease throughout and a 50-60% stenosis in the distal segment. The large LCx had luminal irregularities up to 30%; there was a large first OMB with a superior and inferior branch, a large first and second posterolateral branch, and a large dominant PDA. These vessels were free of angiographically-apparent disease. The non-dominant RCA was small and diffusely diseased. 1. Anterior STEMI. 2. Single vessel coronary artery disease with LAD occlusion. 3. Successful drug-eluting stents to the mid-LAD. [**2129-6-29**] Cardiac Echo: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with akinesis of the mid and apical anteroseptal wall, and dyskinesis of the apex. Overall left ventricular systolic function is moderately depressed (EF is 30-35% %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is no pericardial effusion. IMPRESSION: Severe regional wall motion abnormalities consistent with infarct in the mid-LAD territory. Borderline pulmonary hypertension. [**2129-6-27**] 10:52PM BLOOD WBC-8.8 RBC-4.50* Hgb-13.4* Hct-37.4* MCV-83 MCH-29.8 MCHC-35.8* RDW-12.8 Plt Ct-219 [**2129-6-28**] 05:49AM BLOOD Glucose-144* UreaN-11 Creat-0.9 Na-132* K-4.1 Cl-98 HCO3-23 AnGap-15 [**2129-6-28**] 05:49AM BLOOD CK(CPK)-4219* [**2129-6-28**] 05:49AM BLOOD CK-MB-245* MB Indx-5.8 cTropnT-10.92* [**2129-6-28**] 05:50AM BLOOD CK-MB-159* [**2129-6-28**] 05:49AM BLOOD Triglyc-171* HDL-36 CHOL/HD-4.7 LDLcalc-99 [**2129-6-28**] 05:49AM BLOOD %HbA1c-5.4 eAG-108 Brief Hospital Course: 44 year old male with Hx HTN and HLD presented with chest pain and was found to have a large STEMI. #STEMI: Patiently initially presented to OSH with complaints of chest pain and then transferred to [**Hospital1 18**]. His EKG was notable for 2-3mm ST elevations in the anterio-septal leads. He was loaded with ASA, plavix, placed on heparin ggt and he was taken urgently to the cardiac cath lab where he was found to have 100% occlusion of the mid LAD. The LAD was opened and DES x3 were placed. We was placed on Integrillin following the cath and he was loaded with Prasugrel. His CK peaked at 4219, MB: 5.8 troponin I 10.58. An echo on HD2 showed an EF of 30-35%, severe regional wall motion abnormalities consistent with infarct in the mid-LAD territory, and borderline pulmonary hypertension. He was placed on coumadin given the decreased EF and apical akinesis. Given the increased bleeding risk of prasugrel and coumadin the prasugrel was discontinued and he was loaded with plavix. He was maintained on ASA, plavix, coumadin, metoprolol, and lisinopril while in the hospital without bleeding and with his blood pressure well controlled in the 110s. He was discharged with cardiology follow-up. A repeat echo should be obtained in several weeks to evaulate if there is any return on LV function and if continued coumadin is required. . #Hypertension: Per report he has a history of HTN that was being treated with lifestyle modification. On arrival to the hospital his SBP was in the 130's. Following the cardiac cath he was started on metoporol and captopril and his SBP was in the 110's. He was transitioned to metoprolol XL and lisinopril. He tolerated this regimen with blood pressures at goal SBP<130 prior to discharge. . #HLD: Per report he has a history of HLD that was being treated with lifestyle modification. He was placed on atorvastatin 80mg for post MI treatment. This should be reevaluated as an outpatient with a target LDL <70. . Transitions of Care: - Patient being discahrged on coumadin, He will follow-up in [**Hospital 197**] clinic for monitoring of INR. - Patient will likely need a repeat TTE in 6 weeks to assess for akinesis, dyskinesis of ventricle and to decide on further need for anticoagulation. Medications on Admission: None Discharge Medications: 1. Aspirin EC 325 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 3. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 4. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 5. Warfarin 5 mg PO DAILY16 RX *Coumadin 2 mg 2.5 tablet(s) by mouth daily Disp #*90 Tablet Refills:*2 6. Outpatient Lab Work Please check Chem-7 and INR on [**Hospital 766**] [**2129-7-4**] with results to [**Hospital 18**] [**Hospital3 **] at [**Telephone/Fax (1) 3534**] and Dr. [**Last Name (STitle) **] at Phone: [**Telephone/Fax (1) 2010**] Fax: [**Telephone/Fax (1) 4004**] ICD-9: 410 7. Lisinopril 2.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: ST elevation myocardial infarction Acute systolic dysfunction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had chest pain and was found to have a heart attack. A cardiac catheterization showed that you had a blockage in your left anterior descending artery and you received three drug eluting stents to open the artery. The other main arteries did not have any significant blockages. You have tolerated this well and have been very stable. An echocardiogram showed that your heart is weaker than before and you will need to be on some medicines to help your heart recover and prevent more clots. You will need to take aspirin and plavix every day without fail for at least one year to prevent a clot in the new stent. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking plavix unless Dr.[**Name (NI) 3733**] says that it is OK. You have been started on warfarin to prevent a blood clot and a stroke from your weak heart, this is very likely temporary as your heart recovers and gets stronger. The [**Hospital 3052**] at [**Hospital1 18**] will contact you on [**Name (NI) 766**] and tell you how much warfarin to take every day. Followup Instructions: Department: [**Hospital3 249**] When: TUESDAY [**2129-7-5**] at 9:30 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 25193**], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Notes: Please call your insurance and name Dr. [**Last Name (STitle) **] as your PCP. [**Name10 (NameIs) **] MUST BE DONE BEFORE YOUR APPOINTMENT. Department: CARDIAC SERVICES When: FRIDAY [**2129-8-5**] at 1:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "V15.82", "427.1", "410.11", "414.2", "414.01", "401.9", "278.00", "429.9", "272.4" ]

icd9cm

[ [ [] ] ]

[ "36.07", "00.40", "00.66", "99.20", "37.22", "88.56", "00.47" ]

icd9pcs

[ [ [] ] ]

8639, 8645

5518, 7474

314, 1090

8751, 8751

3044, 5495

9987, 10742

2216, 2292

7811, 8616

8666, 8730

7782, 7788

8902, 9964

2307, 3025

264, 276

1118, 1934

8766, 8878

7495, 7756

1956, 1984

2000, 2200

80,423

149,476

32752

Discharge summary

report

Admission Date: [**2103-11-22**] Discharge Date: [**2103-11-27**] Date of Birth: [**2029-7-6**] Sex: M Service: CARDIOTHORACIC Allergies: Aspirin / Lasix / Monosodium Glutamate / Cucumber (Cucumis Sativus) Attending:[**First Name3 (LF) 165**] Chief Complaint: Fatigue w/ Supraventricular Tachycardia. Admitted for RV biopsy. Major Surgical or Invasive Procedure: [**2103-11-22**] Repair of Right Ventricle Perforation History of Present Illness: 74 y/o male with very complex past medical history with newly diagnosed episodes of supraventricular tachycardia and cardiomyopathy. Referred for cardiac cath with RV biopsy to evaluate for amyloidosis Past Medical History: Cardiomyopathy, Supraventricular Tachycardia, Hypertension, Waldenstroms Macroglobulinemia, Lymphoma, Multiple Myeloma, End-stage Renal Disease on Hemodialysis, Anasarca, Kidney stones, Prostate Cancer with bone metastases, Congestive heart failure w/ bilateral pleural effusion [**9-26**], s/p Left AV fistula, Left inguinal hernia, Anemia, s/p Tonsillectomy, h/o AVNRT Social History: He is married, former smoker quit [**2056**], occasional EtOH, no ilicit drug use. Family History: No h/o sudden death, arrhythmia, CAD or other heart disease Physical Exam: At discharge: VS: 98.7, 115/73, 96RA 20, 96%RA Gen: NAD Chest: scattered rhonchi- clears after cough Heart: RRR, no murmur or rub Abd: NABS, soft, non-tender, non-distended Ext: 1+ edema bilaterally Neuro: grossly intact Pertinent Results: [**9-22**] Echo: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The right atrium is moderately dilated. A patent foramen ovale is present. There is moderate to severe global left ventricular hypokinesis (LVEF = 20 %). The right ventricular cavity is dilated with moderate global free wall hypokinesis. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is a moderate sized pericardial effusion. The effusion appears loculated. There was no specific area of bleeding noted from the RV wall. Dr.[**First Name (STitle) **] was notified in person of the results on [**Known firstname **] [**Known lastname 76298**]. Post RV repair: RV moderately to severe dilated. Moderate TR. IVC size 25mm. Severe LV global hypokinesis 20%. One snapshot of TGSAX showed no circumferential or eccentric fluid accumulation. [**2103-11-27**] 08:17AM BLOOD WBC-3.5* RBC-2.84* Hgb-9.8* Hct-28.4* MCV-100* MCH-34.6* MCHC-34.6 RDW-18.2* Plt Ct-185 [**2103-11-27**] 08:17AM BLOOD Glucose-110* UreaN-44* Creat-6.4*# Na-138 K-4.2 Cl-99 HCO3-28 AnGap-15 [**2103-11-27**] 08:17AM BLOOD Albumin-3.0* Calcium-9.5 Phos-3.7 Mg-2.0 Brief Hospital Course: Mr. [**Known lastname 76298**] was electively brought for a cardiac cath and RV biopsy. During this procedure his RV was perforated and he was brought to the operating room where he underwent an emergent repair to his RV. Please see operative report for surgical details. Following surgery he was brought to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. He was also seen by renal and underwent hemodialysis after surgery. The patient was found to have swelling in his parotid gland and was started on amoxicillin. Swelling resolved. Chest tubes were discontinued without complication. The patient has a history of atrial fibrillation/NSVT following dialysis. He was monitored closely for this. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. Medications on Admission: Nephrocaps, Vicodin prn, Toprol XL 12.5mg qd, Renagel 1600mg TID, MVI Discharge Medications: 1. Toprol XL 25 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* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* 4. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet(s)* Refills:*0* 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 7. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 9. B Complex Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*0* 10. Thiamine HCl 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Right Ventricle Perforation s/p Repair PMH: Cardiomyopathy, Supraventricular Tachycardia, Hypertension, Waldenstroms Macroglobulinemia, Lymphoma, Multiple Myeloma, End-stage Renal Disease on Hemodialysis, Anasarca, Kidney stones, Prostate Cancer with bone metastases, Congestive heart failure w/ bilateral pleural effusion [**9-26**], s/p Left AV fistula, Left inguinal hernia, Anemia, s/p Tonsillectomy, h/o AVNRT Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) **] in [**1-21**] weeksProvider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2103-12-3**] 3:00 Provider: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**] Date/Time:[**2103-12-3**] 3:00 Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2103-12-7**] 11:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2103-11-27**]

[ "785.6", "273.3", "427.89", "428.0", "414.01", "997.1", "458.21", "427.31", "V10.46", "403.91", "202.80", "998.2", "E879.0", "511.9", "425.4", "585.6", "203.00", "V45.11" ]

icd9cm

[ [ [] ] ]

[ "37.49", "88.72", "37.25", "88.56", "34.09", "39.95" ]

icd9pcs

[ [ [] ] ]

5153, 5236

2946, 3881

399, 455

5694, 5700

1513, 2923

6211, 6873

1196, 1257

4001, 5130

5257, 5673

3907, 3978

5724, 6188

1272, 1272

1286, 1494

295, 361

483, 686

708, 1080

1096, 1180

68,454

167,670

38008

Discharge summary

report

Admission Date: [**2154-9-2**] Discharge Date: [**2154-9-5**] Date of Birth: [**2133-4-3**] Sex: M Service: MEDICINE Allergies: Shellfish Derived / Tylenol Attending:[**First Name3 (LF) 3326**] Chief Complaint: PCP: [**Name10 (NameIs) 3050**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] . CHIEF COMPLAINT: Melena REASON FOR MICU ADMISSION: Melena Major Surgical or Invasive Procedure: Endoscopy x 2 History of Present Illness: Mr. [**Known lastname 22656**] is a 21 y/oM with pmhx of prior esophageal webs who had a single and largely unprovoked episode of a black tarry stool around 1pm. He otherwise had been feeling well, without nausea or significant abdominal pain, though in retrospect he felt like he had a mild mid-epigastric discomfort for 3-4 days. He reports being a social EtOH user, but no significant increase in alcohol use and reports drinking less than his peers. He had taken motrin 2-3 days prior though only approximately 400mg. He has never had an episode like this previously. He has no notable family history. In the ED, he was found to be hemodynamically stable, and hypertensive if anything; vitals were 98.8 87 bp 157/90 18 98% on room air. NG lavage returned red blood, and coffee grounds that did not clear. GI was consulted in the ED, and he was brought into the MICU for endoscopy. ROS: Denies fever, chills, night sweats, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation, dysuria, hematuria. Past Medical History: - Recently has come to attention that his Blood Pressures are elevated, within the last 6 months to 140s-150s systolic - h/o croop with intubation during childhood - esophageal webs Social History: College senior at [**Hospital1 3278**], swim team. Family History: No family history of hypertension Physical Exam: Physical Examination: VS: 99.3F, 141/72, 73, 18, 100% on RA GEN: lying in bed, in nad HEENT: perla, eomi PUL: ctab CVS: s1s2+, rrr, no mrg Abd: soft, bs+, nt Rectal: G+ brown stools CNS: aox3 Pertinent Results: TSH 5.9 Hct trend: 40.5 - 37.8 - 36.2 - 39.9 - 38.3 - 37.4 - 37.9 [**2154-9-3**] 12:13 am SEROLOGY/BLOOD ADDED TO CHEM #62064F. HELICOBACTER PYLORI ANTIBODY TEST (Pending): [**9-3**] ABD U/S FINDINGS: The liver shows no focal or textural abnormalities. The gallbladder is normal without evidence of stones. There is no intra- or extra-hepatic biliary duct dilatation. The common bile duct is not dilated. Both right and left kidneys are normal without hydronephrosis or stones. The right kidney measures 11.3 cm. The left kidney measures 10.4 cm. Suboptimal evaluation of the pancreas due to overlapping bowel gas, however, no gross abnormality is seen. Spleen is enlarged measuring 16 cm. The aorta is of normal caliber throughout. Normal waveforms were seen in the main portal vein, left portal vein, right portal vein, main hepatic artery and splenic veins. Wall-to-wall flow was seen in the hepatic veins. IMPRESSION: 1. Enlarged spleen. 2. Normal waveforms in hepatic vessels. Brief Hospital Course: MICU 7 COURSE [**Date range (1) 17948**] ======================= 21 y.o. M with upper GI bleeding 1. Upper GI Bleeding: Endoscopy showed likely mixture of new ooze and old blood predominantly within the cardia of the stomach. This likely relates either peptic ulcer disease, diffuse gastritis, or potential dieulafoy lesion, though ultimately culprit was not identified during 1st EGD. No lesions were seen in the esophagus or in the duodenum. Fistula not visualized on EGD. Pt was given IVFs. Serial Hcts were followed. PPI infusion started and continued. GI and surgery were following the patient. Pt was transferred to [**Hospital Unit Name 153**] for 2nd endoscopy by GI on [**9-3**] per family wishes. H. pylori pending. 2. Hypertension: Given elevation present outside of stress/exercise, and negative family history with young age, this does merit further investigation for potential renal or endocrine disorders. TSH elevated. Free T4 added. FEN: IVFs / replete lytes prn / NPO for procedure PPX: PPI, pneumoboots ACCESS: PIV CODE: Full DISPO: Transfer to [**Hospital Unit Name 153**] for 2nd endoscopy [**Hospital Unit Name 13533**] [**Date range (1) 80149**]: ====================== 21 y.o. M with upper GI bleeding 1. Upper GI bleed: patient transferred to the [**Hospital Ward Name **] for further work up of his upper GI bleed. He was taken to endoscopy for another evaluation where they saw fresh oozing of the blood from the fundus of the stomach, a linear ulcer also in the fundus of the stomach that did not look like it had recently bled. Attempts to cauterize the oozing led to oozing around the sites of cautery, so no further cautery attempts were tried. He also had an abdominal ultrasound to evaluate for portal pressures, which showed an enlarged spleen at 16 cm. Throughout his course in the [**Hospital Unit Name 153**] his HCT remained stable between 35 and 38, he was maintained on an IV PPI and his diet advanced to clears. He did experience some orthostatic hypotension, which was thought to be due to volume depletion, so he was fluid resusciated with NS. Also, an H.pylori stool antigen was added on since the serum test that was sent with an IgG, the results were still pending at the time of transfer. At the time of discharge, patient was transitioned to oral pantoprazole 40 mg [**Hospital1 **] and his diet was advanced. He will be followed closely by PCP of his choosing in the next week and by GI. Medications on Admission: - PRN Motrin - minocycline Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*11* 2. Outpatient Lab Work Please have HCT drawn on [**9-7**] Discharge Disposition: Home Discharge Diagnosis: Acute blood loss anemia from upper GI bleed. Discharge Condition: Stable, HCT 37, tolerating full liquids Discharge Instructions: You came to the hospital with melena (blood in your stool). GI did and EGD and saw that you had evidence of bleeding in your stomach with a fragile mucosa but no ulcer. You were treated with anti-acid medications and your blood counts remained stable. You were able to tolerate food and discharged home with follow up in our [**Hospital **] clinic. . We made the following changes to your medications: ADDED Pantoprozole 40mg by mouth twice daily. You should continue to take this medication until told by your GI doctors to stop. . If you have further episodes of blood in your stool, if you feel dizzy, lightheaded, have palpitations, chest pain, abdominal pain or burning, nausea, vomiting or any other symptom that is concerning to you please call your doctor or come to the emergency room. . Please keep your appointments as below. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 40119**] Date/Time:[**2154-9-25**] 9:30 Provider: [**Name10 (NameIs) **],ROOM GI ROOMS Date/Time:[**2154-9-25**] 9:30 . Please make an appointment with a Primary Care Provider of your choosing in the next 1-2 weeks. We have scheduled you an appointment with your Pediatrician on ..... in case you are unable to make a new PCP appointment soon. You are scheduled to see: MD: [**First Name8 (NamePattern2) 17563**] [**Last Name (NamePattern1) **] Specialty: Pediatrics/PCP Date and time: Wednesday, [**9-11**], 1:30pm Location: [**Name (NI) 84891**], [**Location (un) 1887**] MA Phone number: [**Telephone/Fax (1) 37518**]

[ "276.50", "789.2", "750.3", "796.2", "285.1", "578.9" ]

icd9cm

[ [ [] ] ]

[ "45.13", "44.43" ]

icd9pcs

[ [ [] ] ]

5918, 5924

3123, 5577

474, 489

6013, 6055

2102, 3100

6944, 7683

1839, 1874

5655, 5895

5945, 5992

5603, 5632

6079, 6455

1889, 1889

1911, 2083

6484, 6921

393, 436

517, 1549

1571, 1755

1771, 1823

29,579

183,679

33026+57828

Discharge summary

report+addendum

Admission Date: [**2177-2-19**] Discharge Date: [**2177-3-14**] Date of Birth: [**2112-11-4**] Sex: M Service: SURGERY Allergies: Glyburide / Sulfonylureas Attending:[**First Name3 (LF) 3376**] Chief Complaint: Patient transferred from an outside hospital for management of multiple abdominal abscesses Major Surgical or Invasive Procedure: 1. Abscess Drain placed [**2177-2-18**] at OSH. 2. Drain repositioned on [**2177-2-21**] into abscess cavity. 3. Exploratory Laparotomy, lysis of adhesions, Drainage of abdominal wall abscess, End left colostomy on [**2177-3-5**] History of Present Illness: 64M with h/o colon cancer s/p resection [**2175**]. Pt presented to OSH on [**2177-2-17**] with crampy lower abdominal pain. CT scan on admission showed pre-sacral 15x50cm fluid collection with foci of air in collection, an additional [**Hospital1 **]-lobed 5x2.5cm fluid collection in the R lateral pelvis, as well as a 1cm collection medial to the pelvic collection. An attempt for CT guided drainage was made only yielding a scant amount of fluid. Pt was started on Imipenem-Cilastatin 250 [**Hospital1 **] on [**2177-2-17**]. On [**2-19**] the pt was rescanned and a drainage catheter was successfuly placed in one fluid collection and left to gravity. Drain cultures growing Gram-negative rods, Gram-positive rods and Gram-positive cocci per OSH. WBC 21.7 on [**2-17**] down to 15.2 on [**2-18**]. Past Medical History: PMH: DM II, ESRD from post-surgical ATN from which pt never recovered - currently on dialysis MWF, Colon Ca, CHF, Hyperlipidemia, HTN, Gout, h/o EF of 20% while in A-flutter, ECHO [**2176-1-15**] reports EF 60-65%, moderate AS, mild AR PSH: AV fistula for dialysis access L arm, colon ca resection [**2175**] with J pouch c post-op Chemo/XRT temporary diverting ileostomy subsequently taken down. Social History: Lives with wife, quit smoking 22 years ago but smoked 3 ppd x ?20 years (60 pack-years), quit etoh 2 years ago (drank on weekends, denies heavy use), denies illicit drug use. Family History: Mother alive and healthy, father deceased when pt a baby, unknown cause, son healthy, no siblings. Physical Exam: On admission: Vital signs: T 98.2 BP 120/60, P 58, R 18, O2 sat 100% RA General: 59-year-old female, cachectic but in no acute distress. HEENT: Atraumatic, normocephalic head. Sclerae anicteric. Pupils equal, round, and reactive to light. Extraocular movements intact. No oral lesions. Mucous membranes are moist. +NG tube. Neck: Supple. Lymph: No cervical, supraclavicular, axillary, occipital, or inguinal lymphadenopathy. CV: Regular rate and rhythm. No murmurs, gallops or rubs. Lungs: Clear to auscultation and percussion bilaterally. Abdomen: Soft, nontender, minimally distended. Normoactive bowel sounds present. Liver margin is palpable but non-tender. No splenomegaly or ascites. Extremities: No clubbing, cyanosis, or edema. Pertinent Results: RADIOLOGY Final Report CHEST (PORTABLE AP) [**2177-2-19**] 9:39 PM [**Hospital 93**] MEDICAL CONDITION: 64 year old man with h/o CHF, baseline CXR FINDINGS: There is moderate hyperelevation of the hemidiaphragms on both the right and the left side. At the right lung base, the presence of mild-to-moderate pleural effusion cannot be excluded. Hypoventilation of the right lung base. On the left, there is no reliable evidence of pleural effusion. However, there is also mild hypoventilation in the retrocardiac area. The visible parts of the cardiac silhouette indicates mild cardiomegaly. No signs of overhydration, no signs of pneumonia in the adequately visible parts of the lung parenchyma. . RADIOLOGY Final Report CT PELVIS W/CONTRAST [**2177-2-20**] 12:46 PM Reason: PO/IV contrast - please evaluate abdominal abscesses CONCLUSION: 1. Free fluid in the abdomen and pelvis along with several small collections along the anterior abdominal wall as well as in the pelvis as described above. 2. Catheter in a presacral nearly completely drained collection. 3. Enlarged nodular left adrenal gland is suggestive of adenoma and an MRI or non contrast CT could be performed to confirm this diagnosis. 4. Small atrophic kidneys with cysts. 5. Atelectasis and consolidation at the lung bases with bibasal effusions. 6. Expansion of the cortex of left femoral shaft with a ground-glass appearance suggestive of fibrous dysplasia. . Portable TTE (Complete) Done [**2177-2-20**] at 2:05:16 PM The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. The right ventricular cavity is mildly dilated with borderline normal free wall function. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (area 1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal systolic function and moderate diastolic dysfunction. Moderate aortic stenosis. Mild mitral regurgitation. . RADIOLOGY Final Report FISUTLOGRAM INJ THRU SINUS TRACT [**2177-2-21**] 11:25 AM Reason: ?fistula IMPRESSION: 1. Malpositioned pigtail catheter terminated in the ileoanal pouch. After consultation with Dr. [**Last Name (STitle) 1120**], the catheter was exchanged over a wire and repositioned to terminate in the presacral collection. 2. Multiple additional intra-abdominal abscesses without direct connection demonstrated to the presacral collection. 3. Unchanged appearance of the bones, with lucent lesion of the right acetabulum and of the left proximal femur. . POUCHOGRAM [**2177-2-26**] 3:17 PM [**Hospital 93**] MEDICAL CONDITION: 64 year old man s/p j pouch creation for colon ca now with pelvic abscess IMPRESSION: A leak posteriorly from the rectum to the area drained by the catheter with other fistulae demonstrated posteriorly. . Sigmoidoscopy Date: [**Last Name (LF) 2974**], [**2177-2-28**] Findings: Other The patient is status-post sigmoid resection. The anastamosis was examined and there was no sign of disease recurrence. Adjacent to the anasatamosis there was both a blind pouch (with suture) and a probable fistula with purulent material (above and to the left on the picture). The colon was unremarkable on examination to 80cm. There was an raised and erythematous area on the anal verge. Impression: The patient is status-post sigmoid resection. The anastamosis was examined and there was no sign of disease recurrence. Adjacent to the anasatamosis there was both a blind pouch (with suture) and a probable fistula with purulent material (above and to the left on the picture). The colon was unremarkable on examination to 80cm. There was an raised and erythematous area on the anal verge. Otherwise normal sigmoidoscopy to 80cm Recommendations: Return to hospital [**Hospital1 **] . RADIOLOGY Final Report PERSANTINE MIBI [**2177-3-4**] Reason: PRE-OP EVAL ? PERFUSION HISTORY: 64 year old man with history of DM, CHF, cadiomyopathy, and moderate aortic stenosis, referred for pre-operative evaluation. IMPRESSION: No perfusion defects identified. Left ventricle appears enlarged, consistent with provided history of cardiomyopathy. Computer calculated left ventricle volume is 165 ml. Calculated LVEF of 51%. . Pathology Examination Procedure date [**2177-3-5**] DIAGNOSIS: Peritoneal implant: Fibrin, necrotic tissue with acute inflammation. Clinical: Fistula of the colon. . Stress Test [**2177-3-5**] EXERCISE RESULTS RESTING DATA EKG: SINUS, AV DELAY, LAA, MODEST RV COND. DELAY PATTERN, NSSTTW HEART RATE: 74 BLOOD PRESSURE: 104/- STAGE TIME SPEED ELEVATION [**Doctor Last Name 10502**] HEART BLOOD RPP (MIN) (MPH) (%) RATE PRESSURE 1 0-4 .142MG KG/MIN 76 88/ 6688 IMPRESSION: No anginal symptoms or ST segment changes from baseline. Nuclear report sent separately. . RADIOLOGY Final Report UNILAT UP EXT VEINS US RIGHT [**2177-3-9**] 9:23 AM Reason: SWELLING R/O DVT RUE INDICATION: 64-year-old male with right arm swelling. IMPRESSION: Occlusive thrombus within the right cephalic vein. No other thrombus detected. . RADIOLOGY Final Report SHOULDER [**3-9**] VIEWS NON TRAUMA LEFT [**2177-3-9**] 10:09 AM [**Hospital 93**] MEDICAL CONDITION: 64 year old man with L shoulder pain HISTORY: Left shoulder pain. FINDINGS: There are degenerative changes around the shoulder joint with some soft tissue ossification medially. The alignment is normal and no fracture is identified. Brief Hospital Course: The patient was transferred from an outside institution after having a drain inserted via IR. He was admitted directly to the intensive care unit. He was treated with IV fluids and continued on antibiotics - imipenem and vancomycin. Oral antihyperglycemics were held due to low blood glucose levels. [**2-20**] - The patient was transferred to the floor for close monitoring. Antibiotics changed to meropenem and vancomycin. CT performed showing multiple abdominal abscesses. [**2-21**] - A fistulagram demonstrated positioning of the drain within the rectum. The drain was changed over a wire and positioned within the pelvic abscess. Continued to drain feculent drainage. Multiple cultures were obtained during this admission. Please refer to pertinent results section. The patient's dialysis continued per his normal Monday, Wednesday, [**Month/Year (2) 2974**] schedule. His most recent medication regimen was confirmed with the Dialysis Center. [**2-25**] - Patient made NPO and a PICC line was placed and TPN (nephramine) was started. Nutrition was consulted, and TPN was modified. Nephramine not indicated in this case since he already has a diagnosis of ESRD. [**2-26**] - Barium enema revealed a fistula. Decision for surgical intervention was considered. Due to multiple medical concerns, patient required Pulm & Cardiac clearance. [**Date range (1) 34519**] - Underwent a sigmoidoscopy, prepped with enema. Confirmed site of fistula. He continued on TPN, and IV antibiotics. Prepped & consented for OR. [**3-3**] - Medical team was consulted for pre-op evaluation of patient due to multiple medical concerns. Recommendations included a PMIBI to assess CV status, pulmology and cardiology consults. He underwent a PMIBI on [**2177-3-4**]. [**3-4**] - Cardiology reviewed case, and cleared patient for surgery. Adjustments were made to his cardiac regimen. Amiodarone decreased to 200mg PO from 400mg-toxicity likely related to decompensated pulmonary status. Cardizem changed to 30mg PO QID, and Toprol Xl remains unchanged. Both his blood pressure and HR have remained stable. [**3-5**] - He underwent diverting colostomy with Dr. [**Last Name (STitle) 1120**]. He tolerated the procedure well. He was monitored in the PACU longer than usual due to low Oxygen sats when attempting to wean from Vent. He was eventually extubated successfully with stable sats >95% on 3L. He was transferred to CC6. [**3-7**] - Pulmonology team consulted due to patient's intermittent need of supplemental oxygen during this admission. Patient also states using intermittent oxygen at home. He is a poor historian, and was not able to explain reasoning for home use. During this admission oxygen needs likely related to fluid volume overload which was confirmed with RA sats >95% after dialysis. In addition, he uses CPAP at home for OSA. His oxygen sats have remained stable with minimal to no supplemental oxygen use. He will follow-up with Pulmonolgy outpatient for PFT's and sleep studies. TPN was weaned, and regular diet re-started. [**3-9**] - Received oral dose of glyburide (medication regimen confirmed per out-patient dialysis center). Due to ESRD and renal excretion of glyburide, patient became hypoglycemic, dropped to 30's. Treated with D10% intravenous drip with frequent blood sugar monitoring resulting in transfer of patient to PACU for closer monitoring. In addition, he became lethargic, weak, with some cognitive changes. IV antibiotics discontinued. [**3-10**] - In the morning, he was dialyzed and then transferred to the PACU. Despite dialysis and D10 drip, his blood sugars remained low ranging 40-59, for which he received multiple boluses of D50 q1h. By evening, his sugars ... He was transferred to [**Hospital Ward Name **] with 1 hour blood sugar checks, and continuous D10 IV drip. [**Date range (1) 76800**] - Blood sugars remained stable, blood sugar checks decreased to every 4 hours, and IV D10% was discontinued. He continued with his regular diet, with adequate ostomy output and flatus. He continued to work with Physical Therapy. He ambulated well with rolling walker and supervision. He has been evaluated per the ostomy care specialist throughout this admission. He has had an ostomy in past, and was semi-independent with care with wife's assistance at home. He has decreased LUE ROM exact etiology unknown, XRAY on [**2177-3-9**] revealed degenerative changes but no trauma or fracture. Please refer to Physical Therapy evaluation. He continued to be dialyzed MWF during this admission. He was last dialyzed on [**2177-3-14**]. Medications on Admission: RISS, Imipenem-cilastatin 250'', Amiodarone 400, Celexa 40, Cardizem CD 240, Colace 100, Metoprolol 100, Crestor 5, Allopurinol 100, Protonix 40, Glyburide 2.5, Flomax 0.4, Loperamide 4, Lipitor 10 mg'; Nephrocaps 1 cap QD, Tylenol#3 PRN, Percocet PRN, Morphine PRN, Zofran PRN Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. 14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 16. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 17. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection QID & HS: Refer to sliding scale. 18. Regular Insulin Sliding Scale Regular Insulin Sliding Scale Check Blood sugars QID & HS 201-220mg/dL 2 Units 221-240mg/dL 3 Units 241-260mg/dL 4 Units 261-280mg/dL 5 Units Titrate sliding scale accordingly. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Health Care Center Discharge Diagnosis: Primary: Multiple abdominal abscesses RUE-Thrombosis Hypoglycemia Acute pulmonary edema Heart failure-Diastolic . Secondary: DM II, ESRD from post-surgical ATN - dialysis MWF, Colon Ca, CHF, hyperlipidemia, HTN, Gout, h/o EF of 20% while in A-flutter, ECHO [**2176-1-15**] reports EF 60-65%, moderate AS, mild AR Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Drain Care: -Please look at the site every day for signs of infection (increased redness, swelling, odor, yellow or bloody discharge, fever). -Note color, consistency, and amount of fluid in drain. Call doctor if amount increases significantly or changes in character. -Be sure to empty the drain frequently. -You may shower, wash area gently with warm, soapy water. -Maintain the site clean, dry, and intact. -Avoid swimming, baths, hot tubs-do not submerge yourself in water. -Keep drain attached safely to body to prevent pulling . Monitoring Ostomy output/Prevention of Dehydration: -Keep well hydrated. -Replace fluid loss from ostomy daily. -Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. -Try to maintain ostomy output between 500mL to 1000mL per day. -If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. . SULFONYLUREA's: *Please Hold all SFU's (ie) glyburide due to renal excretion. Patient developed profound hypoglycemia in-patient after taking PO glyburide as indicated per Out-patient Dialysis Medication List. Further evaluation required per primary care physician/Nephrologist. . Regular Insulin Sliding Slide: *Due to hypoglycemic episode during this admission related to PO glyburide, the patient's Regular insulin sliding scale was adjusted to low-dose coverage, starting at 200. Please titrate sliding scale accordingly. Blood sugars have remained stable, and have continued to trend up to 200's. Followup Instructions: 1.Please make a follow-up appointment with Dr. [**Last Name (STitle) 1120**] [**Telephone/Fax (1) **] in [**3-9**] weeks. 2. Make a follow-up appointment with your primary care provider (Nephrologist), Dr. [**Last Name (STitle) 76801**] [**Name (STitle) 62195**], [**Telephone/Fax (1) **] in for further evaluation of your respiratory status including PFT's and sleep study, management of your diabetes and hypoglycemia, and management of kidney function. 3. Please follow-up with your Cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 656**] [**Telephone/Fax (1) **] in [**3-9**] weeks. 4. Follow-up with [**Last Name (un) **] Diabetes center as needed, you were seen by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2489**]-NP in patient. She may be reached at [**Telephone/Fax (1) 2490**]. Completed by:[**2177-3-14**] Name: [**Known lastname 8774**],[**Known firstname 11300**] M Unit No: [**Numeric Identifier 12495**] Admission Date: [**2177-2-19**] Discharge Date: [**2177-3-14**] Date of Birth: [**2112-11-4**] Sex: M Service: SURGERY Allergies: Glyburide / Sulfonylureas Attending:[**First Name3 (LF) 1859**] Addendum: Addendum to Physcial Exam section. Physical Exam: Physical Exam: On admission: Vital signs: T 98.2 BP 120/60, P 58, R 18, O2 sat 100% RA General: 64yo male in no acute distress. HEENT: Atraumatic, normocephalic head. Sclerae anicteric. Pupils equal, round, and reactive to light. Extraocular movements intact. No oral lesions. Mucous membranes are moist. +NG tube. Neck: Supple. Lymph: No cervical, supraclavicular, axillary, occipital, or inguinal lymphadenopathy. CV: Regular rate and rhythm. No murmurs, gallops or rubs. Lungs: Clear to auscultation and percussion bilaterally. Abdomen: Soft, nontender, minimally distended. Normoactive bowel sounds present. Liver margin is palpable but non-tender. No splenomegaly or ascites. Extremities: No clubbing, cyanosis, or edema. Discharge Disposition: Extended Care Facility: [**Hospital3 12496**] Health Care Center [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1871**] MD [**MD Number(2) 1872**] Completed by:[**2177-5-8**]

[ "453.8", "250.82", "998.59", "567.22", "403.91", "998.6", "428.33", "682.2", "428.0", "427.32", "585.6", "V10.06" ]

icd9cm

[ [ [] ] ]

[ "46.11", "38.93", "99.77", "48.23", "99.15", "54.19", "39.95" ]

icd9pcs

[ [ [] ] ]

20775, 20998

8933, 13519

377, 609

16021, 16099

2945, 3014

18744, 20007

2072, 2172

13848, 15578

8673, 8910

15684, 16000

13545, 13825

16123, 18721

20037, 20037

246, 339

637, 1442

20051, 20752

1464, 1864

1880, 2056

14,227

111,310

1557

Discharge summary

report

Admission Date: [**2103-12-30**] Discharge Date: [**2104-1-8**] Date of Birth: [**2053-6-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: Acute Appendicitis Major Surgical or Invasive Procedure: Open Appendectomy History of Present Illness: 50-year-old man with progressive signs and symptoms consistent with appendicitis and probable small bowel involvement and/or abscess. He presents for emergency appendectomy. He reported right sided diffuse abdominal pain x 4-5 days. He described sharp, constant, worsening RLQ pain. He had a fever to 100.9, chills, decreased appetite and poor PO intake. Past Medical History: HIV X 20 yrs (CD4 213,VL undetectable), h/o CMV hepatitis, h/o PCP PNA, [**Name Initial (PRE) **]/o ? hep A in 70's, h/o penile kaposi sarcoma sp excision/chemo tx X 13 yrs ago, HPV sp anal fulguration [**5-21**], [**3-23**]. s/p R SCV port & removal Social History: He reports no Tobacco, or ETOH. Physical Exam: VS: 99.3, 77, 157/85, 20, 95% RA Gen: Sick comfortable, tired HEENT: Anicteric, dry mucosa, no LAD, supple Chest: CTA bilat. CV: RRR, no murmurs GI/Abd: soft, +tenderness periumbilical and RLQ, +Rovsign's sign, hypoactive BS, no flank tenderness. Skin: diaphoretic, no rash Neuro: A+O x 3, no focal deficits Psych: Appropriate Pertinent Results: [**2104-1-5**] 04:42AM BLOOD WBC-4.6 RBC-3.98* Hgb-10.8* Hct-32.3* MCV-81* MCH-27.2 MCHC-33.5 RDW-13.9 Plt Ct-260 [**2104-1-3**] 03:36AM BLOOD Neuts-55 Bands-4 Lymphs-23 Monos-16* Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2104-1-1**] 11:24AM BLOOD WBC-8.5 Lymph-19 Abs [**Last Name (un) **]-1615 CD3%-85 Abs CD3-1370 CD4%-10 Abs CD4-156* CD8%-71 Abs CD8-1150* CD4/CD8-0.1* [**2104-1-6**] 05:00AM BLOOD Glucose-112* UreaN-5* Creat-0.6 Na-137 K-3.7 Cl-102 HCO3-27 AnGap-12 [**2104-1-6**] 05:00AM BLOOD ALT-21 AST-34 AlkPhos-101 Amylase-54 TotBili-1.9* [**2104-1-1**] 09:30AM BLOOD ALT-34 AST-34 AlkPhos-159* Amylase-26 TotBili-5.5* [**2104-1-6**] 05:00AM BLOOD Lipase-73* [**2104-1-6**] 05:00AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.9 [**2104-1-1**] 08:37PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2104-1-1**] 08:37PM BLOOD HCV Ab-NEGATIVE CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST INDICATION: Right lower quadrant pain. IMPRESSION: 1. Markedly abnormal appendix with large amount of stranding around the distal tip. Findings are more suggestive of acute appendicitis, though other etiologies for appendiceal inflammation including appendiceal carcinoma or mucocele should be considered. 2. Inflamed small bowel, probably due to its proximity to the inflamed appendix. 3. Right renal cyst. LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2104-1-1**] 3:14 PM Reason: JAUNDICE ,RUQ PAIN EVAL FOR GB STONES,OBSTRUCTIVE JAUNDICE IMPRESSION: 1. Gallbladder wall edema. Differential diagnosis includes hypoproteinemia, hepatitis, pancreatitis, or CHF. Cholecystitis seems unlikely, although this cannot be entirely excluded. Further evaluation with HIDA scan could be considered. 2. No evidence for biliary obstruction. Cardiology Report ECG Study Date of [**2104-1-1**] 10:53:48 PM Sinus rhythm. No significant change compared to the previous tracing of [**2104-1-1**]. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] B. Intervals Axes Rate PR QRS QT/QTc P QRS T 83 152 94 364/403.71 55 -4 6 ABDOMEN U.S. (COMPLETE STUDY) PORT [**2104-1-2**] 10:49 AM [**Hospital 93**] MEDICAL CONDITION: 50 year old man HIV+, POD 3 s/p open appy, with rising bilrubin and abdominal distension. REASON FOR THIS EXAMINATION: please evaluate for mesenteric venous thrombosis, portal/hepatic/splenic vein thrombosis & ascites IMPRESSION: 1. Normal hepatic vasculature, as clinically questioned. 2. Ascites. 3. Persistent diffuse gallbladder wall thickening. Gallbladder sludge without evidence of gallstones. 4. Dilated small bowel loops in left lower quadrant, postoperative ileus versus small bowel obstruction. SMV not viisualized. ABDOMEN (SUPINE & ERECT) [**2104-1-3**] 10:43 AM Reason: interval change, ileus pattern vs. bowel obstruction INDICATION: Abdominal pain after open appendectomy. IMPRESSION: Continued appearance of gas filled bowel loops in a pattern suggestive of ileus, though early or partial SBO cannot be excluded. Continued followup recommended. Brief Hospital Course: He was admitted to [**Hospital1 18**] on [**2103-12-30**] for an Acute laparoscopic to open Appendectomy. Post-operatively he was NPO, with IV fluids and a PCA for pain control. He was Levo/Flagyl antibiotics. On POD 1, he was noted to be sweating and appearing uncomfortable. An EKG and tropins were done and were negative. Pain: He was slightly hypertensive post-operatively (BP 160/100) with movement. His PCA was increased in order to help gain better pain control. Renal: He was noted to have a low urine output on POD 1. He received 500 cc bolus x 2 and his fluid rate was increased to 150cc/hr. He continued to have low urine output, dark amber in appearance. GI/Abd: His abdomen was round and distended and he had hypoactive bowel sounds. The evening of POD 1, he was transferred to the ICU for +++ sweating, a very distended abdomen, abdominal pain, poor urine output and a rapidly rising Bilirubin. An Ultrasound showed gallbladder wall edema and no evidence for biliary obstruction. GI: A NGT was placed and returned 1400cc immediately. This was consistent with an Ileus. He reported + BM on POD 4. His abdomen began to soften with less tenderness. The NGT was removed on [**1-4**]. He was started back on his HIV meds once tolerating clears on [**2104-1-4**]. He was having frequent watery stools. C.diff was negative. He was tolerating a regular diet and pain was well controlled. Heme: He had a rising TBili and Hepatitis labs were drawn. He was shown to have + hepatitis A and + HepBsAb. Blood cultures and Urine cultures were negative. His WBC was trending down and was 3.3 on [**1-4**]. His WBC stabilized at 4.6. Wound: His abdominal wound was noted to be slightly red with induration and he was still slightly distended. An US showed normal hepatic vasculature, ascites, persistent diffuse gallbladder wall thickening (Gallbladder sludge without evidence of gallstones), dilated small bowel loops in left lower quadrant, postoperative ileus versus small bowel obstruction. SMV not visualized. Some staples were removed from the inferior portion of the incision and the wound opened slightly. The superior staples remained in place. The wound was opened about 5 cm and the edges were pink. A wound swab showed E.coli and he continued on Keflex and Flagyl. He will continue with dressing changes at home. Blood pressure: He continued to have elevated blood pressures. He was started back on Atenolol 25 mg qd and his pressures were 150-160/80. Medications on Admission: trivata, norvir, 2 test drugs?, fuzeon injections", omeprazole 30', prozac', wellbutrin 150' Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Appendicitis Small Bowel Ileus Post-op Low Urine Output Abdominal Distension Wound Infection Discharge Condition: Good Discharge Instructions: * Increasing pain * Fever (>101.5 F) * Inability to eat or persistent vomiting * Inability to pass gas or stool * Increasing shortness of breath * Chest pain Please resume all of your regular medications and take any new meds as ordered. Continue to ambulate several times per day. You will have a visitng nurse assist you with dressing changes. Change dressing [**Hospital1 **]. Pack lightly with wet to dry 4x4 gauze. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 468**] in [**3-23**] weeks. Call ([**Telephone/Fax (1) 9058**] to schedule an appointment. Completed by:[**2104-1-8**]

[ "682.2", "540.1", "070.30", "401.9", "070.1", "V64.41", "789.5", "788.5", "042", "998.59", "560.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.07", "47.09" ]

icd9pcs

[ [ [] ] ]

7056, 7113

4442, 6913

332, 352

7250, 7257

1422, 3513

7726, 7895

3550, 3640

7134, 7229

6939, 7033

7281, 7703

1074, 1403

274, 294

3669, 4419

380, 736

758, 1010

1026, 1059

67,735

141,202

26596

Discharge summary

report

Admission Date: [**2200-4-5**] Discharge Date: [**2200-5-16**] Date of Birth: [**2160-2-16**] Sex: M Service: SURGERY Allergies: Sulfasalazine / Tape [**12-22**]"X10YD / Lactose / Optiray 350 Attending:[**First Name3 (LF) 5569**] Chief Complaint: ESLD Major Surgical or Invasive Procedure: liver transplant4/29/11 Exploratory laparotomy, takedown jejunojejunostomy and liver biopsy [**2200-4-27**] History of Present Illness: 40 yoM who was seen this morning for reposition of his NJ tube which had 'fallen out.' His laboratory values at that time happened to notice that his bilirubin and creatinine were acutely elevated. He was referred to the ED for further work up. Per report from the ED, when he arrived he was hypotensive and minimally repsonsive. He was immediately placed on Dopamine and gievne Normal saline boluses. He was then consented for and a Right sided central venous access was obtained via Internal jugular vein. He stabilized and at that point transplant surgery was consulted approximately 2.5 hours after admission to the ED. When I arrived to see this patient, he was awake, alert and in no apparent distress. He complained only of suprapubic pain. He was jaundiced and lethargic. He denies fevers or chills. He denies dysuria or decreased frequency or volume. He denies abnormal bowel movements. He denies changes in mental status (confirmed by his family) and denies vision changes or dizziness. No acute musculoskeletal weakness or instability although he is cachectic and has difficulty ambulating at times. Past Medical History: 1. Ulcerative colitis s/p subtotal cholectomy 2. Primary sclerosing cholangitis 3. Esophageal varices s/p banding Social History: He is single and heterosexual; He is currently not working and is on disability. He lives at home with parents. No alcohol or drugs. Family History: His father has [**Name (NI) 4522**] disease. There is no known family history of colon cancer. He does not smoke cigarettes or use NSAIDs. He is not certain whether stress makes his condition worse. Both parents are well. He has no siblings. Physical Exam: Afebrile, VSS AAO x3, NAD, depressed affect RRR no MRG appreciated CTA soft, protuberant, mild to moderate supraumbilical pain, scar c/w prior surgery. JP drain in place to splenic bed + 1 edema of LE's Pertinent Results: On Admission: [**2200-4-4**] WBC-17.1*# RBC-3.74*# Hgb-13.4*# Hct-40.1# MCV-107*# MCH-35.8* MCHC-33.3 RDW-21.1* Plt Ct-244# PT-24.2* INR(PT)-2.3* UreaN-157* Creat-6.0*# Na-135 K-5.4* Cl-100 HCO3-9* AnGap-31* Glucose-84 ALT-286* AST-285* AlkPhos-217* TotBili-50.0* Albumin-3.0* Calcium-7.8* Phos-10.6*# Mg-2.6 [**2200-4-25**] HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE At Discharge [**2200-5-16**] WBC-10.5 RBC-3.19* Hgb-9.9* Hct-29.9* MCV-94 MCH-31.1 MCHC-33.2 RDW-18.2* Plt Ct-868* PT-12.1 PTT-22.2 INR(PT)-1.0 Glucose-96 UreaN-39* Creat-0.8 Na-139 K-4.6 Cl-108 HCO3-24 AnGap-12 ALT-29 AST-24 AlkPhos-107 TotBili-0.4 Albumin-2.6* Calcium-8.4 Phos-4.6* Mg-1.8 tacroFK-9.1 Brief Hospital Course: 40 yoM with liver failure secondary to PSC cirrhosis was admitted to the Transplant service under Dr. [**Last Name (STitle) **]. He was started on IVF resuscitation. Vanc and Zosyn were started for broad coverage after pan-culturing. [**4-5**]: Admitted to SICU. H Bedside R-sided thoracentesis for 1L fluid. Repleted calcium. Guaiac positive. He was sent to the SICU on [**4-5**] for management of acidosis and hyperkalemia. HD line placed was placed and CVVH started. BP was low requiring Levo, vasopressin and dobutamine-->weaned to levophed and dobutamine overnight. Increased large right and new small left pleural effusions, with new multifocal pneumonia and continued right lower lobe collapse was seen on CXR [**4-7**]. On [**4-10**] a R chest tube was placed by IP with large outputs (4.5L). Vancomycin was started for GPCs in pleural fluid.Pleural fluid culture was negative. CVVHD continued. He did have a positive blood culture on [**4-12**] isolating VRE. Antibiotics were adjusted and subsequent blood cultures remained negative. On [**4-15**] a donor liver was available. A TTE was done showing mildly dilated LA and RA. LV wall thickness, cavity size and regional/global systolic function normal (LVEF 75%). RV chamber size & free wall motion normal. AV leaflets (3) structurally normal w/good leaflet excursion--no stenosis or regurge. MV leaflets mildly thickened & myxomatous & borderline/mild post leaflet MV prolapse. Borderline PA systolic HTN. No pericardial effusion. Liver transplant was cancelled for positive blood cultures. He was treated with daptomycin ([**Date range (1) 65627**])] then was cleared for liver transplant. On [**4-18**], a liver donor offer was available. On [**2200-4-18**] he underwent liver transplant with splenectomy given B incompatible status (patient blood type O). He received one pheresis treatment prior to OR. Intraop, 3 JPs were placed (2 around the liver) and 1 in the splenic bed. Surgeon was [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative notes for details. Postop hepatic duplex revealed patent hepatic vasculature. However, there was slight reversal of flow in diastole and then absence of flow in end diastole. A small subhepatic collection seen inferior to the left lobe of the liver Postop, he was sent to the SICU for management and required many blood products per protocol to keep hemodynamically stable. Daily anti B antibodies were check daily for 2 weeks. He did not require additional pheresis treatments. He experinnced increasing depression with psychotic features including hallucinations and delusions of people intending to harm him. Pt. transferred to SICU for mangagement and monitoring. He still required multiple transfusions. On [**4-24**], an abdominal CT was done for continued drop in HCT despite numerous blood transfusion and blood products. No active extravasation was identified. Hyperdense bowel contents, incl. along the hepaticojejunostomy limb suggestive of bleeding was noted. Thrombosis of right portal vein was noted. Delayed and decreased renal parenchymal enhancement, compatible with ARF He then underwent CT angio without bleeding source seen. On [**4-26**], a bleeding scan was performed noting acute GI bleeding from splenic flexure. On [**4-27**], he required take back to the OR for revision of the J-J anastomosis for bleeding after significant bloody stools and decrease in HCT from 38-->15.7 over 36 hours. On [**4-28**], RUQ US showed occlusive thrombus seen within the right anterior and right posterior portal veins. Hepatopetal flow was seen within the main and left portal veins. The hepatic arteries, hepatic veins, and IVC were patent. Postop, he was doing well and had been started on a heparin gtt for his portal vein thrombosis. He was transferred to the floor [**5-2**]. The thrombosis had resolved on US, but his heparin drip was continued and he was started on coumadin [**5-5**]. In the early AM on [**5-6**], however, he was noted to have melena. His hct had dropped from 27-20, though he was HDS. He was then transferred to the SICU, where he received 3u PRBC and 2u FFP. Hct stablized and he eventually transferred out of the SICU to the med [**Doctor First Name **] unit. US showed resolution of PV clot Neurologically/psychologically, he had metabolic encephalopathy and severe depression with paranoia and self-deprecating behavior. Appetite was absent. Psych saw the pt and he was given Haldol for hallucinations, but he became flaccid and min responsive after receiving. Haldol was discontinued. Haldol and trazadone were held also for long QT (calculated on ECG [**4-30**]). A post pyloric feeding tube was placed on [**4-28**]. Brain MRI on [**5-1**] was notable hyperintensity within the basal ganglia extending into the superior mid brain. This was too focal for leukencephalopathy, rather it was c/w hepatic encephalopathy. On [**5-6**] he was readmitted to the SICU for an episode of melena with a hct drop from 27-20. HDS. Gave 4u PRBC, 2u FFP. Placed aline. Repeat duplex of liver was without clot. Heparin drip and coumadin were stopped on [**5-5**] for 2nd bleed and resolution of PV clot. PPI continued. Dobhoff replaced on [**5-7**]. Tube feedings were adjusted. Most recently for hyperkalemia. Hyperkalemia was treated with kayexalate once then with standing lasix and florinef. Psyche recommended starting Remeron and Ritalin [**Hospital1 **]. Mental status improved with brighter affect and near resolution of paranoia. PT recommended rehab for significant deconditioning. L arm became swollen. This was evaluated with US noting a non- occlusive thrombus in left subclavian and occlusive thrombus in left basilic. Patient was to be discharged to rehab on [**5-15**], immediately prior to discharge the patient had a fall, discharge was cancelled. Head CT was performed and negative for fracture or intracranial process. Hip, arm and leg x-rays were also obtained and negative for fracture. The patient felt fine overnight and was cleared for discharge to rehab the following day. Tube feeds still running, clips have been removed from incision, splenic drain remains in place. Medications on Admission: CIPROFLOXACIN 500', ERGOCALCIFEROL 50,000 q week, FUROSEMIDE (held), LOPERAMIDE 2"", NADOLOL 20', NYSTATIN QID, OMEPRAZOLE 20', MEPHYTON 5', SPIRONOLACTONE (hold), URSODIOL 600", CALCIUM CARBONATE-VITAMIN D3 600 mg-400 unit Tablet", FERROUSUL 325", MAGNESIUM OXIDE 400', MULTIVITAMIN', VITAMIN A 8000 TIW Discharge Medications: 1. insulin regular human 100 unit/mL Solution Sig: follow printed sliding scale Injection ASDIR (AS DIRECTED). 2. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): see printed taper schedule. 8. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): give at 7am and 1200 noon . 10. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for hyperkalemia: for hyperkalemia. 12. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as needed for hyperkalemia: for hyperkalemia prevention. 13. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours): give at 6pm and 6am must have trough level on Monday and Thursdays Do not adjust dose without checking with [**Hospital1 18**] Transplant. 14. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 15. Outpatient Lab Work Every Monday and Thursday cbc,chem 10, ast, alt, alk phos, t.bili, albumin, trough prograf level and UA fax results to [**Hospital1 18**] Transplant Office [**Telephone/Fax (1) 697**] Discharge Disposition: Extended Care Facility: [**Hospital1 **] [**Location (un) 686**] Discharge Diagnosis: UC/PSC ESLD s/p liver transplant Depression/paranoia J-J anastomosis bleed at splenic flexure Left subclavian non-occlusive thrombus, occlusive left basilic thrombus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Withdrawn at times/flat affect Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You will be transferring to [**Hospital1 **] Rehab in [**Location (un) 686**] Please call the Transplant Office [**Telephone/Fax (1) 673**] if you experience the following fever, chills, nausea, vomiting,inability to take any of your medications, jaundice, increased abdominal pain, abdominal distension, incision redness/bleeding/drainage, feeding tube clogs Followup Instructions: Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2200-5-22**] 1:40 Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2200-5-29**] 1:20 Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2200-6-5**] 1:00 Completed by:[**2200-5-16**]

[ "576.1", "276.7", "560.1", "790.7", "041.04", "789.59", "571.6", "511.89", "572.2", "453.85", "567.23", "296.23", "785.59", "584.5", "E888.9", "570", "456.21", "E879.8", "572.4", "261", "453.82", "599.0", "998.11", "276.2", "452", "E878.2", "572.3", "297.1", "556.9" ]

icd9cm

[ [ [] ] ]

[ "46.93", "99.71", "00.93", "38.97", "34.91", "34.04", "50.12", "88.47", "39.95", "41.5", "50.59" ]

icd9pcs

[ [ [] ] ]

11334, 11401

3078, 9272

326, 437

11611, 11611

2379, 2379

12209, 12698

1897, 2140

9629, 11311

11422, 11590

9298, 9606

11825, 12186

2155, 2360

282, 288

465, 1591

2393, 3055

11626, 11801

1613, 1729

1745, 1881

80,650

185,263

41289

Discharge summary

report

Admission Date: [**2135-3-16**] Discharge Date: [**2135-4-1**] Date of Birth: [**2051-1-28**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Headache, left-sided weakness Major Surgical or Invasive Procedure: N/A History of Present Illness: History of Present Illness (per Dr. [**Last Name (STitle) 87837**]): Mr [**Known lastname 89906**] is an 84 M w/ history of hypertension, HLP, glaucoma, prostate cancer, squamous cell cancer, and hernias who presents from an outside hospital with with right sided weakness, headache, and new temporal lobe intraparechymal hemorrhage. History taken from wife who is at bedside. Mr [**Known lastname 89906**] has never been one to experience headaches. However, over the past couple of weeks he has been experiencing new onset headaches off and on that have been for the most part relieved with tylenol. However, last night he was on the couch and began experiencing the sudden onset of a rigtht sided headache. He went to bed but was very restless. He woke up at midnight and started vomiting around 2 am . Around 6 am this morning his wife noticed that he was unable to walk and was having weakness along the left side of his body. At this point he was brought to an OSH where he had a BP of 190/95 and a CT of the head demonstrated a right IPH. With no neurology on staff he was transferred to [**Hospital1 18**] for further evaluation. Upon arrival he was reportedly aggitated and was given 2.5 mg of IV haldol. He has been somulent since. Per wife On neuro ROS, the pt denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal numbness, parasthesiae. No bowel or bladder incontinence or retention. Per wife On general review of systems, the pt denies recent fever or chills. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Had recent eczema. Past Medical History: hypertension HLP glaucoma prostate cancer s/p prostectomy ([**2119**]) squamous cell carcinoma Hernia X 2 ([**2129**]) Social History: married, social EtOH, no smoking, no recreational drugs Family History: noncontributory Physical Exam: Physical Examination (on admission per Dr.[**Last Name (STitle) 87837**]): Vitals: T:98.7 P:56 R: 20 BP:142/58 SaO2:99% General: drowsy. Requires fequent simulation to maintain consciousness. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, 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:warm and well perfused Neurologic: -Mental Status: drowsy requiring frequent stimulation. oriented to person, place and date. Unable to relay story. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Able to follow simple commands. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1.5mm. Reacts to threat in BL visual fields. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: increased tone on left. Left sided pronator drift. Was able to keep right arm elevated greater than 10 seconds. Left arm less than 8 seconds. Too inattentive to test individual muscle groups reliably. In lower extremities was able to keep right leg elevated greater than 5 seconds. Left leg about 3 seconds. -Sensory: withdrew all 4 extremities to noxious. Left sided extinction to DSS both tactile and visual. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response was extensor on the left and flexor on the right -Coordination: no obvious abnormal movements. -Gait: not tested Pertinent Results: LABS: [**2135-3-16**] 05:34PM CK(CPK)-89 [**2135-3-16**] 05:34PM CK-MB-3 [**2135-3-16**] 03:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2135-3-16**] 03:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2135-3-16**] 03:35PM URINE RBC-244* WBC-3 BACTERIA-NONE YEAST-NONE EPI-0 [**2135-3-16**] 10:00AM GLUCOSE-153* UREA N-22* CREAT-1.3* SODIUM-140 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-27 ANION GAP-16 [**2135-3-16**] 10:00AM estGFR-Using this [**2135-3-16**] 10:00AM ALT(SGPT)-30 AST(SGOT)-32 LD(LDH)-219 CK(CPK)-84 ALK PHOS-77 TOT BILI-0.5 [**2135-3-16**] 10:00AM CK-MB-3 cTropnT-<0.01 [**2135-3-16**] 10:00AM ALBUMIN-4.4 [**2135-3-16**] 10:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2135-3-16**] 10:00AM URINE HOURS-RANDOM [**2135-3-16**] 10:00AM URINE HOURS-RANDOM [**2135-3-16**] 10:00AM URINE UHOLD-HOLD [**2135-3-16**] 10:00AM URINE GR HOLD-HOLD [**2135-3-16**] 10:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2135-3-16**] 10:00AM WBC-16.1* RBC-4.44* HGB-14.7 HCT-40.7 MCV-92 MCH-33.1* MCHC-36.1* RDW-11.8 [**2135-3-16**] 10:00AM NEUTS-91.8* LYMPHS-5.9* MONOS-1.9* EOS-0.1 BASOS-0.4 [**2135-3-16**] 10:00AM PLT COUNT-248 [**2135-3-16**] 10:00AM PT-12.8 PTT-20.0* INR(PT)-1.1 MICRO: Urine Cx ([**3-16**] neg, [**3-20**] Enterococcus x2, [**3-23**] neg, [**3-25**] neg) Blood Cx ([**3-20**] negx2, [**3-22**] negx2, [**3-23**] negx2, [**3-23**] pendingx2) BAL ([**3-22**] >100,000 ORGANISMS/ML. Commensal Respiratory Flora, [**3-25**] Enterobacter) IMAGING: CT Head ([**3-16**]): IMPRESSION: Large right frontotemporal hematoma and blood components in the subdural space and intraventricular region with leftward midline shift is unchanged. CT Head ([**3-17**]): IMPRESSION: 1. No significant change in the right intraparenchymal hemorrhage with minimal decrease/technical with unchanged right subdural hemorrhage. 2. New extension of blood into the left occipital [**Doctor Last Name 534**] of the lateral ventricle. EEG ([**3-25**]): slow background which reached a maximum of 7 Hz frequency which represents a mild encephalopathy and diffuse cerebral dysfunction. It is also abnormal due to the presence of bifrontal and right centro-temporal delta slowing which represents a focal subcortical dysfunction. There were no epileptiform discharges or electrographic seizures. Carotid U/S ([**3-17**]): Impression: Right ICA stenosis 40-59%. Left ICA stenosis <40%. Bilateral LENIs ([**3-20**] and [**3-27**]): IMPRESSION: No evidence of deep venous thrombosis of the bilateral lower extremities. CXR ([**3-17**]): Cardiomegaly is stable. Bilateral pleural effusions are small. The lungs are clear. CXR ([**3-18**]): Pulmonary vascular congestion has improved since earlier in the day. Residual peribronchial opacification in the left lower lobe is probably dependent edema but should be followed to exclude an early pneumonia. The right lung is entirely clear. CXR ([**3-30**]): The cardiac silhouette is stable. Indistinctness of somewhat engorged pulmonary vessels suggests elevated pulmonary venous pressure. Minimal atelectatic changes are seen at the bases and no discrete focal pneumonia is appreciated. Gallbladder U/S ([**3-26**]): IMPRESSION: Moderately distended gallbladder containing sludge. These findings may represent acute cholecystitis in the correct clinical setting, but are not specific for it. If there is continued clinical concern, a HIDA scan can be obtained. No biliary dilatation. HIDA scan ([**3-27**]): IMPRESSION: Chronic cholecystitis. Brief Hospital Course: Mr. [**Known lastname 89906**] is an 84 year old male who was admitted on [**2135-3-16**]. He was initially transferred to the ICU for management and was transferred out of the ICU on [**2135-3-30**]. Below are the events that transpired during his hospital stay. . Neurology: Right temporal hemorrhage. Stable on repeat CT scans. Had BP parameters < 160. HOB greater than 30 degrees. Able to move his right upper and lower extremities spontaneously. Opens eyes and follows some commands. He is moving left lower extremity in the plane of the bed, but he is not moving his left upper extremity. . Cardiovascular: BP medications were adjusted. He is currently on amlodipine, lisinopril, and metoprolol. He was started on clonidine in the surgical ICU. We have started HCTZ for further blood pressure control. We discontinued his clonidine on the day of discharge. . ID: Spiked fever in ICU. U/A was positive and was initially started on ciprofloxacin. Remained febrile and urine culture grew Enterococcus. He was started on linezolid (in case of VRE b/c he remained febrile). Despite linezolid, fevers persisted. He underwent bronchoscopy. Prior to culture data becoming available and because he was still spiking daily fevers, abdominal source was sought after and an abdominal U/S performed. The study revealed a distended gallbladder w/ sludge and was concerning for possible acute cholecystitis. HIDA scan was performed for further evaluation, which revealed chronic cholecystitis. Surgery consult was obtained and no immediate intervention was recommended. . Cultures from BAL eventually grew enterobacter and Kliebsiella. ID was consulted. He is completing an 8 day course of treatment for treatment of VAP. His antibiotics for treatment of PNA also covered Enterococcus from urine culture. Therefore, his UTI is adequately treated. . Pulmonary: Was intubated in the ICU for airway protection initially. He is s/p trach and maintaining good O2 sats on trach collar. . Gastrointestinal: Had PEG tube placed for nutrition in the ICU. His tubefeeds are Boost Glucose control (full strength). We add banana flakes on his tubefeeds. His rate is 60cc/hr and his residual checks should be every 4 hours. Tubefeeds should be held for residuals greater than 200cc. His PEG tube should be flushed with 30cc of water every four hours. . He had a speech and swallow consult on transfer to the floor and they recommended a PMV with oral care every 4 hours. Instructions for PMV care will be included in his discharge paperwork. He should continue with speech therapy at rehab. General Care: Pt. should wear multipodus boots until he starts ambulating. He does have a Foley and Flexiseal are in place. Medications on Admission: Aspirin 81 mg PO daily Lipitor 10 mg PO daily Lisinopril/HCTZ 5mg? unsure dosing Glaucoma eye drop (alphagan?)and steroid eye drop. Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 2. sulfacetamide-prednisolone 10-0.2 % Drops, Suspension Sig: One (1) Drop Ophthalmic Q6H (every 6 hours). 3. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain/fever. 8. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 9. metoprolol tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 10. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for restlessness. 12. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 14. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. aspirin, buffered 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**] Discharge Diagnosis: Primary Diagnosis: Temporal Intraparenchymal Hemorrhage . Secondary Diagnosis: Urinary Tract Infection Ventilator-associated pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 89906**], It was a pleasure taking care of you during your hospital stay. You were admitted after you developed a new intracranial bleed. You had a short hospital stay in the intensive care unit. During your hospital stay, you had a trach and PEG completed. You were treated with antibiotics for a ventilator-associated pneumonia and urinary tract infection. You will finish your course of antibiotics on [**2135-4-1**]. Please follow up with your primary care physician [**Last Name (NamePattern4) **] 1 week. In addition, you should follow up with Dr. [**Last Name (STitle) **] as an outpatient. Please follow up in 6 to 8 weeks with Dr. [**Last Name (STitle) **] after discharge. His office phone number is as follows: ([**Telephone/Fax (1) 2574**]. Followup Instructions: Please follow-up in 6 weeks in the stroke clinic. We have scheduled an appointment with Dr. [**Last Name (STitle) **] on Tuesday, [**6-21**] at 1:30pm. If you need to change your appointment date, please call ([**Telephone/Fax (1) 2574**]. Dr. [**Last Name (STitle) **] office is located in the [**Hospital Ward Name 23**] building on the [**Location (un) **].

[ "342.90", "401.9", "V10.46", "575.11", "348.5", "599.0", "365.9", "997.31", "263.9", "431", "041.04", "V10.83", "272.4", "518.81", "041.3" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.93", "43.11", "96.6", "33.24", "00.14", "31.1" ]

icd9pcs

[ [ [] ] ]

12489, 12587

8160, 10856

342, 348

12766, 12766

4446, 8137

13727, 14092

2485, 2502

11038, 12466

12608, 12608

10882, 11015

12917, 13704

3324, 4427

2517, 3021

273, 304

376, 2252

12687, 12745

12627, 12666

12781, 12893

2274, 2395

2411, 2469

47,785

151,840

25135+57437

Discharge summary

report+addendum

Admission Date: [**2133-10-1**] Discharge Date: [**2133-10-16**] Date of Birth: [**2059-11-16**] Sex: F Service: SURGERY Allergies: Latex / Penicillins / Advair Diskus Attending:[**First Name3 (LF) 6088**] Chief Complaint: 73F with h/o AAA with EVAR in [**2130**] s/p explant in [**2130**] for [**Year (4 digits) **] infection with subsequent aorto to right common iliac artery [**Year (4 digits) **]. Yesterday [**9-30**] she presented to an OSH in [**State 1727**] with acute abdominal pain and reported one having bright red blood per rectum and diarrhea. The patient also reports falling in the bathroom on [**9-30**] and complains of right shoulder and abdominal pain. A non-contrast CT was done which showed fluid in the pelvis. She was then transferred to [**Hospital 1727**] Medical Center where she was remained hemodynamically stable, had a HCT of 30.4, and a WBC of 10.2. As there was concern for a leaking [**Hospital **] with fluid in the pelvis, she was transferred to [**Hospital1 18**] via [**Location (un) 7622**]. Major Surgical or Invasive Procedure: [**2133-10-1**] Exploratory Lap [**2133-10-1**] Endovascular Covered stent [**Month/Day/Year **] Right Iliac Anastomosis [**2133-10-2**] PICC line placement [**2133-10-8**] Tunneled HD line placement History of Present Illness: T 74 y/o F with PVD, CAD (MI [**2132-8-18**] s/p 4 DES), CKD (on dialysis from [**2132-8-18**] to [**2133-2-18**] for CIN after cardiac cath) transferred from [**Hospital 1727**] Medical Center for concern of AAA rupture. She has a history of AAA with s/p repair in [**2130**] followed by explant in [**2130**] for [**Year (4 digits) **] infection with subsequent aorto to right common iliac artery [**Year (4 digits) **]. She presented to an OSH in [**State 1727**] with acute abdominal pain and reported having bright red blood per rectum. Her HCT there was 30. A non-contrast CT showed fluid in the pelvis consistent with blood. She was then transferred to [**Hospital 1727**] Medical Center where she was remained hemodynamically stable, had a HCT of 30.4. She was transferred to [**Hospital1 18**] via [**Location (un) 7622**] for concern of leaking aortic [**Location (un) **] and taken directly to the OR for exploration. Past Medical History: - CKD, developed CIN after her MI in [**2132-8-18**] and was on dialysis from [**2132-8-18**] to [**2133-2-18**]. - MI in [**2132-8-18**] s/p 4 [**Name Prefix (Prefixes) **] - [**Last Name (Prefixes) **] - Diabetes (on the patient's list, but she denies having diabetes) - GERD - Hypothyroidism - PVD - History of C-diff - History of MRSA pneumonia - History of DVT - History of VISA fem-fem [**Last Name (Prefixes) **] infection - s/p Tonsillectomy - s/p Appendectomy - s/p Cholecystectomy - s/p Achilles tendon repair - s/p Exlap for ?UC - s/p EVAR c/b left limb occlusion [**2-26**] - s/p L ileofemoral bypass s/p R->L fem/fem bypass - s/p Left AKA & AKA revision - s/p STSG L groin wound - s/p R FEA, vein patch, R iliac limb angio, removal fem/fem [**Month/Year (2) **] - s/p Aortic and Iliac endarterectomies, Conversion to open retroperitoneal repair of abdominal aortic aneurysm with aorto-uni-iliac tube [**Month/Year (2) **]. Social History: She lives alone in [**Location (un) 12017**], NH. She is retired and had previously worked as a real estate [**Doctor Last Name 360**] in [**Location (un) 24402**], [**State 1727**]. She quit smoking in [**2130**], but had smoked for 40 years. Rare alcohol use. No drug use. She is able to transfer herself from bed to her wheelchair on a daily basis, perform her ADLs. Family History: Positive for renal cancer and rheumatologic disease in her mother, lung disease in three uncles. Pertinent Results: [**2133-10-1**] CT ABD FINDINGS: CTA OF THE ABDOMEN AND PELVIS: The patient is status post aorto-right iliac [**Month/Day/Year **] repair (AAA repair) and status post left AKA. There is no contrast opacification of the left common iliac artery, unchanged from [**2132-5-18**]. The distal aortic aneurysm sac is only slightly enlarged compared to [**Month (only) 116**] [**2132**], but contains no acute hemorrhage. There is no definite evidence of endoleak or active extravasation. There is large amount of acute intraperitoneal hemorrhage, with the largest amount and with the highest density in the RLQ around the cecum. Slightly lower density blood tracks towards the aortic bifurcation (aorta-right iliac bifurcation). Lower density blood is is seen in the perihepatic spaces. There is no evidence of active extravasation in the RLQ; however, dense foci are seen at the cecum, which might represent contrast in an abnormal ileocolic branch. There is stable stenosis at the takeoff of the celiac artery trunk. The [**Female First Name (un) 899**] does not fill with contrast as seen on previous examinations. There are moderate atherosclerotic calcifications of the native aorta. BONES: No suspicious lytic or sclerotic bony lesions. There are small bilateral pleural effusions. There are no focal hepatic lesions. There is mild intra- and extra-hepatic biliary dilatation consistent with a history of cholecystectomy. The pancreas, spleen, both adrenal glands are normal. There are hypoattenuating foci in both kidneys, incompletely characterized by likely representing simple cysts. There are no obstructing renal stones. There is no retroperitoneal or mesenteric lymphadenopathy. The stomach is normal. There is slight dilatation of small bowel loops in the left mid abdomen, likely due to a mild reactive ileus. There is diverticulosis of the sigmoid colon without evidence of diverticulitis. The urinary bladder and uterus are normal. IMPRESSION: 1. Moderate to large amount of acute lower abdominal intraperitoneal hemorrhage, with the largest amount and with the highest density in the RLQ around the cecum, but no definite evidence of active contrast extravasation. 2. The distal aortic aneurysm sac is slightly enlarged compared to [**2132-5-18**], but contains no acute hemorrhage, and there is no definite evidence of endoleak or active extravasation. 3. Source of intraperitoneal hemorraghe remains uncertain, but either the aortic bifurcation at the aorto-right iliac [**Year (4 digits) **] or the ileocolic artery appear most likely. 4. If indicated, conventional angiography or repeat CTA with delayed phase imaging should be considered. [**2133-10-1**] CT HEAD FINDINGS: There is no evidence of acute intracranial hemorrhage, discrete masses, mass effect or shift of normally midline structures. The ventricles and sulci are prominent consistent with age-related involutional changes. Periventricular and subcortical low-attenuating regions appear consistent with sequelae of chronic small vessel ischemic disease. Lacune is noted within the left basal ganglia (2:12). There is no evidence of large acute major vascular territory infarction. Bilateral mastoid air cells and visualized maxillary sinuses are clear. Minimal mucosal thickening in bilateral ethmoid air cells. IMPRESSION: 1. No acute intracranial pathology. 2. Age-related involutional changes. 3. Periventricular and subcortical low-attenuating regions appear consistent with sequelae of chronic small vessel ischemic disease. 4. Ethmoid sinus disease. [**2133-10-8**] tunneled HD catheter TUNNELED DIALYSIS LINE PLACEMENT Study Date of [**2133-10-8**] 1:27 PM [**2133-10-10**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 62957**], [**Known firstname 2747**] [**Hospital1 18**] [**Numeric Identifier 63031**]Portable TTE (Complete) Done [**2133-10-10**] at 10:57:34 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 251**] C. Cardiovascular Institute at [**Hospital1 **] [**Hospital Unit Name 22682**] [**Location (un) 86**], [**Numeric Identifier 63032**] Status: Inpatient DOB: [**2059-11-16**] Age (years): 73 F Hgt (in): 61 BP (mm Hg): 146/55 Wgt (lb): 155 HR (bpm): 76 BSA (m2): 1.70 m2 Indication: Left ventricular function. Right ventricular function. ICD-9 Codes: 424.0 Test Information Date/Time: [**2133-10-10**] at 10:57 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) **], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 16812**] [**Last Name (un) 16813**], RDCS Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Suboptimal Tape #: 2012W000-0:00 Machine: E9-2 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 2.7 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm Right Atrium - Four Chamber Length: *5.6 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.8 cm Left Ventricle - Fractional Shortening: 0.30 >= 0.29 Left Ventricle - Ejection Fraction: >= 60% >= 55% Aorta - Sinus Level: 2.7 cm <= 3.6 cm Aorta - Ascending: 2.5 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 12 Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A ratio: 1.25 Mitral Valve - E Wave deceleration time: 217 ms 140-250 ms Findings This study was compared to the prior study of [**2133-4-28**]. LEFT ATRIUM: Elongated LA. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (?#). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - body habitus. Conclusions The left atrium is elongated. 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. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. No clinically significant valvular regurgitation or stenosis. Indeterminate pulmonary artery systolic pressure. Compared with the prior study (images reviewed) of [**2133-4-28**], the current study is very limited in nature (poor image quality (body habitus)), but no major changes are appreciated. [**2133-10-11**] Abdominal plain film The patient is after recent abdominal surgery. IVC filter is in place. Stent in the right iliac artery is in place. Overall unremarkable distribution of bowel in the abdomen is seen. No definitive dilatation of bowel loops is demonstrated. [**2133-10-12**] ABD SUPINE/ERECT FINDINGS: Supine and lateral decubitus views of the abdomen demonstrate mildly dilated, air filled central small bowel loops, which may represent early or small-bowel obstruction, given relatively normal caliber of the colon. There is air in the rectum. No pneumoperitoneum or pneumatosis. A right iliac stent [**Month/Day/Year **] is in place. Surgical clips are seen in the right upper quadrant. Anterior abdominal surgical staples are unchanged. An IVC filter is in expected location. There is mild diffuse osseous demineralization as well as mild multilevel lumbar spondylosis and bilateral hip osteoarthritis. IMPRESSION: Findings may represent early or partial bowel obstruction. Brief Hospital Course: The patient is a 73-year-old, unfortunate female who has had multiple complications that relate all back to a prior endovascular aneurysm repair. This initial management repair was done in [**State 108**], and subsequent problems with [**Name2 (NI) **] limb occlusion and infection resulted in left above knee amputation, removal of an infected femoral- femoral bypass [**Name2 (NI) **], and ultimately removal of the infected main body of the endovascular device. This was performed 2- [**1-19**] years ago, and the aorta was reconstructed with a rifampin-soaked tube [**Month/Day (2) **] from the infrarenal aorta to the common iliac artery on the right. She did remarkably well after this and had no evidence of recurrent [**Month/Day (2) **] infection for 2-1/2 years. Her initial organism was fairly resistant (VISA). She was unable to tolerate her Bactrim due to neutropenia, and after stopping it, never resumed any suppressive antibiotic therapy. She returned to the hospital with hemoperitoneum with unclear bleeding source. There was no CT evidence of recurrent [**Month/Day (2) **] infection. She was explored by Dr. [**Last Name (STitle) 16471**] of the Acute Care Surgery Service, who found a large amount of acute blood clot in the pelvis with evidence of inflammation in the retroperitoneum overlying the [**Last Name (STitle) **]. A perigraft abscess was found without evidence of ongoing bleeding; but a high index is suspicion that the distal anastomosis was the source of her hemoperitoneum bleeding. She was treated with a covered stent [**Last Name (STitle) **] R iliac anastamosis. She was recoverd in the ICU until the 15th when she was extubated. She was transfered to the VICU. HD was initiated and a tunneled line was placed. Multiple family meetings were held regarding her goals of care. She was also seen by CSW. The pt together with her family decided that she would not want extensive surgery to explant her aortic [**Last Name (STitle) **]. Their main concern being her quality of life not quantity. It was explained to her that she may only have months to live. She clearly understands this. She was having some difficulty with abdominal pain and diarrhea. Plain films were taken which were concerning for possible early small bowel obstruction however the pt seemed to improve on her own. Her abdominal incision line is non erythematous and has staples in place. She was evaluated by PT and was found to be below her functional baseline and she requires inpt PT for maximizing her functional status. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from team census . 1. Aspirin 325 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Amlodipine 5 mg PO DAILY 4. Calcitriol 0.25 mcg PO DAILY 5. Duloxetine 30 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Furosemide 80 mg PO DAILY 8. Gabapentin 300 mg PO TID 9. Hydrocodone-Acetaminophen (5mg-500mg) [**1-19**] TAB PO Q4H:PRN pain 10. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 11. Levothyroxine Sodium 112 mcg PO DAILY 12. Pantoprazole 40 mg PO Q24H 13. Temazepam 7.5 mg PO HS:PRN insomnia Discharge Medications: 1. Amlodipine 10 mg PO BID 2. Aspirin EC 325 mg PO DAILY 3. Gabapentin 300 mg PO DAILY 4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 5. Levothyroxine Sodium 112 mcg PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. Acetaminophen 500 mg PO Q6H:PRN discomfort 8. Linezolid 600 mg IV Q12H 9. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 10. Calcium Carbonate 500 mg PO QID:PRN heart burn 11. Docusate Sodium 100 mg PO BID 12. Heparin 5000 UNIT SC TID 13. 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. 14. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Tunneled Access Line (e.g. Hickman), heparin dependent: Flush with 10 mL Normal saline followed by Heparin as above daily and PRN per lumen. 15. Heparin Flush (1000 units/mL) 4000-[**Numeric Identifier 2249**] UNIT DWELL PRN line flush Dialysis Catheter (Tunneled 2-Lumen): DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. 16. Lorazepam 0.5 mg PO BID 17. Metoprolol Tartrate 50 mg PO TID Hold for sbp<100 hr<60 18. Nephrocaps 1 CAP PO DAILY 19. Nystatin Oral Suspension 5 mL PO QID:PRN thrush swish and swallow 20. Simvastatin 10 mg PO DAILY 21. Lidocaine 5% Patch 1 PTCH TD DAILY 22. HYDROmorphone (Dilaudid) 0.25 mg IV Q2H:PRN pain 23. HydrALAzine 50 mg PO Q6H hold SBP<100 24. HydrALAzine 20 mg IV Q6H:PRN >160 25. Duloxetine 30 mg PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: Infected aortic [**Location (un) **] Acute Renal failure Failure to thrive Intraabdominal hemorrhage Diffuse peritonitis Disruption of the the distal anastomosis from aorta to the right common iliac artery. postoperative anemia requiring transfusion 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: Ms. [**Known lastname **] - you were admitted to [**Hospital1 1170**] after you were transferred by [**Location (un) **] out of concern for your aneurysm. You were explored surgically and your abdomen washed out because of infection. Your bleeding was able to be controlled by endovascular means. Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions WHAT TO EXPECT: 1. It is normal to feel weak and tired, this will last for [**6-26**] 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! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart with 2-3 pillows every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication ?????? ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ACTIVITIES: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (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 CALL THE OFFICE FOR : [**Telephone/Fax (1) 63033**] ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: The following appointment was listed in the system. It is put here to serve as a reminder. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 32437**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2133-11-12**] 10:00 Please call the office of Dr. [**Last Name (STitle) **]. [**Telephone/Fax (1) **] / Vascular surgery / to be seen in two weeks for staple removal and follow up. Completed by:[**2133-10-16**] Name: [**Known lastname 11266**],[**Known firstname 1647**] Unit No: [**Numeric Identifier 11267**] Admission Date: [**2133-10-1**] Discharge Date: [**2133-10-16**] Date of Birth: [**2059-11-16**] Sex: F Service: SURGERY Allergies: Latex / Penicillins / Advair Diskus Attending:[**First Name3 (LF) 5118**] Addendum: The pt was also seen by and followed closely by Infectious Disease. She was started on lenezolid and will continue this until seen in the [**Hospital **] clinic. She has a Picc line for infusion. Discharge Disposition: Extended Care Facility: [**Hospital6 2876**] - [**Location (un) 2877**] [**Name6 (MD) 116**] [**Last Name (NamePattern4) 2878**] MD [**MD Number(2) 5119**] Completed by:[**2133-10-16**]

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Discharge summary

report

Admission Date: [**2150-4-4**] Discharge Date: [**2150-4-7**] Date of Birth: [**2078-6-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: CHIEF COMPLAINT: Pre syncope REASON FOR CCU TRANSFER: pericardial effusion, hemodynamic monitoring Major Surgical or Invasive Procedure: [**4-4**]- PERICARDIOCENTESIS, DRAIN PLACEMENT [**4-4**]- RIGHT HEART CATHETERIZATION [**4-6**]- DRAIN REMOVAL History of Present Illness: Mr [**Known lastname 11198**] is a 71-year-old man with a history of high degree av block, s/p PPM implantation and recent RV lead extraction with re-implantation, who presented with presyncope and was found to have a moderate/large pericardial effusion and is transferred to the CCU for hemodynamic monitoring. . Per [**Hospital1 1516**] admission note, patient reports that since his last lead extraction and revision on [**2-26**] for a fractured RV lead, he has been having chest pain, described as a stinging sensation in his chest wall. He was evaluated by outpatient EP and had pacer output reduced, with some improvement in his sypmtoms but still with a noticeable chest sensation that coincided with his pulse. He remained active and observed post pacemaker precautions, however started performing situps on a daily basis. About one week ago he felt a muscle sprain and started taking over the counter ibuprofen 600mg three times daily. . On the day of admission, he activated EMS after developing abdominal discomfort and severe nausea, followed by diaphoresis, weakness, and light-headedness. He was brought into ED for further evaluation. . In the ED, VS: 75 18 99% 100/77. He complained of nausea and was found to be hypotensive to 60's systolic. Fluid boluses were given and bedside ultrasound performed which was concerning for large effusion and RV collapse. Cardiology was consulted and a STAT echo was performed, which confirmed a large effusion but did not find evidence of tamponade with a pulsus of 8. His blood pressure improved with fluids and he was admitted to cardiology for further evaluation. Of note, he recently underwent RV lead extraction [**2150-2-26**] and implantation of a dual chamber [**Company 1543**] Adapta L pacemaker. . On arrival to the CCU, he is comfortable and free of chest pain or shortness of breath. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Complete heart block -- s/p multiple lead and generator changes GI bleed Social History: Retired investment banker, does not smoke, drink alcohol, or use drugs, exercises at least 5 times per week. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS - 97.8 120/70 55 16 96% RA Pulsus 8mmHg Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of approximately 20cm at 60 degrees. CV: Distant heart sounds, regular rate, no murmurs, rubs or gallops. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: 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: [**2150-4-4**] 12:20AM BLOOD WBC-11.0# RBC-4.27* Hgb-12.7* Hct-39.3* MCV-92 MCH-29.9 MCHC-32.4 RDW-14.3 Plt Ct-212 [**2150-4-4**] 07:40AM BLOOD PT-12.7 PTT-25.8 INR(PT)-1.1 [**2150-4-4**] 12:20AM BLOOD Glucose-138* UreaN-42* Creat-1.5* Na-139 K-4.5 Cl-103 HCO3-26 AnGap-15 [**2150-4-4**] 12:20AM BLOOD CK-MB-3 [**2150-4-4**] 12:20AM BLOOD cTropnT-<0.01 [**2150-4-4**] 12:20AM BLOOD CK(CPK)-110 [**2150-4-4**] 07:40AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.1 CXR PA/LAT [**2150-4-4**]: FINDINGS: As compared to the previous radiograph, there is no relevant change. Unchanged course of the old and new leads. Borderline size of the cardiac silhouette, no pulmonary edema, no pneumothorax. TTE [**2150-4-4**]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is a moderate to large sized circumferential pericardial effusion with left atrial and right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. There is also significant, accentuated respiratory variation in mitral valve inflows, consistent with impaired ventricular filling. Compared with the prior intraoperative TEE study (images reviewed) of [**2150-2-26**], the pericardial effusion is new and c/w tamponade physiology. CARDIAC CATH [**2150-4-4**]: 1. Pericardial tamponade with improvement in hemodynamics after removal of 400 cc of bloody pericardial fluid. 2. Mild biventricular diastolic dysfunction. 3. Mild pulmonary hypertension. TTE [**2150-4-4**]: Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. The patient is s/p pericardiocentesis from image 10 and on. There is minimal residual pericardial fluid. There is still no tamponade seen. Compared with the prior study (images reviewed) of [**2150-4-4**], the pericardial fluid is now drained. TTE [**2150-4-6**]: Overall left ventricular systolic function is normal (LVEF>55%). with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2150-4-4**], no change post drainage. [**2150-4-4**] 2:30 pm SWAB PERICARDIAL FLUID. GRAM STAIN (Final [**2150-4-4**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Preliminary): A swab is not the optimal specimen collection to evaluate body fluids. NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [**2150-4-5**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. NO GROWTH IN PERICARDIAL FLUID CYTOLOGY NEGATIVE FOR MALIGNANT CELLS Brief Hospital Course: Mr [**Known lastname 11198**] is a 71-year-old gentleman with a history of high degree AV block, s/p PPM implantation and recent RV lead extraction with re-implantation, who presented with presyncope and was found to have a moderate/large pericardial effusion, transferred to the CCU for hemodynamic monitoring. 1. PERICARDIAL EFFUSION: There was no evidence of pericardial effusion on prior ECHO on [**2150-2-26**]. The new effusion was likely related to pacemaker lead extraction/revision with micoperforation of RV free wall, exacerbated by ibuprofen use, herbal supplements (some of which have antiplatelet and anticoagulant properties), and strenuous physical exercises at home. Patient likely with active tamponade on ED presentation with the hypotension to the 60s and the RV collapsed that became compensated after IVF. Repeat echo taken after fluid given is probable the reason why RV collapse is gone. Differential for effusion also included infectious and inflammatory processes though much less likely given clinical history. The patient went to the cath lab on [**2150-4-4**] in which a RHC revealed equalization of pressures of the pericardial and right heart pressures to 22mmHg prior to pericardiocentesis. Pericardial pressure was 20mmHg. The patient underwent a pericardiocentesis the following morning whereby 400cc of sanguinous fluid was drained. Post procedure pericardial pressure was 0-2mmHg and post-procedure echo revealed resolution of the pericardial effusion. Pericardial drain was left in place. Pericardial fluid studies were negative for bacterial growth and AFB. Cytology was negative for malignant cells. 2. COMPLETE HEART BLOCK: Pacemaker functioning properly per report. EP team to weigh in on plans for lead adjustment, pending plan for management of above. Suspect that if open procedure is pursued, extraction of old leads and revision of new leads could be performed simultaneously. Patient underwent RV lead revision w/ EP on [**2150-4-6**] and had pericardial drain pulled. He was discharged on [**4-7**] after pacer interrogation by EP, with 7-day course of cephalexin to end on [**4-12**] post-procedure, as well as follow-up in [**Hospital **] clinic within one week. 3. PRESYNCOPE: This was likely secondary to tamponade leading to hypotension and cerebral hypopefusion. Would also consider arrhythmias though pacemaker functioning properly per report. He had no further episodes of syncope or pre-syncope during his hospital course. 4. ACUTE RENAL FAILURE: Creatinine 1.5 on admission from baseline of 1.0, likely in setting of hypoperfusion, volume depletion, and NSAID use. Creatinine impoved with hydration and was 0.9 at the time of discharge. Medications on Admission: CURRENT MEDICATIONS: ACETYLCARNITINE [ACETYL L-CARNITINE] - (Prescribed by Other Provider) - 250 mg Capsule - 1 (One) Capsule(s) by mouth daily ASCORBATE CALCIUM [[**Female First Name (un) **]-C] - (Prescribed by Other Provider) - 500 mg Tablet - one Tablet(s) by mouth twice daily ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a day CALCIUM-MAGNESIUM [CALCIUM AND MAGNESIUM] - (Prescribed by Other Provider) - Dosage uncertain CHOLINE - (Prescribed by Other Provider) - Capsule - one Capsule(s) by mouth twice daily COENZYME Q10 - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth CRANBERRY - (Prescribed by Other Provider) - 500 mg Capsule - one Capsule(s) by mouth twice dialy EVENING PRIMROSE OIL - (Prescribed by Other Provider) - Dosage uncertain GARLIC [ODOR FREE GARLIC] - (Prescribed by Other Provider) - Tablet - two Tablet(s) by mouth daily GINGER (ZINGIBER OFFICINALIS) - (Prescribed by Other Provider) - 500 mg Capsule - one Capsule(s) by mouth daily GINKGO BILOBA - (Prescribed by Other Provider) - 60 mg Capsule - one Capsule(s) by mouth twice daily GINSENG - (Prescribed by Other Provider) - 100 mg Capsule - two Capsule(s) by mouth daily GLUCOSAMINE-CHONDROITIN - (Prescribed by Other Provider) - 500 mg-400 mg Capsule - 2 Capsule(s) by mouth once a day GLUTAMINE [L-GLUTAMINE] - (Prescribed by Other Provider) - 500 mg Capsule - 2 (Two) Capsule(s) by mouth daily GREEN TEA LEAF EXTRACT [GREEN TEA] - (Prescribed by Other Provider) - 315 mg Capsule - one Capsule(s) by mouth daily INOSITOL - (Prescribed by Other Provider) - 500 mg Tablet - one Tablet(s) by mouth daily LECITHIN - (Prescribed by Other Provider) - 518 mg Capsule - one Capsule(s) by mouth daily MILK THISTLE - 200 mg one Capsule by mouth daily MULTIVITAMIN once daily OMEGA-3 FATTY ACIDS 300 mg Capsule by mouth [**Hospital1 **] SAW [**Location (un) **] 160 mg Capsule by mouth twice daily SOY PROTEIN Discharge Medications: 1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 6 days. Disp:*24 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PRIMARY: pericardial effusion, presyncope, acute renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure being involved in your care, Mr. [**Known lastname 11198**]. You were admitted to the hospital because you were feeling dizzy, nauseous and lightheaded which was caused in part by fluid accumulation around your heart (pericardial effusion). This was drained by a needle (pericardiocentesis) followed by a drain, and you had serial echocardiograms (ultrasounds of your heart) to make sure the fluid went away. You also underwent cardiac catheterization. Your medications have CHANGED as follows: 1. Please discontinue all herbal supplements until speaking with your cardiologist. 2. Please discontinue taking Aspirin 81mg daily. 3. We ADDED Cephalexin (Keflex) an antibiotic you will need to take for the next 6 days. (start [**4-6**], end [**4-12**]) Please make an appointment to see your primary care doctor, Dr. [**Last Name (STitle) 58**]. [**Telephone/Fax (1) 3329**] The Electrophysiology (EP) doctors would [**Name5 (PTitle) **] to see you back in clinic within one week. They will call you to make the appointment. Followup Instructions: The Electrophysiology (EP) doctors would [**Name5 (PTitle) **] to see you back in clinic within one week. They will call you to make the appointment. DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2150-4-15**] 4:00 DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2150-8-21**] 2:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2150-8-21**] 2:20 Completed by:[**2150-4-7**]

[ "420.90", "584.9", "V45.01", "785.51", "426.0", "423.3" ]

icd9cm

[ [ [] ] ]

[ "37.75", "37.0", "37.21" ]

icd9pcs

[ [ [] ] ]

12274, 12280

7451, 10151

413, 526

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4112, 7017

13610, 14089

3175, 3257

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41191

Discharge summary

report

Admission Date: [**2156-2-19**] Discharge Date: [**2156-2-25**] Date of Birth: [**2105-12-10**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: right sided weakness and aphasia Major Surgical or Invasive Procedure: none History of Present Illness: 50 year-old right-handed man who presented by ambulance to an outside hospital after sudden onset of right-sided weakness and aphasia. He has no significant past medical history according to his wife. The prior evening he had been out shoveling snow in both his driveway and at a neighbors. [**Name (NI) **] went to sleep normally and then on the morning of [**2156-2-19**] he awoke and had coffee with his wife. She had noticed that he was soft-spoken, but did not notice any language deficits at that time. He went to take a shower and afterwards and then came downstair and gave her a hug. It was around 8:00 am that time she noticed he had developed a right-sided facial droop. He was then quickly becoming weak on his right side. He tried to speak, but she stated that his words were nonsensical. She alos felt as if he was not understanding what she asked him to do. She immediately called 911 and he was taken to [**Hospital3 10310**] hospital. NIHSS at OSH was reported as 20 (right-sided weakness and aphasia) and he was given IV tPA (7.7 mg bolus and then 67.3 mg over 1 hour). CT scan at the OSH was notable for a hyperdense left MCA. Stroke fellow at [**Hospital1 18**] was contact[**Name (NI) **] and he was sent by ambulance for possible neurointervention. A code stroke was called and the patient was taken to CT and then neuro-interventional suite. While on the interventional table at 11:40 am he was noted to be moving his right arm and was now producing speech, although it was still slurred and non-sensical. At this point his NIHSS was down to 8 as detailed below: 1a. Level of Consciousness: 0 1b. LOC Question: 1 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 1 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 1 9. Language: 2 10. Dysarthria: 2 11. Extinction and Neglect: 0 The decision to perform angio was deferred as the patient was improving on the table and given the 2 lesions that would require both stenting and MERCI. Past Medical History: none Social History: works as a marine biologist, lives with his wife, who is a speech therapist, and daughter non-[**Name2 (NI) 1818**] minimal EtOH Family History: Father - had CAD Mother - hypertension no siblings 1 7 yo daughter - healthy Physical Exam: ADMISSION EXAM: T 98 P 60 BP 135/91 R 17 O2 Sat 100% RA GEN: average weight man in NAD, non verbal HEENT: non-icteric sclera, no evidence of trauma CV: no carotid bruits, RRR, nS1S2, no murmurs Pulm: CTABL Abd: soft, NT, ND Ext: no edema Neuro MS: alert, but unable to answer questions of orientation. Language was initially non-verbal and then with nonsensical dysarthric speech. Unable to follow complex commands and only very simple commands were follwed. Attentive to both visual fields. Appears to be trying to understand waht was being said. CN: pupils 4mm b/l and reactive to light, Visual field deficit to right visual field, EOMI w/ no nystgamus, reacts to stimuli on both sides of face, R facial droop, hearing intact b/l, palate symmetric, tongue midline Motor: initial - some movement but inability to maintain antigravity in the right arm and leg ([**3-13**]) Left side full strength in upper and lower extremities; flaccid tone on the right, normal tone on left Reflexes: brisk reflexes b/l in upper and lower extremities; toes up on the right and down on left Sensory: reacted to painful stimuli on both sides but less on the right in the arm and leg Coordination: Left side FNF no dysmetria; right side unable to test Gait: unable to test DISCHARGE EXAM: Global aphasia with improved comprehension, no meaningful verbal output, able to mimick exclaimations. R sided strength antigravity at proximal upper extremity and antigravity at lower extremity. UMN pattern of weakness 4/5. Pertinent Results: ADMISSION LABS: WBC-15.3* RBC-4.64 Hgb-14.4 Hct-41.3 MCV-89 MCH-31.0 MCHC-34.8 RDW-13.6 Plt Ct-237 PT-13.2 PTT-20.3* INR(PT)-1.1 Glucose-140* UreaN-16 Creat-0.9 Na-144 K-3.4 Cl-106 HCO3-29 AnGap-12 ALT-16 AST-16 CK(CPK)-86 AlkPhos-49 TotBili-2.2* Cholest-184 Triglyc-99 HDL-53 CHOL/HD-3.5 LDLcalc-111 %HbA1c-5.5 eAG-111 SERUM TOX NEGATIVE URINE STUDIES: UA NEGATIVE DISCHARGE LABS: Glucose-107* UreaN-14 Creat-0.8 Na-146* K-3.4 Cl-108 HCO3-27 AnGap-14 WBC-9.1 RBC-4.63 Hgb-14.3 Hct-40.1 MCV-87 MCH-30.9 MCHC-35.7* RDW-13.9 Plt Ct-215 ** INR 3.0 EKG: Sinus rhythm. QTc interval prolongation. Left ventricular hypertrophy. Diffuse ST-T wave changes. Cannot rule out acute pericarditis versus early repolarization changes. Clinical correlation is suggested. No previous tracing available for comparison. IMAGING: TRANSTHORACIC ECHOCARDIOGRAM Normal global and regional biventricular systolic function. No pulmonary hypertension or pathologic valvular abnormality seen. Early appearance of agitated saline bubbles in the left atrium/ventricle. This finding is most consistent with a small ASD or "stretched" patent foramen ovale. CT/CTA HEAD AND NECK 1. Long segment non-opacification of the left internal carotid artery, completely occluded from 1 cm beyond the carotid bulb and only reconstituting in the most distal supraclinoid portion from ophthalmic artery. 2. There is complete occlusion of the left middle cerebral artery, and minimal residual luminal enhancement of the A1 segment of the left anterior cerebral artery. 3. Large left MCA territory ischemia with increased mean transit time and decreased blood flow given large area of also decreased volume, there is high risk for this proceeding to infarction. MRI/MRA HEAD AND NECK [**2156-2-19**] 1. There are scattered foci of acute infarction within the left MCA distribution involving the basal ganglia, white matter of the left hemisphere and scattered foci of cortical infarction. No significant edema, or mass effect is demonstrated. No evidence of hemorrhage is present. 2. No discernible change in the occlusion of the left internal carotid artery spanning from approximately 1 cm beyond the carotid bulb to the internal carotid and MCA branches. There is minimal collateral flow through the hypoplastic left A1 and a small left posterior communicating artery. NONCONTRAST HEAD CT ([**2156-2-21**]) 1. No interval hemorrhagic transformation. 2. Interval increased hypodensity along the left MCA territory, compatible with the expected evolution of acute/subacute infarct. 3. Persistent mild effacement of adjacent sulci and left lateral ventricle, without gross midline shift. NONCONTRAST HEAD CT ([**2156-2-23**]) Progressive evolution of left MCA territory infarction with local mass effect on sulci in the left lateral ventricle without midline shift. No hemorrhagic transformation is noted nor elsewhere is there intracranial hemorrhage. Brief Hospital Course: 50 year-old RH man with no significant PMHX presents from OSH after sudden onset of right-sided weakness and aphasia. He received IV tPA at OSH. On presentation to the ED, exam c/w global aphasia and right hemiplegia. CT/CTA showed L carotid dissection with resulting occlusive of L ICA and MCA, and infarction within the L MCA territory. Given his story and presentation, he may have dissected his carotid during shoveling the prior night and then developed extensive thrombosis of the left ICA and left MCA. He may have showered emboli distally as well. Initially he was plegic on the right side with reported gaze deviation and visual field deficits, but this had mostly resolved by the time he reached the neuro interventional angio suite, and he could move his right arm and leg with good resistance at this point. His receptive language ability was improved as well. He therefore did not undergo the interventional procedure for two reasons. First, his neuro exam had improved substantially. Second, there was concern that the attempt to open the left ICA with a stent might cause thrombus to move further down the left MCA and cause more ischemia. He was admitted to the neuro ICU for post-tPA monitoring, and had no complications. At 24 hours post-TPA he was started on IV heparin drip and coumadin. He was continued on heparin drip until INR>2. He was continued then on coumadin with goal INR [**3-11**]. On hospital day 2, the patient had diminished movement on the right side compared to his exam on arrival. He had trace muscle contraction but was not antigravity in either lower or upper extremity, though he did withdraw to pain. Head CT showed local mass effect from edema in the L MCA territory, which likely caused his clinical decline. He was monitored carefully in the stepdown unit, and his exam continued to fluctuate, though it overall improved. There was some concern that he had not completed the stroke, and repeat CT scans were done to evaluate for interval worsening. There remained some local mass effect, with no midline shift or herniation, and no hemorrhagic transformation. He improved more consistently by hospital day 5. At this point, he had antigravity strength of RUE and RLE. Language had minimally improved- he was able to mimick some sounds and exclamations ("boo") and comprehension had improved significantly. Although stroke etiology was clearly L carotid dissection, complete stroke workup was done. TTE showed small stretched PFO or ASD, most likely not related to his current stroke. Fasting lipids were relatively well controlled, and he was started on low dose simvastatin for pleomorphic effects in secondary stroke prevention. PT/OT/S&S evaluated patient. He was cleared for nectars and soft solids. Patient will follow up with Drs. [**Name5 (PTitle) **]/[**Doctor Last Name 7741**] in stroke clinic. Medications on Admission: none Discharge Medications: 1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: dose per daily INR checks. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: L carotid dissection L MCA stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neuro status: global aphasia, R hemiparesis Discharge Instructions: It was a pleasure taking care of you. You were admitted with dificulty speaking and right sided weakness. You were found to have a dissection of your carotid artery on the left, causing a left MCA stroke. You were treated with intravenous and oral blood thinning medication. Followup Instructions: You should follow up with the [**Hospital 4038**] Clinic: Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 7741**] [**2156-4-14**] 1:30 *please call your PCP for [**Name Initial (PRE) **] referral for this appointment [**Telephone/Fax (1) 2574**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]

[ "784.3", "433.80", "443.21", "434.11", "433.10", "342.91", "V45.88" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10278, 10348

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49476

Discharge summary

report

Admission Date: [**2148-7-9**] Discharge Date: [**2148-8-5**] Date of Birth: [**2086-4-8**] Sex: F Service: SURGERY Allergies: Levaquin Attending:[**First Name3 (LF) 148**] Chief Complaint: Gallbladder adenomyomatosis Major Surgical or Invasive Procedure: [**2148-7-9**]: 1. Laparoscopic cholecystectomy. 2. Laparoscopic lysis of adhesions. [**2148-7-13**]: 1. Exploratory laparotomy after recent laparoscopy. 2. Small-bowel resection with primary anastomosis. 3. Adhesiolysis [**2148-7-24**]: 1. IR guided drainage pelvic cul de sac fluid collection History of Present Illness: 62 y/o female with persistent elevation of alk phos and a RUQ ultrasound concerning for a GB mass. She underwent an MRCP which demonstrated a mass in the gallbladder fundus with features consistent with adenomyomatosis. Because of these findings she was scheduled for an elective laproscopic cholecystectomy. Her previous surgical history include an urgent exploratory laparotomy and splenectomy [**2-27**] a splenic laceration during a colonoscopy. Past Medical History: HTN Hyperlipidemia osteoporosis GERD D&C [**11-28**] [**2-27**] vag bleeding: Path non-diagnostic Splenectomy [**8-25**] (perforated during colonoscopy) Social History: no tobacco rare EtOH (1 glass of wine with dinner) works in Dr[**Doctor Last Name **] office (urology) Family History: Mother - DM2, galucoma, breast Ca Mother in her 60's and 70's. [**Name (NI) 8962**] brother with prostate cancer Physical Exam: 97 97 81 106/66 16 98RA NAD, comfortable RRR no m/r/g Breath sounds clear to bases b/l ABd - moderate tenderness over RUQ, port sites c/d/i no drainage. No erythema. ABd soft, non-distended, wound vac in place over 6cm long by 6 cm deep midline incision, with well granulating tissue Ext: no edema or erythema On Discharge: VSS, Afebrile Gen: NAD CV: RRR Lungs: Diminished bilateraly on bases Abd: Midline abdominal incision with VAC dressing. Ext: Warm, no c/c/e. Right UE PICC line. Pertinent Results: [**2148-7-13**] WBC-10.1 Hgb-13.4 Hct-40.0 Plt-540* [**2148-7-13**] Lipase-36 [**2148-7-13**] Calcium-8.6 Phos-3.1 Mg-2.1 Microbiology: [**2148-7-13**] 11:20 pm SWAB Site: PERITONEAL **FINAL REPORT [**2148-7-21**]** GRAM STAIN (Final [**2148-7-14**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final [**2148-7-18**]): PSEUDOMONAS AERUGINOSA. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2148-7-20**]): CLOSTRIDIUM PERFRINGENS. MODERATE GROWTH. BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH. BETA LACTAMASE POSITIVE. [**2148-7-16**] URINE CULTURE: NO GROWTH. [**2148-7-18**] SWAB Source: Abdomen. **FINAL REPORT [**2148-7-22**]** GRAM STAIN (Final [**2148-7-18**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. WOUND CULTURE (Final [**2148-7-22**]): PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 299-9426M [**2148-7-14**]. ANAEROBIC CULTURE (Final [**2148-7-22**]): NO ANAEROBES ISOLATED [**2148-7-20**] 6:40 pm BLOOD CULTURE: No Growth [**2148-7-24**] 11:00 am ABSCESS Site: PELVIS PELVIC COLLECTION. **FINAL REPORT [**2148-7-31**]** GRAM STAIN (Final [**2148-7-24**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. WOUND CULTURE (Final [**2148-7-31**]): [**Female First Name (un) **] ALBICANS. RARE GROWTH. [**2148-7-13**] PATHOLOGY: Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] SPECIMEN SUBMITTED: GALLBLADDER. DIAGNOSIS: Gallbladder, cholecystectomy: Chronic cholecystitis with focal pyloric metaplasia and focal adenomyomatous hyperplasia. Clinical: Adenomyomatosis of gallbladder. [**2148-7-13**]: Pathology Examination SPECIMEN SUBMITTED: Small Bowel. DIAGNOSIS: Small bowel, resection (A-H): Segment of small intestine with perforation most consistent with localized ischemia. Margins viable. RADIOLOGY: [**2148-7-13**] ABD CT: IMPRESSION: 1. Findings consistent with small bowel obstruction with probable transition point in anterior mid abdomen adjacent to which is extensive focal stranding and locally more prominent free air. 2. Free fluid along the inferior tip of the liver tracking along the right and mid abdomen and into the pelvis where there is peripheral enhancement and layering density. [**2148-7-14**] EKG: Sinus tachycardia. Non-specific ST-T wave changes. Compared to the previous tracing of [**2148-7-4**] the rate has increased. [**2148-7-22**] ABD CT: IMPRESSION: 1. Multiple intra-abdominal fluid collections, as detailed, with a collection inferior to the liver demonstrating a hematocrit level, likely reflective of a small hematoma. Superinfection of these small collections are not excluded. [**2148-7-25**] 06:10 Report Comment: Source: Line-PICC COMPLETE BLOOD COUNT White Blood Cells 18.6* 4.0 - 11.0 K/uL PERFORMED AT WEST STAT LAB Red Blood Cells 3.01* 4.2 - 5.4 m/uL PERFORMED AT WEST STAT LAB Hemoglobin 8.9* 12.0 - 16.0 g/dL PERFORMED AT WEST STAT LAB Hematocrit 26.8* 36 - 48 % PERFORMED AT WEST STAT LAB MCV 89 82 - 98 fL PERFORMED AT WEST STAT LAB MCH 29.5 27 - 32 pg PERFORMED AT WEST STAT LAB MCHC 33.2 31 - 35 % PERFORMED AT WEST STAT LAB RDW 14.4 10.5 - 15.5 % PERFORMED AT WEST STAT LAB BASIC COAGULATION (PT, PTT, PLT, INR) Platelet Count 732* 150 - 440 K/uL Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation and treatment. On [**2148-7-9**], the patient underwent laparoscopic cholecystectomy and an extensive laparoscopic lysis of adhesions, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor on clear liquid diet, with a foley catheter, and Oxycodone PO for pain control. The patient was hemodynamically stable. On POD # 1, patient complained increased pain, abdominal discomfort; she was kept in hospital for observation. Diet was increased to regular, but patient had very low PO intake. On POD#2, patient continue to experiencing abdominal pain/discomfort, poor PO, and general weakness/malaise. On POD # 4, patient did not improved in her condition, she underwent abdominal CT, which demonstrated small bowel perforation and obstruction. Patient was taken back in OR, she underwent emergent exploratory laparotomy, small-bowel resection with primary anastomosis, and adhesiolysis. The patient was transferred to the PACU after surgery and was tachycardic and had respiratory distress. Patient was transferred into ICU for further management. Patient was NPO with NGT, started on Vanco/Aztreonam/Zosyn, she had Foley catheter and IV fluids for hydration. Patient's ICU course was complicated by wound infection, her midline incision was open. Wound dressing was changed twice a day with Dakins wet-to-dry dressing. Patient was started on IV Zosyn and Aztreonam, wound cultures came back positive for Pseudomonas Aeruginosa. For detailed ICU course please refer to ICU notes. . On [**2148-7-19**] (POD# [**10-30**]), patient was transferred to the floor on full liquids diet, she was continued on IV Abx., Foley to gravity and telemetry. Patient's diet was advanced to regular, and Foley was d/cd on [**7-23**]. On [**7-22**] patient wound was started on VAC dressing with black sponge. On [**7-23**] patient underwent abdominal CT scan which demonstrated multiple intra-abdominal fluid collections. On [**7-24**] she underwent Ultrasound guided drainage of the intraabdominal fluid collection, fluid was sent in microbiology lab for cultures. Patient tolerated procedure well, she returned on the floor in stable condition. Patient was evaluated by PT and they recommended discharge in Rehab. Prior discharge, patient was continued on VAC dressing and IV antibiotics. Patient was discharge in Rehab on [**2148-8-5**] in stable condition. On discharge he VAC dressing was replaced with wet-to-dry for transport. . Neuro: The patient received Dilaudid PCA and Ketorolac IV for pain control postoperatively with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. After transferred on the floor, and started VAC dressing, patient reported increased abdominal pain. Pain medication was changed from Oxycodone to Dilaudid, she was started on Tylenol around the clock. Patient also received IV Dilaudid prior VAC dressing changes, her pain was adequately controlled since that. CV: Patient had episode of tachycardia post operatively, which were treated with IV/PO Metoprolol. The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: Post operatively patient was required supplemental O2 via tent mask. When stable, patient was continue to receive supplemental O2 via nasal cannula. Chest xrays and CT were negative for PE, patient had atelectasis s/t fluid overload. She was treated with PO diuretics and extensive chest PT. Also, good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. Currently patient's O2 sats stable on room air, her atelectasis improved on radiogram. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: After second surgery, patient's WBC raised to 14.0. She developed purulent discharge from her abdominal incision, and incision was open. Wound cultures were sent and came back positive with Pseudomonas Aeruginosa. Patient was started on antibiotics. Wound dressing was changed [**Hospital1 **] with Dakins solution. Patient's WBC was continued to rise with max 21.3, on [**7-25**] WBC finally started to decline and was 18.6. Patient wet-to-dry dressing was changed to VAC dressing with continuous suction on [**2148-7-22**]. Patient continue on Zosyn and Aztreonam IV. Abscess fluid cultures came back positive for [**Female First Name (un) 564**] Albicans, patient was started on Micafungin 100 mg qd, switched to Fluconazole 200 mg qd, her Aztreonam was d/cd, and Zosyn dose was increased per ID recommendations. Patient's WBC continue to improve and was 10.2 on [**8-3**]. On time of discharge patient continue to receive IV Zosyn, PO Cipro and Fluconazole. Abx will be discontinue per ID recommendations. Endocrine: The patient's blood sugar was monitored throughout her stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; her Hct continue to decline post operatively from 40.1 on [**7-14**] to 26.8 on [**7-25**]. Patient remained asymptomatic with stable vital signs, her Hct remains stable low. No blood transfusion was required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible with assist. Physical therapy evaluated the patient and recommended discharge her in Rehab to continue PT. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with minimal 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: 1. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety. 2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety. 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 10 days: While on narcotic pain meds. Disp:*20 Capsule(s)* Refills:*0* 6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule 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. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 10. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 2 days. 11. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): last dose on [**2148-8-14**]. 12. 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. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 15. HYDROmorphone (Dilaudid) 0.5-1.0 mg IV Q6H:PRN breakthrough pain give prior VAC change Discharge Disposition: Extended Care Facility: [**Hospital1 **] Senior Healthcare - [**Location (un) 1887**] Discharge Diagnosis: 1. Gallbladder mass--adenomyomatosis 2. Small bowel obstruction. 3. Perforated small bowel with peritonitis 4. Wound infection 5. Respiratory distress Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. . 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 [**6-3**] 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: You will continue to have VAC dreesing on your abdominal incision. Dressing will be changed by the nurses in Rehab. Followup Instructions: Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2148-7-25**] 9:45 . Provider: [**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2148-11-8**] 8:00 . Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2149-3-20**] 8:30 Completed by:[**2148-8-5**]

[ "518.0", "041.7", "567.29", "575.11", "998.59", "997.4", "112.89", "997.39", "569.83", "568.0", "401.9", "584.9", "511.9", "E849.7", "272.4", "E878.6", "518.5", "278.00", "238.71", "560.9", "V45.79", "785.0", "211.5", "733.90" ]

icd9cm

[ [ [] ] ]

[ "54.12", "86.28", "54.59", "45.62", "54.91", "51.23", "38.93", "54.51" ]

icd9pcs

[ [ [] ] ]

14232, 14320

6217, 12394

292, 591

14515, 14515

2021, 6194

16414, 16895

1384, 1499

12694, 14209

14341, 14494

12420, 12671

14698, 16259

16274, 16391

1514, 1825

1839, 2002

225, 254

619, 1071

14530, 14674

1093, 1247

1263, 1368

21,460

182,232

51245+51246

Discharge summary

report+report

Admission Date: [**2137-2-19**] Discharge Date: [**2137-2-27**] Date of Birth: [**2095-4-26**] Sex: F Service: Transplant Surgery Service CHIEF COMPLAINT: Elevated liver function tests. HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old female (status post liver-related liver transplant in [**2136-5-31**] with hepatic artery stenosis with stenting times three) who returns with an increase in liver function tests. The patient's denies nausea, vomiting, fevers, chills, or diarrhea. The patient is otherwise doing well. PAST MEDICAL HISTORY: 1. Alcohol abuse. 2. Hemochromatosis. 3. Phospholipase antibody. 4. Neuropathy. 5. Myopathy. 6. Hyponatremia. PAST SURGICAL HISTORY: 1. Status post cesarean section. 2. Status post sweat gland incision. 3. Status post liver-related liver transplant in [**2136-5-31**]. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Bactrim single strength one tablet by mouth once per day. 2. Aspirin 81 mg by mouth once per day. 3. Prednisone 5 mg by mouth once per day. 4. Protonix 40 mg by mouth once per day. 5. Ciprofloxacin 500 mg by mouth once per day. 6. OxyContin 20 mg by mouth twice per day. 7. Percocet as needed. 8. Neurontin 900 mg by mouth three times per day. 9. Actigall 600 mg by mouth twice per day. 10. CellCept [**Pager number **] mg by mouth twice per day. 11. Ambien 10 mg by mouth once per day. 12. Plavix 75 mg by mouth once per day. 13. Neoral 125 mg by mouth twice per day. 14. Fluconazole 200 mg by mouth once per day. 15. Linezolid 600 mg by mouth twice per day. PHYSICAL EXAMINATION ON PRESENTATION: The patient's was afebrile with stable vital signs. In no apparent distress. Examination of the lungs revealed clear to auscultation bilaterally. Examination of the heart revealed a regular rate and rhythm without any murmurs. The patient's abdomen revealed a soft, nontender, and nondistended abdomen with positive bowel sounds. Examination of her wounds revealed they were clean, dry, and intact and well healed. Examination of the legs revealed no edema. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Transplant Surgery Service, laboratories were sent, and a computed tomography was obtained to evaluate thrombosis of the hepatic artery, and percutaneous transhepatic cholangiography drains were opened. On hospital day one, the patient was tremulous, and the patient's systolic blood pressure was down to 95 to 100, and her oxygenation was down to 92% to 94% on room air. However, the patient's gas showed a pH of 7.21/29/15/12 and -15. At this time, a computed tomography revealed that the patient had a thrombosed hepatic artery and the transaminase and alkaline phosphatase were markedly elevated. At this time, the decision was made to intubate the patient to improve the patient's hemodynamics. Considering the fact that the hepatic artery was completely thrombosed and that the patient's liver function tests were markedly elevated, the clinical picture at this time was consistent with liver failure. The Transplant Listing Committee convened an emergency meeting to discuss the possibility for the patient's care. Due to the fact that the patient used alcohol on [**2137-1-9**]; and as per a subsequent contract signed by her, the decision was made that she was not eligible for transplant for three months beginning on [**2137-1-14**] (the date of the contract). The patient will be reactivated on the transplant list on [**2137-4-15**] when she has satisfied the conditions for the contract. Thus, the decision was made to do supportive care for this picture that was consistent with liver failure. The patient's bile culture was sent. A blood culture and urine culture were sent on admission. The patient was sent to the Intensive Care Unit where the patient was put on linezolid, Zosyn, Bactrim, and fluconazole for a temperature of 101.8. She continued to be intubated and remained for supportive care. The patient's alanine-aminotransferase on presentation was 803, her aspartate aminotransferase was 1022, her alkaline phosphatase was 502, and the patient's total bilirubin was 9.2. On hospital day two, the patient's symptoms markedly improved. The patient was extubated. The patient's alanine-aminotransferase decreased to 378, aspartate aminotransferase decreased to 192, and her alkaline phosphatase decreased to 220. An ultrasound showed that the portal vein was patent. While there was no arterial flow, a chest x-ray did not show any acute process. A computed tomography of the abdomen was read as having a heterogeneous hypoattenuation of the left lobe of the liver, a new foci of air level in the right area of the infarction, and thrombosis in the hepatic artery. On hospital day three, the patient continued to improve. The patient's mental status improved. The patient's cardiac status was stable. She remained nothing by mouth and was continued on linezolid and Zosyn. The patient's white count improved as well. The patient's transaminase, and alkaline phosphatase, and total bilirubin also improved throughout the day. On hospital day four, the patient was transferred to the floor. The patient remained stable and was continued on linezolid and Zosyn. On hospital day five, overnight, the patient's temperature went up to 103.5. The patient was pan-cultured. Otherwise, the patient's vital signs remained stable. A chest x-ray showed a possible left lower lobe infiltrate. The patient's antibiotics were changed to meropenem and linezolid. Her fluconazole was increased to empirically cover her. On hospital day six, the patient continued to have high temperatures up to 103.1 and a low temperature of 92.6. Otherwise, the patient had stable vital signs. She obtained good oral intake. Good drainage from both one and two drains. The patient continued with pain. The patient was started back on her OxyContin 20 mg twice per day. Otherwise, the patient's liver function tests had improved dramatically from the prior day. On hospital day seven, the patient had no complaints. The patient remained afebrile with stable vital signs. The patient was continued on meropenem and linezolid. Otherwise, she had some edema in the lower extremities which was treated with Lasix. On hospital day eight, the patient had no complaints. She remained afebrile with stable vital signs. The patient's transaminase, alkaline phosphatase, and total bilirubin all improved dramatically compared to the prior day. The patient continued to do well. On hospital day nine, the patient had no complaints. She remained afebrile with stable vital signs. A peripherally inserted central catheter line was placed, and the patient was discharged to home. DISCHARGE DISPOSITION: Discharge status was to home. CONDITION AT DISCHARGE: Condition on discharge was good. FINAL DISCHARGE DIAGNOSES: 1. Elevated liver function tests. 2. Alcohol abuse. 3. Status post cesarean section. 4. Status post liver-related liver transplant. DISCHARGE INSTRUCTIONS/FOLLOWUP: Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] next week. Please call for an appointment. MEDICATIONS ON DISCHARGE: 1. Bactrim single strength one tablet by mouth once per day. 2. Protonix 40 mg by mouth once per day. 3. Actigall 600 mg by mouth twice per day. 4. Neurontin 900 mg by mouth three times per day. 5. Prednisone 5 mg by mouth once per day. 6. Oxycodone slow release one tablet by mouth q.12h. 7. Fluconazole 400 mg by mouth once per day. 8. Lasix 20 mg by mouth once per day. 9. Cyclosporine modified 100 mg by mouth twice per day. 10. Linezolid 600 mg by mouth twice per day. 11. Meropenem 1 gram intravenously twice per day. [**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**] Dictated By:[**Last Name (NamePattern1) 3118**] MEDQUIST36 D: [**2137-2-28**] 11:13 T: [**2137-2-28**] 15:55 JOB#: [**Job Number 106326**] Admission Date: [**2137-2-19**] Discharge Date: [**2137-2-27**] Date of Birth: [**2095-4-26**] Sex: F Service: Transplant Surgery CHIEF COMPLAINT: Elevated liver function tests. HISTORY OF PRESENT ILLNESS: This is a 41 year old female who is well known to the Transplant Service, status post autotopic liver transplant in [**2136-5-31**] which is complicated by hepatic artery stenosis, status post stent and shows both percutaneous transluminal coronary angioplasty and multiple mention for elevated liver function tests, and was transferred again with elevated liver function tests. PAST MEDICAL HISTORY: End stage liver disease secondary to alcoholic cirrhosis, hematochromatosis, alpha and phospholipid antibody, neuropathy, myopathy, hyponatremia. PAST SURGICAL HISTORY: Status post orthotopic liver transplant in [**2136-5-31**], status post cesarean section in [**2122**], status post axillary sweat gland excision in [**2122**]. MEDICATIONS AT HOME: Protonix 40 mg p.o. q. day; Aspirin 81 mg p.o. q. day; Oxycontin 20 mg p.o. b.i.d.; Prednisone 5 mg p.o. q. day; Bactrim single strength one tablet p.o. q. day; Neurontin 600 mg p.o. t.i.d.; Cellcept [**Pager number **] mg p.o. q. day; Cipro 500 mg p.o. q. day; Neoral 125 mg p.o. b.i.d. PHYSICAL EXAMINATION: On examination the patient was afebrile with stable vital signs without any apparent distress. Heart sounds heard with regular rate and rhythm. Examination of the lungs revealed clear to auscultation bilaterally. Examination of the abdomen revealed, soft, nontender, nondistended abdomen. Extremities were warm. LABORATORY DATA: The patient had obtained an ultrasound of the liver which revealed that there was patent hepatic artery with flow in the upper direction. The main portal vein and hepatic veins were open and there was no significant change in echogenic foci of the liver parenchyma which represents the sequelae of the bowel leak complicated by hematoma and necrotic tissues. The patient had no focal lesions on laboratory examination. HOSPITAL COURSE: The patient was admitted to the Transplant Surgery Service and kept NPO after midnight for two cholangiogram and transjugular biopsy. The patient, on hospital day #2, had no complaints, and had a low-grade fever of 100.4 over night, otherwise had stable vital signs. The patient had elevated alkaline phosphatase up to 1839 on admission with an ALT 153 and AST of 235, total bilirubin was 1.7. The patient had the cholangiogram which showed nondilated bile duct and antegrade flow of contrast. The patient also had a liver biopsy which showed no rejection. On hospital day #3, the patient complained of neuropathy of the right leg and continued to have a low-grade fever. The patient had a liver angiogram which showed kinking of the common hepatic artery distal to the previously placed stent with 10 mm systolic gradient. This area was stented with improvement in gradient and the patient had a [**4-11**] stent in the common hepatic artery. The PTC drains, left and right drains, put out minimal amount that day and PTC irrigation was started. The patient's Neurontin was increased to 900 p.o. t.i.d. and Actigall was also started that day. On hospital day #4 the patient had no complaints, remaining afebrile with stable vital signs. The patient's Cellcept was increased to 1000 b.i.d. and Valcyte was stopped. On hospital day #4 the patient had no complaints. The patient remained afebrile with stable vital signs. The patient on examination noticed a hole in the tubing of the right drain which was externalized. Interventional Radiology was consulted and the decision was made to take the patient to Interventional Radiology the next morning to replace the tube. On hospital day #6, the patient was seen by Interventional Radiology, to have that replaced which was successful. On hospital day #7, the patient spiked a fever to 102.3 post procedure and the patient was put on Zosyn and was sent for cultures. On hospital day #8, the patient had no complaints, remained afebrile with stable vital signs. The patient's alkaline phosphatase continued to improve after the stenting of the hepatic artery. The patient on hospital day #9 had no complaints, was continued on Zosyn and the patient's urine output also picked up and was doing well. The patient was discharged home in good condition. FINAL DIAGNOSIS: 1. End stage liver disease secondary to alcoholic cirrhosis 2. Hematochromatosis. 3. Alpha phospholipid antibody 4. Neuropathy. 5. Myopathy. 6. Hyponatremia. 7. Status post orthotopic liver transplant. 8. Status post cesarean section. 9. Axillary sweat gland excision. 10. Status post stenting of hepatic artery. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. q. day 2. Aspirin 81 mg p.o. q. day 3. Oxycontin 20 mg p.o. b.i.d. 4. Prednisone 5 mg p.o. q. day 5. Bactrim 1 tablet p.o. q. day 6. Cipro 500 mg p.o. q. day 7. Ambien 5 mg p.o. q.h.s. 8. Actigall 600 mg p.o. b.i.d. 9. Cellcept [**Pager number **] mg p.o. b.i.d. 10. Gabapentin 900 mg p.o. t.i.d. 11. Percocet 1 to 2 tablets q. 4-6 hours prn 12. Plavix 75 mg p.o. q. day 13. Fluconazole 1200 mg p.o. q. day 14. Neoral 125 mg p.o. b.i.d. 15. Linezolid 600 mg p.o. b.i.d. for two weeks. FOLLOW UP PLANS: Please follow up with Dr. [**Last Name (STitle) **] on [**2137-3-2**]. [**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**] Dictated By:[**Last Name (NamePattern1) 3118**] MEDQUIST36 D: [**2137-2-28**] 20:14 T: [**2137-2-28**] 21:46 JOB#: [**Job Number 106327**]

[ "794.8", "305.00", "572.2", "359.9", "996.74", "E878.0", "572.8", "996.82", "444.89" ]

icd9cm

[ [ [] ] ]

[ "88.47", "96.71", "99.07", "99.04", "96.04", "38.93", "00.14" ]

icd9pcs

[ [ [] ] ]

6807, 6848

12797, 13655

7242, 8191

918, 2113

10114, 12433

12450, 12774

7096, 7215

9028, 9317

8844, 9006

2143, 6782

9340, 10096

6863, 6897

8209, 8241

6924, 7061

8270, 8650

8673, 8820

14,129

132,696

7006

Discharge summary

report

Admission Date: [**2142-4-22**] Discharge Date: [**2142-4-25**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 85 yo male, h/o CAD s/p CABG, Hypercholesterolemia, presenign from OSH with chest pain and EKG changes. He states that he has been getting chest pressure intermittently for the past year; this pain gets worse with exertion, better when he lies down, and improves after SL NTG. It is usually associated with some SOB, but he denies any nausea/vomiting/diaphoresis/palpitations. He was scheduled for an outpatient elective catheterization this week. On day of admission, however, he was at his granddaughter's birthday party, when he noticed the gradual onset of this pain. It started in his mid/lower chest and radiated bilaterally to under his armpits. It was associated with SOB and was [**10-15**] at its worst. EMS was called, and he was given NTG spray en route to [**Hospital6 **]. Initial EKG at OSH showed 1-[**Street Address(2) 26224**] elevations with 3-[**Street Address(2) 5366**] depressions anterolaterally, and he was started on NTG drip, given morphine, heparin, and Lopressor. He was transferred here for urgent catheterization which revealed severe native disease with occlusion of SVG-RCA, patent SVG-LAD. Hct was noted to be 23, and first set of CE's was negative. No intervention was performed in the cath lab, and he was transferred to CCU for blood and further mgt. He denies any blood in stool but states he has had a few episodes of hematuria; he has a history of colon cancer for which he had a partial resection of his colon many years ago (?when last colonoscopy). Past Medical History: PMH: 1. CAD, s/p CABG [**62**] yrs ago, with multiple catheterization with stenting in the past (?[**2136**]) Cath: 50% calcified LMCA, prox RCA occlusion, LAD occluded proximally, LCX with prox disease, SVG-RCA occl prox, SVG-LAD patent CO=4.04, CI=2.23, PCWP>30's 2. Aortic Stenosis 3. Colon cancer, s/p resection yrs ago, no chemotherapy 4. Hernia Repair 5. Cholecystectomy 6. CHF, EF unknown Social History: Married, lives with wife, 2 kids Never smoked, no alcohol/drugs Family History: Father with CAD (?age) Physical Exam: VS: 98.6 116/45 68 16 100% 3L NC Gen: very pleasant male, lying in bed, NAD HEENT: PERRL, OP clear Neck: radiation of murmur to carotids, no JVD Lungs: CTA bilaterally, no w/r/r CV: RRR, nl s1/s3, 3/6 SEM heard best at RUSB with radiation to carotids Abd: somewhat tense, NT, NABS, no masses Groin: with arterial and venous sheaths in right groin Extr: no c/c/e, PT 1+ bilat Rectal: soft brown stool in vault, guaiac positive Pertinent Results: [**2142-4-22**] 07:39PM GLUCOSE-127* UREA N-33* CREAT-1.5* SODIUM-142 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-24 ANION GAP-12 [**2142-4-22**] 07:39PM CK(CPK)-198* [**2142-4-22**] 07:39PM CK-MB-24* MB INDX-12.1* cTropnT-0.35* [**2142-4-22**] 07:39PM CALCIUM-8.0* PHOSPHATE-3.9 MAGNESIUM-2.2 [**2142-4-22**] 07:39PM WBC-7.3 RBC-2.50* HGB-7.3* HCT-22.0* MCV-88 MCH-29.0 MCHC-33.1 RDW-13.5 [**2142-4-22**] 07:39PM NEUTS-87.8* BANDS-0 LYMPHS-9.6* MONOS-1.7* EOS-0.8 BASOS-0.1 Brief Hospital Course: 1. CAD: pt was admitted with chest pain with EKG changes (?ST elevations at OSH, although this ECG was not transferred with the pt and ECG at [**Hospital1 **] showed ST depressions only). He was taken to cardiac catheterization, but no intervention was done as the lesion in the graft appeared to have been chronic. There was a question if symptoms of chest pain were all in setting of demand given that the pt's Hct was 23. He was transfused a total of 4 units pRBC's and Hct came up to 34. He was weaned off of the nitro gtt, and BP was controlled with ACEi. Enzymes peaked with a CK of 574, troponin of 1.21. After arriving in the CCU he stated he had no further chest pain and was comfortable. He was started on plavix and kept on ASA. He was not started on a beta blocker because his heart rate was in the 50's without this medication and given his h/o moderate to severe AS, it was felt this medication might worsen his symptoms. ACEi was titrated up to Lisinopril 10mg daily to maintain the pt's sBP around 120. 2. Pump: Echo was performed which showed a nml EF (>55%) but also moderate to severe AS. The pt was gently diuresed while receiving the blood products. He maintained excellent oxygenation and had no edema in his LE's. He was discharged with the increased dose of lisinopril while his outpatient lasix dose was kept the same. 3. Anemia: Hct was 23 on admission, unclear etiology. Pt has a history of colon cancer and ?recent GU bleeding. He was not sure when his last colonoscopy was performed. His Hct remained stable after the transfusions and stool remained brown but guiac positive. He should follow up with Dr. [**Last Name (STitle) 26225**], his PCP, [**Name10 (NameIs) 1023**] may direct a iron deficiency anemia workup which should likely include a colonoscopy as well as possible workup for hematuria. 4. Hypercholesterolemia: Given pt's MI, it was felt that a higher dose of statin would likely be beneficial. His Zocor was increased to 40mg daily and should likely be titrated up if his LFT's remain stable. These should be tested by his PCP and further [**Name9 (PRE) 26226**] carried out in the outpatient setting. 6. AD: Pt was continued on aricept, celexa, and memantine. He was slightly disoriented on first arrival to the CCU, but improved after he was given his medications. 7. BPH: He was continued on finasteride. When his foley catheter was taken out, he had difficulty urinating at first, but eventually voided spontaneously before he left the hospital. 8. ?glucose intolerance: Pt's blood sugars were monitored but his fasting sugars remained below 120 while in house and he did not require any therapy. 9. Renal insufficiency: creatinine was 1.5 on admission. Outside records showed that his recent Cr values were 1.5 to 1.8. The etiology of this CRI is unclear and should be monitored by his PCP. Medications on Admission: Memantine 10 [**Hospital1 **] Aricept 5 QD Finasteride 5 QD Centrum silver ASA 325 QD Lisinopril 5 QD Furosemide Zocor Citalopram 20 QD ALL: NKDA Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Donepezil Hydrochloride 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Memantine HCl 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: MI AS Dementia CRI Iron deficiency anemia Discharge Condition: stable Discharge Instructions: Please continue to take all medications as prescribed. Please resume your prior dose of lasix. Your new medications include: 1. plavix 75 mg once a day. 2. Lisinopril was increased from 5mg to 10mg once a day. 3. Zocor was increased from 20mg to 40 mg once a day. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 26225**]. His office will call you to schedule an appointment in the next two weeks. Please call [**Telephone/Fax (1) 26227**] if you do not hear from them. Please also follow up with Dr. [**First Name (STitle) 1557**] in the next several weeks.

[ "410.71", "294.10", "428.0", "792.1", "414.02", "331.0", "280.9", "414.01", "424.1", "780.6" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.23", "99.04" ]

icd9pcs

[ [ [] ] ]

7210, 7273

3351, 6209

272, 297

7359, 7367

2846, 3328

7679, 7977

2353, 2377

6406, 7187

7294, 7338

6235, 6383

7391, 7656

2392, 2827

222, 234

325, 1831

1853, 2256

2272, 2337

30,464

134,280

29882

Discharge summary

report

Admission Date: [**2174-12-12**] Discharge Date: [**2175-1-23**] Date of Birth: [**2128-5-2**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: Sleeping all day, fatigue, decreased PO intake Major Surgical or Invasive Procedure: Therapeutic paracentesis History of Present Illness: 46 yo M w/cryptogenic cirrhosis ([**1-21**] NASH or alpha-1-antitrypsin deficiency), GERD, OSA, awaiting liver transplant (MELD of 24), well known to our service, here with vomiting x 1 day, decreased PO intake x several months, extreme fatigue/sleepiness x 3 days. History was acquired from the patient's wife, since the patient was cooperative but too somnolent to answer questions. The patient vomited 3-4 times yesterday, small amounts, watery, no blood. He has vomited blood once in his life several months ago, and not since. He has had no sick contacts. He has had decreased PO intake for the past year since being diagnosed with cirrhosis, with a 50 lb weight loss over the past year, thought to be due from decreased PO intake. Patient has no appetite, but no abdominal pain upon eating and no vomiting with eating. He has had no blood in his stool. This decreased PO intake has been progressively becoming more severe over the past several months. He has had extreme fatigue/sleepiness for the past 3 days. He has been taking lactulose 30 ml [**Hospital1 **] and his wife confirms that he did actually take these doses, but she feels that although he has been having BMs, that they have been small. He has not been able to take more lactulose than [**Hospital1 **] due to sleepiness. His last paracentesis was 3.5 L, performed 5 days ago in outpatient clinic. 3-4 weeks ago, he had a thoracentesis of his R lung, 2 L removed. Past Medical History: 1)Cryptogenic cirrhosis ([**1-21**] NASH vs. alpha-1-antitrypsin deficiency), MELD score 21. Patient was found to be negative for hemachromatosis genes. He is negative for hepatitis A, B and C. He is HIV negative, [**Doctor First Name **] negative. [**Doctor First Name **] is positive with a low titer of 140. Recent alpha-fetoprotein was 2.7. Alpha-1 antitrypsin genotype which was negative. 2)OSA on CPAP 3)GERD 4)s/p inguinal hernia repair about 40 years ago Social History: The patient lives with his wife and two children. He works in a sprayed asphalt business for approximately 18 years. He does not smoke tobacco or drink EtOH. Family History: The patient's sister has been treated for non-[**Name (NI) 4278**] lymphoma. The patient's brother has hypertension. The patient's father had hypertension and alcoholism. The patient's mother had kidney disease. Physical Exam: VS: 98.4, 84/50, 61, 16, 94 RA GENERAL: Diffusely jaundiced, easily arousable but very sleepy, cooperative HEENT: Moist MM, PERRL, icteric sclera LUNGS: CTA B, no rales, no wheezing HEART: RRR, no m/r/g, PMI nondisplaced ABDOMEN: Soft, mildly distended, +BS, no tenderness to palpation throughout, clean para site with no erythema EXTR: 1+ pitting edema bilaterally, mild asterixis SKIN: Skin tags in axillae bilaterally, cherry angiomata on abdomen, no rash NEURO: Normal gait, [**4-24**] motor Pertinent Results: [**2174-12-12**] 12:45PM WBC-4.1 RBC-2.77* HGB-11.0* HCT-32.0* MCV-116* MCH-39.6* MCHC-34.3 RDW-15.4 [**2174-12-12**] 12:45PM ALT(SGPT)-87* AST(SGOT)-105* LD(LDH)-207 ALK PHOS-94 AMYLASE-35 TOT BILI-10.7* [**2175-1-23**] 03:20AM BLOOD WBC-7.5 RBC-3.15* Hgb-10.5* Hct-30.2* MCV-96 MCH-33.2* MCHC-34.6 RDW-20.2* Plt Ct-265 [**2175-1-22**] 05:35AM BLOOD WBC-5.4 RBC-2.93* Hgb-9.1* Hct-27.7* MCV-94 MCH-30.9 MCHC-32.8 RDW-19.9* Plt Ct-217 [**2175-1-23**] 03:20AM BLOOD PT-12.4 PTT-24.1 INR(PT)-1.0 [**2175-1-23**] 03:20AM BLOOD Glucose-120* UreaN-17 Creat-0.6 Na-136 K-4.1 Cl-97 HCO3-37* AnGap-6* [**2175-1-22**] 05:35AM BLOOD Glucose-101 UreaN-13 Creat-0.5 Na-140 K-4.2 Cl-99 HCO3-33* AnGap-12 [**2175-1-23**] 03:20AM BLOOD ALT-24 AST-15 AlkPhos-65 TotBili-0.6 [**2175-1-22**] 05:35AM BLOOD ALT-24 AST-16 AlkPhos-62 TotBili-0.6 [**2175-1-23**] 03:20AM BLOOD Calcium-8.3* Phos-4.7* Mg-1.2* [**2175-1-13**] 05:06AM BLOOD VitB12-783 Folate-9.6 [**2174-12-23**] 05:10AM BLOOD Triglyc-50 HDL-17 CHOL/HD-3.7 LDLcalc-36 [**2175-1-13**] 05:06AM BLOOD TSH-3.4 [**2175-1-23**] 03:20AM BLOOD FK506-15.5 (not true trough, as blood drawn early) [**2175-1-22**] 05:35AM BLOOD FK506-11.6 [**2175-1-21**] 05:15AM BLOOD FK506-10.2 Brief Hospital Course: He was initally admitted to the medical service and the following problems were managed. #GI Bleed,N/V: few episodes of melanotic stool associated with drop in HCT. PRBCs given; however,melanotic stools continued and hematocrit not maintained. Transfered ICU. A total of 8 units FFP, 6 units FFP, 1 unit cryo given. EGD showed diffuse portal gastrophy but no evidence of active bleeding. Hct stabalized in upper 30's. Lasix, spironolactone, nadolol held for BP 85/50. IV hydration given. Blood cx, urine cx, and stool cx negative. Vomiting improved by [**12-17**]. #50 lb weight loss over the past year with decreased PO intake due to lack of appetite and intermittent vomiting. Dobhoff placed under fluoroscopy by IR and tube feeds were started. #Fatigue/sleepiness: Likely from decreased lactulose intake and decreased BMs, in addition to evolving cirrhotic disease. There was concern on admission for SBP, although the patient had confusion 5 days before admission and had undergone a therapeutic paracentesis of 3.5L showing no SBP. Mental status improved with lactulose. A diagnostic tap showed no SBP. Lactulose QID was titrate with slow improvement of his mental status. Rifaximin was continued. A complete infectious work up was completed which only revealed a small lingular pneumonia for which levoquin was given. # Hyponatremia: Na slowly began to improve but subsequently dropped to 119 on [**12-20**] and 117 on [**12-20**]. Fluid restriction was tightened to 1 Liter. Sodium continued to be low and was not responsive to the fluid restriction. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test performed interpreted as low. Stress dose steroids started and transitioned to oral therapy without improvement of his hyponatremia. Free cortisol was low normal. An endocrine consult was obtained and they did not believe that his clinical situation could be completely explained by the adrenal insufficiency. #Hyperkalemia: Patient was noted to have refractory hyperkalemia. Initial concern was for adrenal insufficiency. However, ACTH was low. Endocrine deemed this to not be compatable with primary adrenal insufficiency. They believed that his aldosterone axis should be intact. #High MCV: The patient was noted to have a high MCV while admitted. His B12, folate, and TFTs were normal. It was thought that the degree of elevation of his MCV was higher than typically seen in liver disease. Heme/Onc was consulted and they performed a bone marrow biopsy which showed ... NORMOCELLULAR ERYTHROID-DOMINANT BONE MARROW WITH MATURING TRILINEAGE HEMATOPOIESIS # Right hepatic hydrothorax: On his last admission 3-4 weeks ago, he was found to have a R hepatic hydrothorax with associated RML collapse. Thoracentesis showed serosanguinous fluid. Two CT scans of his chest during his stay showed improvement of the RML collapse. He was followed by the pulmonary clinic [**11-29**], noting improvement. On [**2175-1-5**] he underwent cadaveric liver transplant with Roux-en-Y hepaticojejunostomy reconstruction from a 21 y.o. brain dead donor. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. The Transplant Surgical service managed his care postop. Please see operative report for further details. EBL was 600cc. He received standard induction immunosuppression. Two JPs and a Roux tube were present. Immediately postop, he was transferred to the SICU intubated for management. Hcts trended down and he required 4 units of PRBC and 5 platelets on [**1-6**]. He was taken back to the OR for exploration for concern for hemorrhage. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Per the OR report, "there was an area in the retroperitoneum which was oozing which was cauterized. There was also some noted on the diaphragm which was oozing which was cauterized." Postop, he returned to the SICU. He had high outputs from the medial and lateral JPs (up to 3.5liters/day)for which he received IV fluid replacements and albumin. The drains were eventually removed. LFTs trended down to normal ranges. On [**1-9**], he was transferred out of the SICU. Mental status was altered with lethargy. A Head CT was done and this was normal. Neuro was consulted and felt that altered mental status was secondary to encephalopathy with altered sleep-wake cycle. Thyroid function was normal, as well as B12, folate. EEG findings were suggestive of excessive drowsiness but could not rule out an early mild encephalopathy. There were no areas of prominent focal slowing. There were no epileptiform features. An MRI was done showing no acute infarct or abnormal enhancement identified. Increased pre-gadolinium signal in the basal ganglia was consistent with a history of hepatic disease. Mental status slowly improved. On [**1-15**], a liver duplex was performed to evaluate hepatic vasculature. There was moderate volume ascites with more loculated ascites below the left lobe of the liver. Doppler examination of the liver was normal with patent portal and hepatic veins, as well as hepatic arteries. As previously state, the JPs were eventually removed. The incision remained dry and without redness. Staples were to remain in place until follow up in the outpatient transplant center. Diet was advanced, but intake was insufficient partially due to his altered mental status. KCALs were low. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-intestinal tube was placed and tube feedings were initiated. Replete with fiber was the final formula utilized. His po intake did improve some. He did experience loose, frequent stools. Stools were negative for C.diff x2. PT evaluated and recommended rehab for deconditioning and self-care deficit. He was ambulatory with supervision. He did experience a fall while transferring from bed to chair sustaining L facial abrasion that was healing at time of discharge. On [**1-11**], an U/S was done for L arm swelling. This was negative for DVT. Immunosuppresion was adjusted with steroids tapered per protocol. Prednisone dose was 20mg qd. Cellcept remained at 1 gram [**Hospital1 **] and prograf dose was adjusted based on trough levels that were in the 10-12 range. Goal trough levels were [**10-3**]. He was started on Ciprofloxacin 500mg qd for SBP prophylaxis. He was remain on this indefinately. The plan is for him to transfer to [**Hospital **] Rehab. Twice weekly labs should be drawn on Mondays and Thursdays with results fax'd immediately to [**Telephone/Fax (1) 697**] attention [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **], RN coordinator. Medications on Admission: 1. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO TID (3 times a day). 2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 5. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for NAUSEA. 8. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 10. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection four times a day. 11. Outpatient Lab Work Labs every Monday and Thursday for cbc, chem 10, ast, alt, alk phos, t.bili, albumin, and trough prograf level. Fax results to [**Telephone/Fax (1) 697**] attention [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **], RN coordinator 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 15. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: ESLD Malnutrition Discharge Condition: good Discharge Instructions: Please call the Transplant Office [**Telephone/Fax (1) 673**] if you develop fever, chills, nausea, vomiting, inability to take any of your medications, abdominal pain/distension, jaundice, incision redness/drainage or any concerns. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2175-1-26**] 1:10 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2175-1-26**] 11:30 Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2175-2-2**] 11:20 Completed by:[**2175-1-23**]

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icd9cm

[ [ [] ] ]

[ "99.07", "45.13", "50.59", "54.91", "00.93", "38.93", "54.12", "96.6", "99.04", "99.06", "41.31", "99.05" ]

icd9pcs

[ [ [] ] ]

13469, 13548

4522, 11173

360, 386

13610, 13617

3282, 4499

13899, 14348

2538, 2751

12006, 13446

13569, 13589

11199, 11983

13641, 13876

2766, 3263

274, 322

414, 1855

1877, 2346

2362, 2522

54,979

128,748

49454

Discharge summary

report

Admission Date: [**2166-6-5**] Discharge Date: [**2166-6-9**] Date of Birth: [**2090-9-4**] Sex: M Service: NEUROLOGY Allergies: Lipitor / Penicillins Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: acute onset of left facial droop and left sided weakness. Major Surgical or Invasive Procedure: Intravenous tissue plasminogen activator administration History of Present Illness: HPI: The pt is a 75 year-old right-handed man with a history of HTN, HLD and CAD s/p multiple stents who presents with acute onset of left facial droop and left sided weakness. He was having dinner with his family, including his son, who is an [**Name (NI) **] physician at [**Hospital3 4298**]. Acutely at 8:50pm he was noted to have a left facial droop, left arm and left leg weakness, and complained of numbness and tingling on the left side of his body. His speech was also thought to be slightly slurred. A nurse from [**Hospital3 **] happened to be sitting at the table next to them, and helped them in getting a 325mg aspirin, which his son crushed and gave to him, and called 911. He was brought immediately to [**Hospital1 18**], within 30 minutes of the onset of his symptoms, at which time a Code Stroke was called. On neuro ROS, the pt reoirts a slight headache. He denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. No bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: See below -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: 3VD CAD, s/p MI, s/p DES OM1 stent [**2159-1-25**], DES to proximal RCA for 70% ostial proximal in-stent restenosis [**2160-11-25**], Stent to LCx. HTN hypercholesterolemia OSA Low back pain OA (?psoriatic arthritis) Social History: Patient lives in [**Location 620**] in a house with his wife. -Tobacco history:None -ETOH: None -Illicit drugs: None Family History: Family history of DM. ? CAD Physical Exam: Physical Exam: Vitals: P: 76 R: 16 BP: 178/83 SaO2: 99% on RA 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: Obese, soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Very mild dysarthria. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: Left sided facial droop VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Left sided pronator drift. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 4 4 4 5 5 4 5 3 5 4 3 5 3 3 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: Decreased light touch and pinprick in the left face, arm and leg compared to the right. -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. -Coordination: Mild dysmetria on the left arm, possibly secondary to proximal weakness. -Gait: Deferred. Pertinent Results: [**2166-6-5**] 10:16PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2166-6-5**] 10:16PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2166-6-5**] 10:16PM URINE RBC-38* WBC-<1 BACTERIA-FEW YEAST-NONE EPI-0 [**2166-6-5**] 09:38PM GLUCOSE-139* UREA N-22* CREAT-1.0 SODIUM-141 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-15 [**2166-6-5**] 09:38PM estGFR-Using this [**2166-6-5**] 09:38PM ALT(SGPT)-26 AST(SGOT)-24 CK(CPK)-151 ALK PHOS-55 TOT BILI-0.2 [**2166-6-5**] 09:38PM CK-MB-5 [**2166-6-5**] 09:38PM cTropnT-<0.01 [**2166-6-5**] 09:38PM ASA-5.1 ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2166-6-5**] 09:38PM WBC-7.2 RBC-4.82 HGB-14.1 HCT-42.5 MCV-88 MCH-29.3 MCHC-33.3 RDW-14.0 [**2166-6-5**] 09:38PM PT-12.0 PTT-24.4 INR(PT)-1.0 [**2166-6-5**] 09:38PM PLT COUNT-166 Brief Hospital Course: Mr [**Known lastname 23**] is a 75 y.o. man with PMH of CAD S/P 9 stents, HPL, HTN presented to ER after acute onset of left facial droop left hemi-hypesthesia and left side weakness and slurred speech. Patient was having a dinner with the family and his symptoms were noticed by his son who is ER physician. [**Name10 (NameIs) **] was immediatly brought to ER for evaluation where he received tPA at: 22.26 [**6-5**] Imaging: [**6-5**] NCHCT: limited by motion, but no acute findings. lacunar infarct in the left corona radiata. [**6-5**] CTA head: no aneurysm, stenosis, or dissection. severe intracranial ICA atherosclerotic disease. no carotid stenosis. [**6-5**] CTP head: non diagnostic due to patient motion. Neurologic: His MRI demonstrated an acute infarction in the right lateral thalamus/posterior limb. This was thought to be secondary to small vessel disease. On [**6-6**]: Minimal facial droop, symmetrical strength, still with dysarthria. Had MRI that showed expected lacunar hypodensities, no bleed. He was transferred from the unit to the floor to complete his stroke work up. Stroke workup. He was restarted ASA, plavix, SQH. Sent CYP2c19A to eval plavix resistance. This study was still pending at time of discharge. His hgB A1C 6.5 and was therefore was started on Metformin for further stroke protection. Lipid panel--LDL 96 his simvastatin was changed to crestor. -Cardiovascular: With his significant CAD and nine stents. We kept him on plavix and ASA. Plavix resistence studies were pending on discharge. We maintain SBP<180, DBP <110 while in the unit. Upon discharge his SBP ~ 130. On [**6-6**] ECHO: Left atrium is mildly dilated. Trivial MR seen Endocrine: - RISS, goal BS<150 with adequate BS control currently. His A1C was 6.5. He has either diabetes mellitus type 2 or borderline diabetes. As a result, he was started on low dose metformin. He should continue to follow with his PCP regarding this in the future. Prophylaxis: - DVT: boots, SQH, ASA, plavix - Stress ulcer: ranitidinie Medications on Admission: - Lunesta 3mg QHS - Tricor 48mg daily - Plavix 75mg daily - Celebrex 200mg [**Hospital1 **] - Lopressor 25mg [**Hospital1 **] - Isordil 20mg tid - Aspirin 325mg daily - Simvastatin 80mg daily - Flomax 0.4mg daily - Diovan 160mg daily - Ranitidine 300mg [**Hospital1 **] - Lyrica 75mg tid - Miralax daily Discharge Medications: 1. Lunesta 3 mg Tablet Sig: One (1) Tablet PO at bedtime. 2. Tricor 48 mg Tablet Sig: One (1) Tablet PO once a day. 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Celebrex 200 mg Capsule Sig: One (1) Capsule PO twice a day. 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Isordil 40 mg Tablet Sig: 0.5 Tablet PO three times a day. 7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Flomax 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 10. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day. 11. ranitidine HCl 300 mg Capsule Sig: One (1) Capsule PO twice a day. 12. pregabalin 75 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 13. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Right lateral thalamic infarction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 23**], You were admitted for a right lateral thalamic stroke. This was thought to be secondary to your risk factors of high blood pressure and high cholesterol. You were continued on your home Plavix and aspirin for stroke protection. Your stroke risk factors were checked. Your LDL cholesterol was 96. We discontinued your home simvastatin and started you on Rosuvastatin Calcium 40 mg PO daily for improved cholesterol control. You were checked for blood glucose control with a HgB A1c. The level was 6.5. We started metformin 500mg by mouth twice a day for improved blood glucose control to further reduce your stroke risk; please discuss with your primary card doctor regarding continuing this medication. You had a cardiac echocardiogram which demonstrated no cardioembolic source. You need to continue your blood pressure control. You should not smoke. You should continue to eat a low fat healthy diet, and follow up with your primary care physician and stroke Neurology. It was a pleasure taking care of you. Followup Instructions: Please be sure to call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2204**], ([**Telephone/Fax (1) 2205**]) for an appointment 5-7 days after leaving rehab. Department: SURGICAL SPECIALTIES When: THURSDAY [**2166-10-30**] at 9:15 AM With: [**Name6 (MD) 161**] [**Name8 (MD) 6476**], MD [**Telephone/Fax (1) 2998**] Building: None [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site Department: NEUROLOGY When: MONDAY [**2166-7-14**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**] Building: SC [**Known lastname 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Known lastname 23**] Garage

[ "327.23", "414.01", "V45.82", "342.92", "434.91", "250.00", "437.0", "272.4", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.10" ]

icd9pcs

[ [ [] ] ]

8813, 8883

5414, 7451

346, 404

8961, 8961

4482, 5391

10229, 11019

2509, 2538

7806, 8790

8904, 8940

7477, 7783

9144, 10206

3409, 4463

2568, 3081

2031, 2109

249, 308

432, 1923

8976, 9120

2140, 2358

1945, 2011

2374, 2493

54,452

190,110

54448

Discharge summary

report

Admission Date: [**2187-11-28**] Discharge Date: [**2187-12-5**] Date of Birth: [**2122-7-3**] Sex: M Service: MEDICINE Allergies: Keflex / Iodine Attending:[**First Name3 (LF) 2195**] Chief Complaint: Back pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 28064**] is a 65 year old man with history of COPD (2 L NC at night), and CHF who presented after a fall with lower back pain and shortness of breath. Patient describes having a coughing fit while leaning over the dishwasher on the morning of admission and falling back on his back side. He is uncertain if he lost consciousness. He does not believe he had any head trauma and denies use of anticoagulation. He reports this coughing episode was similar to his baseline daily cough but that it was accompanied by some lightheadedness. He reports being in a seated position on the kitchen floor after his fall and that he was unable to stand up due to lower back pain. He denied shortness of breath, numbness or weakness in his lower extremities contributing to his inability to stand up initially. He denied loss of bowel or bladder function or tongue biting with the fall. He describes eventually being able to crawl upstairs to a phone and calling EMS. He reports his shortness of breath did not begin until EMS arrived and they were attempting to help him to a stretcher. In the ED, initial vs were: T 97.5 P 94 BP 152/77 R 20 O2 sat 98% RA. Labs were notable for BNP 186, Cr 1.8 (baseline 1.2), WBC 12.7, Hct 36 (baseline 46), Etoh 56. Preliminary read of pelvic and lumbar-sacral x-rays were negative for fracture. CXR revealed mild pulmonary congestion. EKG was negative for ischemic changes. Patient received azithromycin 500 mg po, ceftriaxone 1 g IV, albuterol nebs x 6, ipratropium nebs x 6, methylprednisolone 125 mg IV, lasix 40 mg IV empirically for his hypoxia and shortness of breath. He received dilaudid 0.5 mg IV x 2 for pain control and subsequently vomited and was given zofran 4 mg IV. On arrival to the ICU, he reports reports his back pain is slightly improved but still present. He describes a pain across his lower back that progresses until he has to change positions. He reports his breathing feels near baseline though on arrival he is on 5L NC and at home he is on room air. He denies any chest pain, palpitations, increased orthopnea, recent leg swelling, fevers, chills, increased sputum production, sick contacts. [**Name (NI) **] has no history of calf pain, recent immobilization, malignancy or VTE. He does admit to recent weight gain of the last several months which he attributes to his increased caloric intake and sedentary life style after retirement. Past Medical History: HTN COPD on 2 L NC at night Depression Head trauma without loss of consciousness in MVA 35 years ago Diverticulosis BPH Diastolic CHF Tobacco abuse Social History: Patient is a retired managager of [**Company 2318**] "The Ride". He is divorced and lives alone. His emergency contact person is his daughter [**Name (NI) 18079**] [**Last Name (NamePattern1) **] but his ex-wife [**Name (NI) **] [**Name (NI) 28064**] is an alternative contact person who lives locally. He retired 6 months ago and has since then increased his tobacco and alcohol use. He denies use of any illicit drugs or herbal medications. - Tobacco: Significant smoking history (various amounts) x 50 years. - Alcohol: Drinks 3 vodka cranberries each night. He reports he has gone a few days in a row without having a single drink and denies having any problems with withdrawal symptoms. He also reports he is drinking more than usual since he has retired 6 months ago. - Illicits: Denies Family History: Per OMR: Father had an MI at 37 and died at the age of 62 with CHF. Mother died at 36 of complications of polio. No known seizures or other neurological disease. Physical Exam: Physical Exam on [**Hospital Unit Name 153**] Admission Vitals: T: 98.8 BP: 139/84 P: 109 R: 22 O2: 93% 6 L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mm, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diffuse wheezing, good air movement, able to speak in full sentences, not using any accessory muscles CV: Tachycardic rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: No focal deficits, able to stand on his own, CN 2-12 intact (tongue with slight deviation to patient's R), no peripheral numbness or weakness, slightly tremulous. Skin: no rashes Pertinent Results: ADMISSION LABS: - [**2187-11-28**] 06:05AM BLOOD WBC-13.8*# (Neuts-75.1* Lymphs-15.8* Monos-3.4 Eos-4.8* Baso-0.9) RBC-3.72* Hgb-13.2* Hct-38.6* MCV-104* MCH-35.6* MCHC-34.3 RDW-12.4 Plt Ct-290 - [**2187-11-28**] 06:05AM BLOOD [**2187-11-28**] 06:05AM BLOOD Glucose-105* UreaN-32* Creat-1.8* Na-138 K-4.1 Cl-92* HCO3-35* AnGap-15 ALT-11 AST-15 CK(CPK)-63 AlkPhos-59 TotBili-0.6 proBNP-186 cTropnT-<0.01 Lactate-1.6 - [**2187-11-28**] 06:05AM BLOOD Ethanol-56* - [**2187-11-28**] 04:47PM BLOOD pO2-61* pCO2-58* pH-7.40 calTCO2-37* Base XS-8 DISCHARGE LABS: [**2187-12-5**] Glc-88 UreaN-38* Creat-1.6* Na-133 K-4.2 Cl-87* HCO3-39* [**2187-11-29**] WBC-11.9* RBC-3.55* Hgb-12.5* Hct-37.4* MCV-105* Plt Ct-253 IMAGING: - [**2187-11-28**] CXR (PA and LAT): As compared to the previous radiograph there is no relevant change. Moderate elevation of the right hemidiaphragm with basal areas of atelectasis and lateral areas of pleural thickening. Diaphragmatic elevation is not recent and has been present in very similar manner on the previous examination of [**2186-7-22**]. No newly appeared focal parenchymal opacity suggesting pneumonia, minimal retrocardiac atelectasis. Normal size of the cardiac silhouette. Tortuosity of the thoracic aorta. No evidence of larger pleural effusions. - [**2187-11-29**] Renal US: No hydronephrosis. No stone or solid mass seen in either kidney. Bilateral simple renal cysts. - [**2187-11-19**] Head CT with no acute intracranial abnormality. Brief Hospital Course: Mr. [**Known lastname 28064**] is a 65 M with a medical history notable for COPD on home oxygen at night, CHF with preserved LVEF, alcohol dependence, and current tobacco use who presented with back pain from a veterbral compression fracture after a fall. His hospital course was complicated by a COPD exacerbation (briefly admitted to ICU for hypoxia though not intubated) and acute renal failure. 1. COPD: Patient improved with steroids, nebulizer treatments, and a 5 day course of levofloxacin. He was discharged on a steroid taper and with home oxygen. On the day of dicharge he was requiring 2L of oxygen at rest, with O2 saturations of 94% at rest and 88% with ambulation. He was told to wear 2L around the clock while at rest and to increase to 3L with ambulation. A VNA will be monitoring his oxygen saturations after discharge. The risks of continuing to smoke in general, and smoking while wearing oxygen, were explained in full. The patient is pre-contemplative at this time. 2. Acute renal failure: Initially secondary to dehydration on admission with some improvement with hydration. Secondary worsening of renal function later in hospital course thought to be secondary to volume overload and poor forward flow. The patient was diuresed 2L on [**2187-12-4**] with Lasix 40mg IV x 2 and his home Metolazone. The following day he was re-started on his home dose of Lasix 40mg PO daily; his Metolazone was increased from every other day to every day. He was instructed to have his electrolytes checked prior to his follow-up appointment with his PCP. [**Name10 (NameIs) **] [**Name11 (NameIs) **] continued to be held throughout this admission. 3. Recurrent vetebral compression fractures: Pain was well-controlled at the time of discharge. Patient has undergone vertebroplasty in the past with good effect, and was instructed to discuss this with his PCP. [**Name10 (NameIs) **] was advised not to drink alcohol or drive while taking narcotic medications. 4. Eosinophilia: No clear etiology but resolved with steroid use; could consider re-checking once off steroids especially in light of compression fractures 5. Alcohol abuse: Patient reports drinking 3 drinks each night and had a positive alcohol level on admission. He had no signs of alcohol withdrawal during the admission. He was seen by social work who recommended outpatient social work follow-up as his alcohol use seemed to be significantly worse after recently retiring and the patient reported finding difficulty finding other ways to spend his recreational time. He was continued on thiamine/MVI/folate 7. Left calf pain: On [**2187-12-4**] patient reported the acute onset of left calf pain and a "[**Doctor Last Name **]" while ambulating in the [**Doctor Last Name **]. LLE ultrasound was negative for DVT. His pain was felt to be musculoskeletal in nature and he was able to bear weight prior to discharge. He was evaluated by PT and given a cane to use until his pain resolves. Medications on Admission: -list confirmed with patient on admission- Metolazone 2.5 mg q MWF Lasix 40 mg daily Lisinopril 10mg daily Aspirin 81 mg daily Doxazosin 5 mg qhs Finsteride 5 mg qhs Flomax 0.4 mg qhs Klor-Con 20 meq daily Buspirone 30 mg daily Celexa 40 mg daily Vitamin B complex Vitamin C Vitamin D Vitamin E Combivent 2 puffs q6h Flovent 2 puffs [**Hospital1 **] Discharge Medications: 1. ipratropium bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. buspirone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 days. Disp:*20 Tablet(s)* Refills:*0* 11. doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 13. prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day for 2 days: [**Date range (1) 46801**]. Disp:*6 Tablet(s)* Refills:*0* 14. prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for 2 days: [**Date range (1) 111449**]. Disp:*4 Tablet(s)* Refills:*0* 15. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: [**Date range (1) 38649**]. Disp:*2 Tablet(s)* Refills:*0* 16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebullizer Inhalation every four (4) hours as needed for SOB/wheezing. 17. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 19. metolazone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 20. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Outpatient Lab Work Please have your electrolytes (Chem 7) checked on [**2187-12-7**] prior to your appointment with your primary care doctor. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: COPD Acute renal failure Vertebral compression fracture Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 28064**], You were admitted after falling at your home. You were found to have another lumbar compression fracture and eventually developed an exacerbation of your COPD and kidney failure. Your back pain is improving with Dilaudid and Tylenol. It is important that you not mix Dilaudid with alcohol and not take more Tylenol than prescribed. It is unclear why you keep having fractures in your back but you need to follow-up with Dr. [**Last Name (STitle) 4922**] for this. For your COPD, please continue on the steroids as prescribed. It is extremely important that you wear your oxygen at all times, using 2L at rest and 3L with ambulation, and that you NOT smoke while wearing oxygen as this could be fatal. Your kidney problems likely developed due to dehydration initially, and then to congestive heart failure after getting a lot of fluid. Please ensure you are eating 3 meals and drinking plenty of fluids. You should continue taking Lasix and Metolazone every day until you meet with your PCP. [**Name10 (NameIs) 357**] have your blood drawn prior to this appointment. You should continue to hold your Lisinopril. Followup Instructions: Department: [**State **]When: FRIDAY [**2187-12-7**] at 10:45 AM With: [**First Name8 (NamePattern2) 8741**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11696, 11754

6244, 9213

286, 292

11853, 11900

4736, 4736

13212, 13501

3753, 3916

9613, 11673

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237, 248

320, 2747

4753, 5281

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2769, 2919

2935, 3737

22,425

199,679

20979

Discharge summary

report

Admission Date: [**2185-12-7**] Discharge Date: [**2185-12-20**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9569**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: pulmonary artery catheter placement History of Present Illness: 81 yo M with CAD s/p MI x3 (last '[**76**]) and PTCA w/stent x2 to RCA and LCx(@ [**Hospital1 112**], [**11-5**]), systolic heart failure EF ~20% (by cath report; 35% by echo [**10-5**]) and IDDM, p/w SOB. Pt reports that he has been having periodic episodes of dyspnea since [**August 2185**], requiring x3 prior admits to [**Hospital1 112**]. He underwent cardiac cath last month, as he was not a good candidate for CABG, but notes no improvement in sxs since the procedure. He was last admitted to [**Hospital1 112**] [**Date range (1) 55744**], where he was treated for hyperkalemia in the setting of ARF with K 5.4 and Cr 4.1 (baseline 1.9-2.0). He also c/o SOB at that time, but CXR showed no evidence of failure and he was d/c'ed home after his potassium had come down. This morning, he called EMS after waking up multiple times over night feeling as though he "was suffocating." Pt states that this has been going on for several weeks but happens more each night over the past week. In the field, EMS found him to be hypotensive w/BP in 80s and hypoxic with O2sats 84%. He was bolused 500cc and transferred to [**Hospital1 **] for further management. Pt has stable 3 pillow orthopnea, occ PND, can walk several blocks with minor difficulty, but cannot climb a flight of stairs without getting SOB. He awakens 3-4x per night to urinate. He denies any recent LE swelling, any non-compliance with med regimen, and any change in dietary habits (follows low Na diet). He does not use O2 at home. In the ED, he received ASA, SLNTGx1 (which relieved his chest tightness), lasix 40mg IVx2 and 0.5 in NTP. He was hypoxic with O2 sats 84%2L, which increased to 87% on [**Last Name (LF) 597**], [**First Name3 (LF) **] he was placed on BiPAP. He responded to the decreased preload/afterload in addition to diuresis, and O2 sats increased to 100% on 4L. He was transferred to the floor for further management. ROS neg for F/C, N/V, dysuria, constipation/diarrhea Past Medical History: -CAD as above. Cath at [**Hospital1 112**] [**2185-11-9**] showed 95% d2 ostial, 70% Cx, and diffuse RCA dz. Cypher DES x2 were placed (RCA and Cx); estimated EF 20%; prior echo ?[**10-5**] showed EF 35%. -ischemic CM, as above -chronic renal insufficiency -GERD Social History: Pt is originally from [**Country 3594**]. He is a retired diesel mechanical engineer. One of his daughters lives in [**Name (NI) 669**]. He lives alone in JP and has a homemaker come in x3/wk and VNA services at home. His daughter [**Name (NI) **] lives in [**Name (NI) 108**] and helps him to make most medical decisions - she is a LPN. Tob 20py hx, quit '[**76**] Occ EtOH no illicits Family History: Mother, 2 daughter and 2 sons with DM2 Physical Exam: 97.5 103 90/77-116/58 20-33 100%4L Gen: Frail, elderly man lying in bed, speaking in full sentences, appears comfortable HEENT:PERRL, OP clear Neck: No LAD; JVP at 8 CVS: frequent ectopic beats; prom P2; +S3 gallop; No RV heave; PMI ~5-6th ICS MAL; no M/R appreciated Chest: Crackles [**2-3**] way up Abd: soft, NT/ND, NABS Ext: No c/c/e Neuro: non-focal Pertinent Results: [**2185-12-7**] 06:45AM WBC-7.2 RBC-3.92* HGB-11.6* HCT-36.3* MCV-93 MCH-29.7 MCHC-32.0 RDW-14.2 [**2185-12-7**] 06:45AM NEUTS-58.1 LYMPHS-31.0 MONOS-6.7 EOS-3.2 BASOS-1.1 [**2185-12-7**] 06:45AM PLT COUNT-151 [**2185-12-7**] 06:45AM CK-MB-5 cTropnT-0.03* [**2185-12-7**] 06:45AM CK(CPK)-173 [**2185-12-7**] 01:10PM CK-MB-4 cTropnT-0.02* [**2185-12-7**] 01:10PM CK(CPK)-147 EKG: sinus tach @ 100bpm; LAD; L ant hemiblock; Q in II, III, aVf; no ST-T changes CXR: Mild CHF with interstitial edema. . PULMONARY ARTERY CATHETER PLACEMENT: COMMENTS: 1. Resting hemodynamics revealed severely elevted left and right-heart pressures (RA mean 20mmHg, PA mean 36mmHg, PCWP mean 21 mmHg). The estimated cardiac output was 1.9 l/min. Dobutamine 10 mcg/kg/min was started in the catheterization laboratory with systolic augmentation of the aortic pressure. FINAL DIAGNOSIS: 1. Cardiogenic shock. 2. Severely elevated left and right heart filling pressures. Brief Hospital Course: 81 yo M with DM2, CRI, CAD s/p MIx3, ischemic CM, EF ~20%, with x5 months SOB not relieved by cath/PTCA, whose primary complaint is waking up extremely short of breath multiple times at night for the past few days. 1) Heart Failure: Pt's hypotension (most-likely explaining his acute weakness and LH this am) and hypoxia on presentation [**1-4**] decompensated failure as evidenced by CXR and exam. Per [**Hospital1 112**] cath report, EF 20%. Acute myocardial infarction was ruled out by EKG and negative enzymes. He was found to have a urinary tract infection which could possibly be the cause of the acute decompensation of his heart failure. He reports compliance to meds and diet. However, he states that his primary doctor has told him that his regimen has not been adequate and may need to be changed. His carvedilol and Captopril were discontinued during hospitalization in the setting of hypotension and acute renal failure during hospitalization. During this hospitalization he was first diuresed and improved symptomatically briefly but then began to decompensate with development of acute pre-renal failure, hypotension, and multiple episodes of awakening at night acutely short of breath. During this time he continued to deteriorate and further diuresis was attempted with natrecor without response. He was transferred to the CCU for further management. While in the CCU he was monitored closely and it was found that he was having up to 5 episodes of [**Last Name (un) 6055**]-[**Doctor Last Name **] breathing perhour, often times with ventricular ectopy and on few occasions with desaturation,. Apneic episodes lasted up to 60 seconds. During this time he also had acutely worsening renal failure, elevation of liver enzymes, and demonstrated change in mental status. A pulmonary artery catheter was place with elevated PCWP and elevated right sided pressures and a mixed venous 02 saturation of 24%. He was started on Dobutamine and within 24 hours his mental status improved, and the [**Last Name (un) **]-[**Doctor Last Name 6056**] breathing episodes decreased in frequency as the cardiac index increased. Within two days the renal funtion began to improve and the liver enzymes began trending down. After several days on Dobutamine he was started on digoxin qd, level was 1.7 and so regimen was decreased to every other day. It was felt that an inotrope was required and though pt had CRI digoxin would be the most beneficial medication to him at this time though it would have to be monitored closely. A follow-up appointment was made with his primary cardiologist for two days from discharge for monitoring. Beta blocker was held as it was felt that it would not be beneficial to him in the current declined state of cardiac function. He was monitored for three days off the docutamine before discharge. . 2) Non-sustained ventricular tachycardia: Episodes occurred in setting of apnea and also while on Dobutamine. In a family meeting it was decided that Dobutamine would be continued despite the increased ectopy. EP was consulted and found that the pt was no currently a ICD candidate. . 3) DM2: Glyburide and Lantus discontinued during episode of ARF but restarted on return to baseline creatinine. . 4) Acute Renal Failure on CRI: Per [**Hospital1 112**] records, baseline Cr around 2.0. Currently 1.5. During worsening heart failure prior to CCU and Dobutamine initiation acute renal failure developed likely secondary to poor perfusion. During this time BUN was elevated to over 100. Function returned to baseline as cardiac index improved. . 5) [**Name (NI) 12007**] pt was treated for complicated UTI with a course of Bactrim. . 6) Code: DNR/DNI. Discussed with pt and family extensively. Medications on Admission: ASA captopril 12.5 TID colace lasix 80' glyburide 10" lantus 10U QHS carvedilol 6.25" simvastatin 10' Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 months: 3 months beginning from [**2185-11-9**]. 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other day. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO bid:prn. 5. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day. 6. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Congestive Heart Failure Coronary Artery Disease Acute renal failure on chronic renal insufficiency Diabetes Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight changes > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: less than 1500 ml per day Followup Instructions: Appointment with your cardiologist Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 32963**] on [**2185-12-22**] at 2:30 pm at [**Hospital6 1708**] [**Last Name (NamePattern1) 27284**] [**Location (un) 86**] - [**Hospital **] Clinic. Completed by:[**2185-12-20**]

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icd9cm

[ [ [] ] ]

[ "89.63", "89.64", "00.13", "93.90", "37.21" ]

icd9pcs

[ [ [] ] ]

8892, 8947

4451, 8188

283, 321

9100, 9108

3455, 4324

9309, 9595

3022, 3062

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186,981

46084

Discharge summary

report

Admission Date: [**2177-11-28**] Discharge Date: [**2177-12-3**] Date of Birth: [**2115-9-6**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: unstable angina Major Surgical or Invasive Procedure: 1. Coronary bypass grafting x3: Left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the third obtuse marginal coronary artery; as well as reverse saphenous vein graft from aorta to the distal right coronary artery. 2. Concomitant maze procedure with pulmonary vein isolation using the [**Company 1543**] Gemini X system with resection of left atrial appendage. 3. Endoscopic left greater saphenous vein harvesting and right greater saphenous vein harvesting. 4. Epiaortic duplex scanning History of Present Illness: 62 y/o male with h/o PAF, tachy-brady syndrome (s/p PPM), CAD (s/p IMI), and CRI presented with exertional angina failing medical therapy. Nuclear stress test non diagnostic 2nd not achieving optimal HR. Notes worsening SOB and dypsnea over past several month. Unable to walk more than a few blocks before getting SOB. Has had some dizziness and lighnheadness. LVEF 40$. Patient also s/p aorto-bifemoral bypass and renal artery stents bilaterally with right renal bypass. Cath today showed totally occluded RCA, diffuse LAD disease and tight ostial LCX lesion. Dr. [**Last Name (STitle) **] has asked cardiac surgery to evaluation for CABG [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]-risk PCI. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -PACING/ICD: s/p Dual chamber pacemaker implantation 3. OTHER PAST MEDICAL HISTORY: Hypertension Hypercholesterolemia Paraxysmal atrial fibrillation Tachy-Brady Syndrome s/p Dual chamber pacemaker implantation CAD s/p IMI LVEF of 40% Chronic Renal Insufficieny Social History: -Tobacco history: Curently smoking 1pack/day for 40years -ETOH: Takes 3 drinks a day -Illicit drugs: occasional marijuana Family History: He has a family history of early atherosclerosis, with siblings requiring vascular interventions at early ages. Physical Exam: Admission Physical Exam: T - 98.3 BP - 149/48 HR - 60 RR - 20 Sat - 100% on RA General - NAD, alert, cooperative, comfortable lying flat HEENT - EOMI, PERRLA Lungs - CTA Cardio - I/VI SEM 2nd LICS, no S3 or S4 Bilateral carotid bruits Abdomen - well healed midline scar, no bruits noted Pulses: Radial arteries - +2 right +2 left Femoral arteries - +2 right +2 left DP - +1 right +1 left PT - +1 right +1 left Neuro - oriented x 3, answers questions appropriately, follows commands, nl muscle tone/strength Pertinent Results: [**2177-12-2**] 12:40PM BLOOD WBC-7.2 RBC-2.74* Hgb-9.2* Hct-27.3* MCV-100* MCH-33.6* MCHC-33.7 RDW-16.1* Plt Ct-191# [**2177-11-28**] 12:10PM BLOOD WBC-7.0 RBC-2.34*# Hgb-8.2*# Hct-24.1*# MCV-103* MCH-34.9* MCHC-34.0 RDW-14.3 Plt Ct-127* [**2177-12-2**] 12:40PM BLOOD PT-15.4* INR(PT)-1.4* [**2177-11-28**] 12:10PM BLOOD PT-13.8* PTT-27.2 INR(PT)-1.2* [**2177-12-2**] 12:40PM BLOOD Glucose-83 UreaN-33* Creat-2.7* Na-136 K-4.1 Cl-100 HCO3-25 AnGap-15 [**2177-11-28**] 01:08PM BLOOD UreaN-32* Creat-2.8* Na-137 K-4.2 Cl-109* HCO3-22 AnGap-10 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 98066**] (Complete) Done [**2177-11-28**] at 10:23:24 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: [**2115-9-6**] Age (years): 62 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Atrial fibrillation. Coronary artery disease. Hypertension. Shortness of breath. Intraoperative TEE for Maze + CABG. ICD-9 Codes: 428.0, 427.31, 786.05, 786.51, 424.0, 424.2 Test Information Date/Time: [**2177-11-28**] at 10:23 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18397**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW1-: Machine: siemens Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.6 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 5.0 cm Left Ventricle - Fractional Shortening: *0.24 >= 0.29 Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Left Ventricle - Stroke Volume: 48 ml/beat Aorta - Annulus: 2.2 cm <= 3.0 cm Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm Aorta - Ascending: 3.0 cm <= 3.4 cm Aorta - Arch: 3.0 cm <= 3.0 cm Aorta - Descending Thoracic: *2.9 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 6 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 4 mm Hg Aortic Valve - LVOT VTI: 14 Aortic Valve - LVOT diam: 2.1 cm Mitral Valve - Pressure Half Time: 57 ms Mitral Valve - MVA (P [**2-15**] T): 3.9 cm2 Findings LEFT ATRIUM: Moderate LA enlargement. LA not well visualized. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. No atheroma in ascending aorta. Normal aortic arch diameter. Mildly dilated descending aorta. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. No AS. No AR. MITRAL VALVE: No MVP. No MS. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Pulmonic valve not well seen. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Results were personally reviewed with the MD caring for the patient. Conclusions Pre CPB: The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). The inferoseptal wall in hypo/akinetic and thinned. Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. There are complex (aproximately 1.1cm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) 914**] was notified in person of the results. Post CPB: The cardiac output is 6.5L/min while on a phenylephrine infusion. The biventricular systolic function is preserved. There is mild mitral regurgitation. The visible contours of the thoracic aorta are intact. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2177-11-28**] 14:45 ?????? [**2170**] CareGroup IS. All rights reserved. Brief Hospital Course: On [**2177-11-28**] mr.[**Known lastname 23081**] was taken to the operating room and underwent 1. Coronary bypass grafting x3: Left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the third obtuse marginal coronary artery; as well as reverse saphenous vein graft from aorta to the distal right coronary artery.2.Concomitant maze procedure with pulmonary vein isolation using the [**Company 1543**] Gemini X system with resection of left atrial appendage. Please refer to Dr[**Last Name (STitle) 5305**] operative report for further details. He tolerated the procedure well and was transferred tot he CVICU intubated and sedated in critical but stable condition. Postoperatively Electrophysiology was consulted for interrogation of Mr.[**Known lastname **] PPM. He awoke neurologically intact and extubated without difficulty. All lines and drains were discontinued in a timely fashion. He was weaned off all drips and Beta-Blocker/Statin/ASA and gentle diuresis was initiated with a transient postoperative oliguria. Mr.[**Known lastname 23081**] has baseline renal insufficiency and immediately postop his creatnine did rise and peak at 3.0. Renal service was consulted for any recommendations postoperatively regarding his baseline kidney dysfunction. He remained in the CVICU for close observation of renal function and improvement. His rhythm postoperatively went into rapid atrial fibrillation and was treated with Amiodarone and increased beta-blocker.Anticoagulation with Coumadin was resumed for his paroxysmal atrial fibrillation/MAZE procedure. On POD# 3 he was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. He continued to progress and his creatnine improved towards baseline. On POD5 he was cleared by Dr.[**Last Name (STitle) 914**] for discharge to home with VNA. All follow up appointments were advised. His INR and coumadin dosing will be followed by [**Hospital3 3583**] [**Hospital 197**] Clinic. Medications on Admission: plavix 75 mg daily, metoprolol 200 mg [**Hospital1 **], cardura 12 mg daily, ventolin HFA 90 mcg/inh 2 puffs q 4 hours prn, simvastatin 40 mg daily, coumadin 5 mg daily, aspirin 81 mg daily, diltiazem ER 240 mg AM and 120 mg q hs 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. potassium chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO twice a day for 3 weeks. Disp:*84 Tablet Sustained Release(s)* Refills:*0* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 5. warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily). 6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [**Hospital1 **] x5 days then 400mg QD x7 days then 200mg QD. Disp:*60 Tablet(s)* Refills:*1* 7. tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* 8. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 weeks. Disp:*42 Tablet(s)* Refills:*0* 12. metoprolol tartrate 100 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*2* 13. diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). Disp:*60 Capsule, Sustained Release(s)* Refills:*2* 14. warfarin 5 mg Tablet Sig: as directed Tablet PO once a day: 5mg on [**12-4**]&22 then as directed by [**Hospital3 3583**] coumadin clinic . Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1376**] Discharge Diagnosis: 1. Severe 3-vessel coronary disease. s/p CABG 2. Paroxysmal atrial fibrillation. s/p MAZE 3. Status post permanent pacemaker placement. 4. Severe peripheral vascular disease with a totally occluded left internal carotid artery 5. Renal Insufficiency Discharge Condition: Alert and oriented x3 nonfocal exam Ambulating with steady gait Incisional pain managed with Ultram Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema: 3+ bilat 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:[**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2177-12-30**] 2:00 Cardiologist:[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2178-1-20**] 10:40 Please call to schedule appointments with your Primary Care Dr [**First Name (STitle) **],[**First Name3 (LF) 1569**] A in [**2-15**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication:Paroxysmal Atrial Fibrillation/MAZE procedure Goal INR:>2.0 First draw [**12-6**] Results to phone fax [**Hospital3 3583**] [**Hospital 197**] Clinic @[**Telephone/Fax (1) 98067**] Completed by:[**2177-12-3**]

[ "414.01", "V45.01", "427.31", "403.90", "411.1", "584.9", "433.10", "585.9" ]

icd9cm

[ [ [] ] ]

[ "36.12", "36.15", "39.61", "37.36", "37.33" ]

icd9pcs

[ [ [] ] ]

12522, 12573

8372, 10451

336, 939

12871, 13104

2954, 7809

14028, 14965

2211, 2324

10732, 12499

12594, 12850

10477, 10709

13128, 14005

2366, 2935

1792, 1845

281, 298

967, 1682

1876, 2055

1704, 1772

2071, 2195

7819, 8349

22,219

199,941

47718

Discharge summary

report

Admission Date: [**2183-3-24**] Discharge Date: [**2183-3-28**] Service: MEDICINE Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 1711**] Chief Complaint: SOB, "fluttering" in chest Major Surgical or Invasive Procedure: 1. DC cardioversion 2. endotracheal intubation History of Present Illness: [**Age over 90 **] y/o with hx. severe AS, NSTEMI, CHF with preserved EF, Atrial fibrillation, presented to the ED complaining of SOB and "fluttering" sensation in chest. Found to be in unstable atrial fibrillation with RVR with rate in 160's and sbp in 60's. Was given Etomidate for cardioversion sedation, cardioverted without recovery of blood pressure. Was also hypoxic post cardioversion, so was intubated. She was placed on dopamine for blood pressure support and given fluids "wide open". Atrial fibrillation recurred/continued, rate 90's with frequent PVC's. ECG consistent with STEMI. After discussion with interventionalist - no intervention planned given age and critical AS. Admitted to the CCU for medical management under Dr.[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]/[**Doctor Last Name **]. En route to CCU had paroxysm of HR to the 140s in AF with hypotension, responded to 250 cc NS times one. On arrival, dopamine off. . Of note, on last admission pt. was documented to be "clear and adamant" about being DNR/DNI. Past Medical History: - CAD: NSTEMI [**8-31**], CHF 60% EF (diastolic dsfn), critical AS, mod MR. - Atrial fibrillation - Breast ca s/p mastectomy '[**61**], r axillary nodes resection '[**67**] - Colon Ca, s/p L hemicolectomy in [**2171**] - Basal cell Ca of the face - resected recently at [**Hospital1 2025**] - hx of DVT [**2171**]-? due to tamoxifen - BPV with h/o falls - trigeminal neuralgia (on Neurontin) - ? hysterectomy Social History: Lives at home in housing owned by [**Hospital 100**] Rehab alone, walks with walker/cane. Daughter in law helps out and brings food. Also pt has a home-aid 5 days a week for cleaning/personal hygiene. Family History: non-contributory Physical Exam: VS: 98.3 HR 66 BP 99/60 RR HEENT: EOMI, PERRL, no oropharyngeal lesions, erythema, coating. No LAD, no JVD COR: RRR no MRG PULM: CTA t/o ABD: S/NT/ND/BS+ EXT: No edema NEURO: Alert, oriented. Face symmetric. Moves all four extremities. Pertinent Results: CXR on [**2183-3-24**]: SUPINE AP CHEST: An endotracheal tube is in place, with the tip approximately 1.8 cm from the carina. The heart is mildly enlarged with a left ventricular configuration. The aorta is calcified. There is perihilar haze and increased interstitial markings consistent with congestive failure. There is retrocardiac opacity, which may represent an infiltrate or atelectasis. No definite pleural effusion or pneumothorax. IMPRESSION: Endotracheal tube tip is 1.8 cm from the carina. Moderate congestive failure. . CXR on [**2183-3-25**]: PORTABLE CHEST: Comparison to a day prior again demonstrates diffuse increased interstitial markings and patchy retrocardiac opacity which may demonstrate some mild improvement compared to a day prior given the low lung volumes on today's study. Patient has been extubated and NG tube has been removed. Small effusions may be present bilaterally. [**2183-3-24**] 03:15AM BLOOD WBC-11.2* RBC-4.48 Hgb-13.0 Hct-38.8 MCV-87 MCH-29.0 MCHC-33.4 RDW-14.4 Plt Ct-282 [**2183-3-25**] 07:03AM BLOOD WBC-11.4* RBC-4.48 Hgb-12.4 Hct-38.7 MCV-87 MCH-27.8 MCHC-32.1 RDW-14.8 Plt Ct-312 [**2183-3-26**] 05:30AM BLOOD WBC-10.7 RBC-3.95* Hgb-11.4* Hct-33.8* MCV-86 MCH-29.0 MCHC-33.8 RDW-14.8 Plt Ct-249 [**2183-3-27**] 05:21AM BLOOD WBC-11.6* RBC-4.28 Hgb-12.0 Hct-36.5 MCV-85 MCH-28.0 MCHC-32.8 RDW-14.8 Plt Ct-313 [**2183-3-27**] 05:21AM BLOOD PT-12.5 PTT-29.2 INR(PT)-1.1 [**2183-3-27**] 05:21AM BLOOD Glucose-117* UreaN-19 Creat-0.8 Na-143 K-3.9 Cl-107 HCO3-26 AnGap-14 [**2183-3-24**] 03:15AM BLOOD cTropnT-0.14* [**2183-3-25**] 07:03AM BLOOD CK-MB-40* MB Indx-7.2* cTropnT-3.59* [**2183-3-24**] 03:15AM BLOOD CK(CPK)-62 [**2183-3-25**] 07:03AM BLOOD CK(CPK)-556* [**2183-3-27**] 05:21AM BLOOD Calcium-9.1 Phos-2.3* Mg-2.1 Brief Hospital Course: # Atrial Fibrillation: Patient presented to the emergency department with atrial fibrillation and rapid ventricular response, and was hypotensive to systolic in 60's. She was converted to sinus after cardioversion. She was subsequently loaded with amiodarone started on [**2183-3-24**]. She is to receive 200mg [**Hospital1 **] until [**4-6**], 200mg ONCE a day from [**4-6**], and 100mg once a day from [**4-21**] onward for maintenance therapy. She should have a TSH and Liver enzymes checked in [**12-31**] weeks after discharge, as TSH will be unreliable in the setting of acute illness. Continue aspirin for anticoagulation. Will hold off on further anticoagulation given age and risk of fall, and also may not even require this long-term if she stays in sinus rhythm. . # ST-elevations: Patient had initial ST-elevations on initial presentation to the ED. The case was discussed with interventionalist on call and Dr. [**Last Name (STitle) **] and decision was made for medical management. ECG done shortly after arrival and after spontaneous conversion to NSR with rate in the 60's shows resolution of ST and T changes, suggesting demand ischemia as etiology more likely than acute STEMI. Patient had episode of left-sided sharp chest pain on [**2183-3-25**] that was tender to palpation on examination. Her cardiac biomarkers were markedly elevated, although this is difficult to interpret in setting of recent cardioversion. Continue with aspirin, metoprolol. . # Respiratory failure/hypoxia: Initial episode of hypoxia may have been secondary to CHF. Required intubation. Extubated on [**3-24**] after discussion with son, and is DNR/DNI. Tolerated extubation well. Weaned off of oxygen successfully. Will start on low-dose diuretics given history of aortic stenosis. Also may have component of pneumonia. Treating with cefpodoxime, to complete course on [**2183-3-30**]. . # Bacteriuria: No pyuria, however, patient presented in rapid atrial fibrillation and this could be early indication of symptomatic infection. Culture data negative. Will treat with cefpodoxime, as has history of TMP/SMX resistance and also risk of QT prolongation with fluoroquinolones since also on amiodarone load. 7-day course of cefpodoxime since also treating empirically for pneumonia as above. . # Access: HCP states that pt. would not want Central line - NO CENTRAL LINE . # Code: DNR/DNI: discussed with HCP. Explained to him that this information was not available to the ED physicians on presentation and therefore, she was cardioverted and intubated as indicated at the time. He voiced understanding. He is currently in [**State 108**]. Son informed that patient is tolerating extubation well and is otherwise stable, ready to be transferred out of the CCU. . # Communication: Health-care-proxy and son [**Name (NI) **] [**Name (NI) 9780**]: [**Telephone/Fax (1) 100768**]. . # Disposition: To rehab facility. Medications on Admission: 1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY 2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID 3. Aspirin 81 mg: One (1) Tab PO QD 4. Metoprolol 2 mg PO BID given as suspension, 1 mg/mL Discharge Medications: 1. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days: To complete 7-day course on antibiotics with last dose on evening of [**2183-3-30**]. 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): to complete 2-weeks on this dose on [**2183-4-6**]. 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day for 14 days: Start on [**2183-4-7**] and complete 2 week course on [**2183-4-20**]. 4. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day: Maintenance dose to start on [**2183-4-21**]. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q4-6H (every 4 to 6 hours) as needed. 7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO twice a day. 9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO MWF (Monday-Wednesday-Friday). 10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: 1. atrial fibrillation with rapid ventricular response requiring DC cardioversion 2. Urinary tract infection 3. Aortic stenosis 4. hypertension 5. Congestive Heart failure . Secondary: 1. Coronary artery disease Discharge Condition: Stable. Afebrile. Normal sinus rhythm. Discharge Instructions: You were admitted to the hospital for an irregular heart rate and low blood pressure. You also had difficulty breathing and required intubation to help with your breathing. You received an electric shock to help normalize your heart rhythm. You may have also had a heart attack. . Please return to the hospital or call your doctor if you experience any of the following symptoms: Chest pain, shortness of breath, severe abdominal pain, nausea, or any other concerns. . Please follow up with all appointments as instructed. Followup Instructions: Please follow-up with your primary care physician [**Last Name (NamePattern4) **] [**12-31**] weeks after discharge. Completed by:[**2183-3-27**]

[ "414.01", "428.0", "V10.05", "427.31", "401.9", "599.0", "V10.3", "396.2", "518.81", "410.71" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "99.62" ]

icd9pcs

[ [ [] ] ]

8386, 8452

4145, 7068

248, 297

8717, 8758

2340, 4122

9329, 9477

2050, 2068

7333, 8363

8473, 8696

7094, 7310

8782, 9306

2083, 2321

182, 210

325, 1380

1402, 1813

1829, 2034

13,506

140,023

12150

Discharge summary

report

Admission Date: [**2187-11-22**] Discharge Date: [**2187-11-28**] Date of Birth: [**2136-4-28**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: ESRD secondary to Diabetes Mellitus type 2 Major Surgical or Invasive Procedure: deceased kidney transplant [**2187-11-22**] History of Present Illness: The patient is a 51 y/o female with ESRD secondary to malignant hypertension and DM who presents for a cadaveric renal transplant. The patient has been on hemodialysis and makes approximately 100cc of urine per day. The patient was last dialyzed on the day prior to admission. The patient had a right IJ line infection about 4 months ago which was treated with antibiotics. Currently, the patient feels well and denies fever, chills, lightheadedness, dizziness, chest pain, pnd, shortness of breath, abdominal pain, nausea/vomiting, diarrhea, constipation, or dysuria. Past Medical History: 1. Diabetes mellitus type 2 2. morbid obesity 3. diabetic retinopathy 4. cataract surgery 5. htn 6. left ankle charcot joint 7. multiple access procedures Social History: The patient denies smoking or alcohol use. The patient lives at home with her two sons. Family History: non-contributory Physical Exam: T 97.3 P 67 BP 122/53 R 20 SaO2 96% RA 90.8kg Gen - nad Heent - neck supple, no cervical lymphadenopathy, no scleral icterus heart - regular rate and rhythm lungs - clear to auscultation bilaterally abd - obese, soft, nontender, nondistended extrem - 1+ DP pulses bilaterally, no lower extremity edema neuro - alert and oriented x3 Pertinent Results: CHEST (PRE-OP PA & LAT) - Mild cardiomegaly, without evidence of CHF. ECG - sinus rhythm [**2187-11-22**] 06:30AM BLOOD WBC-4.6# RBC-4.91 Hgb-12.5 Hct-38.7 MCV-79* MCH-25.4* MCHC-32.2 RDW-18.2* Plt Ct-157 [**2187-11-22**] 06:30AM BLOOD PT-11.5 PTT-25.8 INR(PT)-1.0 [**2187-11-22**] 06:30AM BLOOD UreaN-21* Creat-5.1* Na-139 K-4.6 Cl-94* HCO3-37* AnGap-13 [**2187-11-22**] 06:30AM BLOOD ALT-18 AST-27 [**2187-11-22**] 06:30AM BLOOD Albumin-3.9 Calcium-9.6 Phos-3.1# Mg-2.2 Brief Hospital Course: The patient was admitted, had a cursory pre-op workup and was taken to the OR for a cadaveric renal transplant which she tolerated well and was transferred to the PACU in stable condition. Initially post-op, the patient had good UOP and was transferred to the floor. However, she became hypotensive overnight with a BP of 70/54 despite fluid boluses and had decreasing urine output and transferred to the SICU to be placed on pressors. A renal u/s was normal. Urine output increased once the patient was started on a dopamine drip. The patient was able to be titrated off the dopamine drip on post-op day 2. There was no clear etiology for the patient's hypotension. The patient remained normotensive with adequate urine output and was transferred to the floor on post-op day 4. The patient was started on Lopressor for her htn. According to the renal transplant protocol, the patient was immunosuppressed with anti-thymocyte globulin, cellcept, tacrolimus and steroids. Tacrolimus was dosed according to daily levels. The patient was treated with Hep B Ig, vancomycin, bactrim, and valcyte for prophylaxis. The donor was Hep B core Antibody positive. The patient was given lasix on post-op day 5 to assist with her diuresis. Her blood glucose was controlled with rosiglitazone and sliding scale insulin. Her Hct remained stable in the post-operative period. The patient was discharged to home with VNA services on post-op day 6 in good condition. Medications on Admission: 1. metoprolol 50mg [**Hospital1 **] 2. Avandia 4mg [**Hospital1 **] 3. Renagel 4. Cartia 5. lipitor 6. enalapril 20mg [**Hospital1 **] 7. Omeprazole 20mg qDay 8. minoxidil 5mg [**Hospital1 **] 9. nifedical 60mg qDay 10. Phos-lo (667mg) 4-6 tablets [**Hospital1 **] 11. tramadol 50mg q4hr prn Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Lamivudine 10 mg/mL Solution Sig: 2.5 ml 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. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). Disp:*12 * Refills:*2* 12. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*168 Tablet(s)* Refills:*2* 13. Tacrolimus 1 mg Capsule Sig: Seven (7) Capsule PO twice a day. 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection four times a day. Disp:*1 * Refills:*2* 15. insulin syringes 1 box refills:2 16. lancets 1 box refill:2 17. test strips 1 box refills:2 Discharge Disposition: Home With Service Facility: Gentiva/[**Location (un) 86**] Discharge Diagnosis: ESRD DM II HTN Discharge Condition: good Discharge Instructions: Call the Transplant office [**Telephone/Fax (1) 673**] if fevers, chills, nausea, vomiting, inability to take medications, redness/bleeding/pus from incision, decreased urine output, weight gain of 3 pounds in a day or shortness of breath. Labs every Monday and Thursday for cbc,chem 10, ast, t.bili, albumin, urinalyis and trough prograf level.fax results to [**Telephone/Fax (1) 697**] attn: [**Name6 (MD) 5036**] [**Name8 (MD) 5039**], RN Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-12-6**] 1:10 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK Date/Time:[**2187-12-6**] 2:00 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-12-11**] 10:50

[ "458.29", "278.01", "250.40", "276.1", "362.01", "250.50", "403.01" ]

icd9cm

[ [ [] ] ]

[ "55.69", "00.93" ]

icd9pcs

[ [ [] ] ]

5452, 5513

2196, 3660

359, 405

5572, 5579

1698, 2173

6069, 6474

1307, 1325

4002, 5429

5534, 5551

3686, 3979

5603, 6046

1340, 1679

277, 321

433, 1007

1029, 1185

1201, 1291

31,470

116,193

32932

Discharge summary

report

Admission Date: [**2149-1-29**] Discharge Date: [**2149-2-5**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: OP CABGx4(SVG-LAD,SVG-Diag,SVG-OM,SVG-PDA)[**1-31**] History of Present Illness: 89 year old man with h/o HTN, admitted to OSH [**1-27**] with severe [**10-21**] substernal chest pain, non-radiating. This occured after the patient had gotten in an argument as well as had been shoveling some snow prior to the onset of chest pain. Patient usually does not have any anginal symptoms. He had some associated SOB, no N/V, lightheadedness of diaphoresis. The pain had improved to [**4-20**] with sublingual nitro he received by EMT en route to the hospital. At the OSH an EKG revealed very mild ST elevation V1-V3 and peaked T's. Initial troponin 0.064 with subsequent troponin .350. CK 76. He receved Lopressor and nitro in the ED. He was subsequently transferred to [**Hospital1 **] where he underwent cardiac cath which revealed 3 vessel disease with a tight proximal LAD lesion with thrombus, moderate stenosis of the ostial RCA, OM2 with tight lesion. Post-cath course complicated by a right groin hematoma 6"long x 1" wide. Hct 40.7 upon transfer (47 on admission). Patient was transfered here for evalution for CABG. He came in on a heparin and integrillin gtt. Past Medical History: hypertension kidney stones polymyalgia [**Hospital1 23389**] [**Hospital1 **] 7 years ago s/p hernia repair Social History: Patient currently works as a constable for the town of [**Location (un) 1110**]. He lives at home with his wife whom he cares for. He formerly smoked (15 pack year history) but quit 50 years ago, denies ETOH or drug use. . Family History: Family history notable for CAD in his brother and sister. [**Name (NI) 6961**] died from cancer. Physical Exam: VS - 98.7 128/66 66 18 Gen: Elderly male in NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Neck: Supple with JVP of 8 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. SEM heard over entire precordium. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. Skin:Ecchymosis on right forearm and 2cm ecchymotic area of left lower lip. Pertinent Results: [**2149-2-5**] 09:20AM BLOOD WBC-12.0* RBC-3.38* Hgb-10.6* Hct-31.9* MCV-94 MCH-31.5 MCHC-33.3 RDW-14.3 Plt Ct-135* [**2149-2-5**] 09:20AM BLOOD Plt Ct-135* [**2149-2-3**] 08:05AM BLOOD PT-15.1* PTT-30.4 INR(PT)-1.3* [**2149-2-5**] 09:20AM BLOOD Glucose-116* UreaN-26* Creat-1.2 Na-135 K-4.2 Cl-101 HCO3-24 AnGap-14 CHEST (PORTABLE AP) [**2149-2-3**] 8:57 AM CHEST (PORTABLE AP) Reason: evaluate for ptx s/p ct removal [**Hospital 93**] MEDICAL CONDITION: 89 year old man with s/p cabg REASON FOR THIS EXAMINATION: evaluate for ptx s/p ct removal REASON FOR EXAMINATION: Chest tube removal in a patient after CABG. Evaluation for pneumothorax. Portable AP chest radiograph compared to [**2149-1-31**]. The patient was extubated in the meantime interval with removal of the Swan- Ganz catheter, NG tube, chest tube, and mediastinal drains. The cardiomediastinal silhouette is stable. Post-sternotomy wires are unremarkable. Lungs are clear. Minimal bilateral pleural effusion is present. There is no pneumothorax. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 76630**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76631**] (Complete) Done [**2149-1-31**] at 8:48:55 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: [**2059-8-10**] Age (years): 89 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Aortic valve disease. Chest pain. Coronary artery disease. Hypertension. ICD-9 Codes: 786.51, 440.0, 424.1 Test Information Date/Time: [**2149-1-31**] at 08:48 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: Suboptimal Tape #: 2007AW2-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 35% to 40% >= 55% Findings LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast 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. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild-moderate regional LV systolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Normal RV wall thickness. Normal RV chamber size. 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: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Mild AS (AoVA 1.2-1.9cm2). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Calcified tips of papillary muscles. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. Conclusions 1. The left atrium is mildly dilated. No spontaneous echo contrast 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 atrial septal defect is seen by 2D or color Doppler. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with anteroseptal inferior hypokinesis. Apical akinesis. 3. . Right ventricular chamber size and free wall motion are normal. Right ventricular chamber size is normal. 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. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is limited mobility of the RCC. There is mild aortic valve stenosis (area 1.2-1.9cm2). Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 7. There is a trivial/physiologic pericardial effusion. On infusions of Levo, epi, phenylephrine during coronary occlusions. Post CABG lvef =35-40%. Inferoseptal, anterior and anteroapical hypokinesis. MR remains 1+. Brief Hospital Course: He was seen by cardiac surgery. His platelet count was low, and HIT ab was negative. He was taken to the operating room on [**1-31**] where he underwent an off pump CABG x 4. He was transferred to the ICU in critical but stable condition on epi, phenylephrine and propofol. He received 48 hours of prophylactic vancomycin as he was in the hospital preoperatively. He was extubated on POD #1. He was transferred to the floor late on POD #1. He was started on plavix for his off pump CABG. Chest tubes and wires were pulled without incident. He did well postoperatively and was ready for discharge to rehab on POD #5. Medications on Admission: CURRENT MEDICATIONS on Transfer: Asa 325mg prednisone 9mg daily lopressor 25mg twice a day protonix 40 mg daily colace heparin gtt Integrellin gtt . Medication at home: HCTZ 25mg daily Diltiazem ER 120mg daily Prednisone 9mg daily Potassium 200mEq daily Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. PredniSONE 1 mg Tablet Sig: Nine (9) Tablet PO DAILY (Daily): 9 mg daily. 6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks: then reassess need for diuresis. Disp:*qs Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 1 weeks: while on lasix . 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital 745**] Health Care Center Discharge Diagnosis: CAD now s/p CABG NSTEMI HTN, kidney stones, polymyalgia [**Last Name (LF) 23389**], [**First Name3 (LF) **] 7 years ago, s/p hernia repair Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) 32255**] 2 weeks Dr. [**Last Name (STitle) 70216**] 2 weeks Dr. [**First Name (STitle) **] 4 weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2149-2-5**]

[ "997.1", "446.5", "E878.2", "427.31", "V15.82", "287.5", "V12.54", "401.9", "725", "410.71", "396.2", "276.2", "V45.89", "414.01" ]

icd9cm

[ [ [] ] ]

[ "88.72", "36.14", "99.20" ]

icd9pcs

[ [ [] ] ]

9952, 10016

7953, 8570

277, 332

10199, 10207

2480, 2904

10506, 10752

1835, 1934

8875, 9929

2941, 2971

10037, 10178

8596, 8604

10231, 10483

1949, 2461

227, 239

3000, 7930

360, 1446

8629, 8852

1468, 1578

1594, 1819

5,598

183,953

18276

Discharge summary

report

Admission Date: [**2175-7-28**] Discharge Date: [**2175-8-2**] Date of Birth: [**2117-10-10**] Sex: M Service: MEDICINE Allergies: Codeine / Zestril Attending:[**First Name3 (LF) 783**] Chief Complaint: transferred from OSH for possible thoracentesis Major Surgical or Invasive Procedure: s/p Bilaretal Thoracenteses History of Present Illness: 57 yo man w/ h/o non-hodgkins lymphoma s/p CHOP, chronic lymphedema, and chronic bilateral effusions who initially presented to an OSH on [**7-28**] after acute onset dyspnea at home. The patient reports mild dyspnea x 1 month. On the night before admission, he experienced acute onset SOB after walking from his car into his house. He felt as though he "couldn't catch his breath." He called 911, and EMS brought him to OSH ER. Patient's dyspnea improved after O2 therapy. Patient then c/o anterior chest "soreness," worse with inspiration. CTA was attempted but patient became SOB in the supine position, so this study was aborted. He was admitted to the MICU and was started on a heparin gtt empirically. After discussion with the family, the patient's wife requested that the patient be transferred to [**Hospital1 18**] for possible therapeutic thoracentesis. . Past Medical History: Non-Hodgkin's lymphoma Congential lymphatic atresia Seminoma s/p radiation and resection Appendectomy, perforated Cholecystectomy SBO ([**2174-12-14**]) s/p resection Social History: Supportive wife, otherwise denies [**Name (NI) **]/EtOH/IDU. Family History: Father - PVD Mother - questionable metastatic ovarian cancer Physical Exam: VS - T 98.8; HR 120; BP 115/56; RR = 30; O2 96% 4L NC GEN - elderly man, appears older than stated age, tachypneic, appears dyspneic, coughing HEENT - NCAT, PERRL bilat, EOMI, OP clear, anicteric NECK: supple, no LAD, no JVD CV: RRR, normal S1S2, no M/R/G PULM: decreased BS [**1-1**] way up bilaterally, no crackles/wheezes ABD: NABS, soft, NT, ND, obese EXT: 3+ pitting edema bilat SKIN: +lichenification of lower ext bilat, +pus drainage from midline abdominal wound, no erythema Neuro: CNII-XII intact, strength symmetric Brief Hospital Course: Briefly, this is a 57 yo man with a h/o NHL s/p CHOP x 6 on [**7-25**], chronic lymphedema/Bilateral pleural effusions who initially was admitted to the MICU from an OSH for evaluation of acute worsening dyspnea and worsening pleural effusions. There was initial concern at the OSH for pulmonary embolism given the pts c/o chest pain and pain which worsened with deep inspiration. The pt was empirically heparinized at the OSH and transferred to [**Hospital1 18**]. Upon arrival to [**Hospital1 **] the pt was tachy to the 120s, tachypneic to 30, and satting at 96 on 4L nC. ABG was 7.41/32/81. The pt had a lactate of 4.2, WBC count greater than 40,000 and new ST-T wave changes (flattened T waves) in V3-V5 when compared to prior EKG. The pt was also documented to have a troponin peak of 0.22. The pt was initially empirically started on Vancomycin and Zosyn for suspected urosepsis, but his UA was negative and his urine culture on [**7-29**] grew out ampicillin resistant enterococcus. Zosyn was discontinued and the Vancomycin (started [**7-31**]) is to be completed for a 2 week course after discharge. Levofloxacin was started on [**7-29**] for a possible pneumonia given this could not be ruled out with large overlying pleural effusions. CT angiogram on [**7-30**] ruled out pulmonary embolism and heparin gtt was discontinued at this time. The pts R sided pleural effusion was tapped on [**7-29**] with 2 L of output, and his L pleural effusion was tapped on [**7-31**]. The effusion from [**7-29**] was slightly exudative, while the effusion from [**7-31**] was borderline transudate/exudate. The pt was clear that he did not want any evaluation for pleurodesis or semi-permanent drain. TTE on [**7-31**] revealed a normal EF, making CHF an unlikely cause of the pts symptoms. . The elevation in the pts troponin was felt to be secondary to demand ischemia in setting of tachycardia and resp. distress. Cardiac enzymes trended down, and the pt vehemently refused CATH. He was continued on ASA and metoprolol 12.5 TID. . The pts WBC, platelets, and red cells all dropped over the course of several days, c/w his recent CHOP regimen. His WBC dropped from [**Numeric Identifier 17451**] on admission to as low as 200 with an ANC of 70, and the pt was placed on neutropenic precautions. He never spiked a fever. The pt was advised that we wanted to watch him in the hospital for a little while given his UTI and abdominal wall cellulitis, but the pt insisted on discharge. He was told to return if he experienced any fevers. The pts Hct also dropped from 33 on admission to 25 prior to discharge. The pt was transfused 1 unit of PRBC. . During his stay the pt was also treated for a small abdominal wall cellultis with Keflex. He was discharged home on a 7 day course of po Keflex. As UA revealed yeast on [**7-31**], the pt was discharged home on a 7 day course of fluconazole. The pts vanc was changed to linezolid for 11 days to treat the enterococcus UTI. The pt was also discharged home on 1 week of levofloxacin for emperic treatment of pneumonia. . The pt was scheduled for follow up with both his PCP for [**Name Initial (PRE) **] wound check and lab draw in the week following discharge as well as with BMT on [**8-7**]. Medications on Admission: ASA 325 mg PO daily MVI Lasix 40 mg PO daily Rhinocort 2 spray [**Hospital1 **] Allopurinol 200 mg PO daily Advair 50/100 mcg 2 puffs [**Hospital1 **] Atrovent MDI 2 puffs Q6H Prednisone 100mg PO daily Keflex 500 mg PO Q6H Accupril 10mg PO daily Ambien 5 mg PO QHS prn Albuterol MDI prn Claritin 10 mg prn Dilaudid 2-4 mg PO Q4 prn . Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 3. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*10 Tablet(s)* Refills:*0* 4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 device* Refills:*2* 5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*1 device* Refills:*2* 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 device* Refills:*3* 7. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). Disp:*1 container* Refills:*2* 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*10 Tablet(s)* Refills:*0* 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Loratadine 10 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*2* 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*0* 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 14. Psyllium Packet Sig: One (1) Packet PO BID (2 times a day) as needed. Disp:*30 Packet(s)* Refills:*0* 15. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. Disp:*100 ML(s)* Refills:*0* 16. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:*120 Capsule(s)* Refills:*2* 17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 18. Insulin Regular Human 100 unit/mL Solution Sig: One (1) as directed Injection ASDIR (AS DIRECTED). Disp:*100 ML* Refills:*2* 19. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 11 days. Disp:*22 Tablet(s)* Refills:*0* 20. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 21. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. Disp:*28 Capsule(s)* Refills:*0* 22. Diflucan 200 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] Discharge Diagnosis: Recurrent Pleural Effusion-s/p thoracentesis Non Hodgkins Disease Discharge Condition: stable. Patient stable on rrom air. Tolerating a PO diet. Discharge Instructions: Patient is to take all medications as perscribed. Please report to your primary care physician or to the ED with any temperatures > 100.5, nausea, vomiting, chills, rigors, dysuria. Followup Instructions: Dr. [**Name (NI) 50409**] [**Name (STitle) **] Physician-[**Telephone/Fax (1) 3183**]-[**Street Address(1) 50410**] Office-at 7:50AM-please have a wound check at this visit, and have your CBC drawn at this visit and results called in to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Office Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 50411**]8/8/05-1:30PM-[**Telephone/Fax (1) 3241**]-you Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD Where: [**Hospital6 29**] HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2175-8-7**] 1:30 Provider: [**Name Initial (NameIs) **] Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2175-8-7**] 1:30 [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "117.9", "599.0", "285.22", "041.00", "401.9", "518.82", "998.59", "276.2", "457.1", "530.81", "759.89", "287.4", "682.2", "V10.47", "202.80", "584.9", "511.9", "288.0", "E933.1" ]

icd9cm

[ [ [] ] ]

[ "99.04", "34.91" ]

icd9pcs

[ [ [] ] ]

8432, 8479

2172, 5433

325, 355

8589, 8648

8879, 9794

1545, 1607

5818, 8409

8500, 8568

5459, 5795

8672, 8856

1622, 2149

238, 287

383, 1259

1281, 1450

1466, 1529

23,680

131,103

47313

Discharge summary

report

Admission Date: [**2172-9-11**] Discharge Date: [**2172-9-16**] Date of Birth: Sex: M Service: DIAGNOSIS: Acute pulmonary edema. HISTORY OF PRESENT ILLNESS: This is a 61 year old male, with past medical history significant for coronary artery disease, status post coronary artery bypass graft, [**Year (4 digits) 1291**], congestive heart failure and diabetes. Transferred from [**Hospital 100167**] rehabilitation on [**9-11**]. The patient had recently been admitted for a left below the knee amputation and was discharged to [**Hospital 100167**] rehabilitation on the 17th. On that morning, he developed hypoxia to 80% on room air, was hypertensive to 212/122 with rales and frothy white sputum. He was intubated and given nitrous oxide, Lasix, Morphine. His chest x-ray showed severe pulmonary edema. The patient had subsequent hypotension to 77/57 and was started on a Dopamine drip. An electrocardiogram at that time showed a left bundle branch block and no ischemic changes. CK was 123. MB was 16.3. Troponin was 1.59. He was transferred to [**Hospital1 69**] off the Dopamine drip, on settings of pressure support of 5 and 5 for further management. PAST MEDICAL HISTORY: Coronary artery disease, status post coronary artery bypass graft and [**Last Name (LF) 1291**], [**2169-4-24**]. Left internal mammary artery to left anterior descending. Saphenous vein graft to LCX and diagonal. Saphenous vein graft to D-1. Coronary artery bypass graft revision was done in [**2169-11-24**], status post percutaneous transluminal coronary angioplasty to right posterior descending artery in [**2170-6-24**] and then on stent of saphenous vein grafts to diagonal in [**2169-10-25**]. Congestive heart failure with ejection fraction of 35%. Diabetes. Hypertension. Hypercholesterolemia. Peripheral vascular disease. Status post femoral endarterectomy, right popliteal peroneal bypass. Left femoral dorsalis pedis bypass. Cerebrovascular accident. Depression. Open reduction and internal fixation of right leg. Open reduction and internal fixation of right hip. Left below the knee amputation for osteomyelitis. MEDICATIONS ON TRANSFER: Aspirin 325 mg. Metoprolol 50 mg p.o. q. six hours. Pravachol 20 mg p.o. q. day. Lasix 80 mg twice a day. Heparin drip. Sliding scale insulin. Aztreonam one gram intravenous q. eight hours. Vancomycin one gram intravenous q. 24 hours. KCl 20 meq. q. day. Pepcid 20 mg intravenously twice a day. Klonopin 2 mg twice a day. Celexa 20 mg q. day. Wellbutrin 150 mg twice a day. Neurontin 300 mg q. day. Dulcolax 10 mg q. day. Multi-vitamins. PRN Ativan. PRN morphine. PRN Albuterol and Atrovent multi-dose inhalers. PRN Oxycodone. PRN Ibuprofen. Trazodone 50 mg q h.s. Senna q. day. Glycerin suppositories prn. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Lives with wife. Transferred from [**Hospital 100167**] Rehabilitation on this admission. 15 pack year history of tobacco, currently smoking. History of no alcohol and drug abuse, not active. PHYSICAL EXAMINATION: Pulse 83; blood pressure 111/63; intubated on pressure support of 5 and 5. Respiratory rate of 25. Tidal volume 450. Saturating 92% on FI02 of .40. General: Easily arousable, in no acute distress. HEAD, EYES, EARS, NOSE AND THROAT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Neck: No jugular venous distention, no bruits. Cardiovascular: Regular rate, 2/6 systolic murmur, heard best at the right upper sternal border and the left lower sternal border. Valve click. No gallops. Lungs: Coarse breath sounds bilaterally, decreased at bases. Abdomen: Soft, nontender, nondistended. Positive bowel sounds. Extremities: Left below the knee amputation stump was well healed. Mild erythema but no skin break down. Right lower extremity: No palpable dorsalis pedis, 1+ posterior tibial, warm. LABORATORY DATA: White count of 10.4; hematocrit of 33.4; platelets 186. Sodium of 145; potassium of 3.7; chloride 103; bicarbonate 74; BUN 24; creatinine 1.4; glucose 220; calcium 8.8. Magnesium 2.1; phosphorus 3.0. CK 123, CK MB 10.6; troponin 1.59. PT of 14.4; PTT of 36.4. INR of 1.3. Electrocardiogram: Normal sinus rhythm; first degree atrioventricular block. Left bundle branch block. Increased T waves as compared to previous electrocardiogram but otherwise no ischemic changes. Chest x-ray on admission: Cardiomegaly; moderate congestive heart failure with cephalization and interstitial infiltrates bilaterally. Right costophrenic angle not visualized. Arterial blood gases 7.46, 51, 65 on a pressure support of 5 and 5. 40% FI02. HOSPITAL COURSE: Coronary artery disease. On admission, the patient initially refused cardiac catheterization. He was continued on Integrolin and heparin drip and also continued on Plavix and aspirin. Beta blocker and ace inhibitor were added and titrated up throughout the hospital as well as Nystatin. The patient's cardiac enzymes were thought to be a troponin leak in the setting of congestive heart failure decompensation. The patient, later in hospitalization, agreed to a cardiac catheterization which was done on [**9-14**]. Following catheterization, the patient was well hydrated and then diuresed and started back on daily Lasix. He also had an echo which showed an ejection fraction of 20 to 30% and mild to moderate mitral regurgitation. As compared to his previous echo, there was a decrease in his ejection fraction and he was successfully extubated on [**2172-9-13**]. His oxygen requirements were titrated down. He had increasing secretions and sputum cultures grew out Staph aureus. His blood and urine cultures were negative. The plan was to treat the patient for a total of two weeks of antibiotics for ventilator acquired pneumonia. Hematology: The patient was admitted and was transfused two units of blood following his cardiac catheterization and his hematocrit responded appropriately. His stools were guaiac negative. The patient had minimal nasal bleeding, thought to be due to traumatic intubation. This resolved and he was briefly placed on Afrin initially. Following his cardiac catheterization, he was transitioned to Coumadin. This was begun for his [**Date Range 1291**]. The patient was started on Coumadin on [**9-15**], with the plan to titrate down his heparin drip as his Coumadin became therapeutic. However, at the time of discharge, this had not been accomplished. He will require further titration and eventually conversion to p.o. Coumadin at rehabilitation. Renal: He was back to his baseline on discharge of 1.0. He received Mucomyst with his catheterization. Fluids, electrolytes and nutrition/endocrine: The patient's electrolytes were followed throughout his hospitalization. He was placed on sliding scale insulin. His blood sugars trended up towards the end of the hospitalization and NPH was added. His insulin regimen will require further assessment over the next few days as his p.o. intake improves. Peripheral access: Patient was kept on pneumoboots and proton pump inhibitor for deep vein thrombosis and gastrointestinal prophylaxis during his hospitalization. He also was on a heparin drip. Code status was full. DISPOSITION: The patient was transferred back to U-Ville, where he will require a resumption of his previous rehabilitation schedule. Call doctor or go to Emergency Room for symptoms of chest pain, shortness of breath, edema, fevers, chills, or other concerning symptoms. DISCHARGE MEDICATIONS: Levofloxacin 500 mg p.o. q. day. Lasix 40 mg p.o. q. p.m. Lasix 80 mg p.o. q. a.m. Lisinopril 10 mg p.o. q. day. Sliding scale insulin. Coumadin 5 mg p.o. q h.s. Heparin drip. Amantadine 20 mg p.o. twice a day. Colace 100 mg p.o. twice a day. Oxycodone 5 mg p.o. every four to six hours prn; hold for respiratory depression or somnolence. Fluconazole powder 2% three times a day prn. Aspirin 325 mg p.o. q. day. Plavix 75 mg p.o. q. day. Glycerin suppositories prn. Trazodone 25 mg q h.s. prn. Ipitroprium inhaler two puffs every four to six hours prn. Albuterol one to two puffs every six hours prn. Multi-vitamin one q. day. Gabapentin 300 mg q. day. Bupropion 150 mg twice a day. Metoprolol 50 mg twice a day. Pravastatin 20 mg p.o. q. day. Clonazepam 2 mg p.o. twice a day. Talopram 20 mg p.o. q. day. Tylenol 325 to 650 mg p.o. every four to six hours prn. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**] Dictated By:[**Last Name (NamePattern1) 100168**] MEDQUIST36 D: [**2172-9-16**] 12:01 T: [**2172-9-16**] 11:16 JOB#: [**Job Number 100169**]

[ "410.71", "414.01", "272.0", "486", "V43.3", "428.20", "428.0", "V45.81", "424.0" ]

icd9cm

[ [ [] ] ]

[ "88.56", "96.04", "37.23", "96.71", "88.53", "38.93" ]

icd9pcs

[ [ [] ] ]

7591, 8737

4709, 7568

3082, 4445

191, 1199

4460, 4691

2188, 2847

1222, 2162

2864, 3059

20,582

141,741

52900+59482

Discharge summary

report+addendum

Admission Date: [**2123-3-30**] Discharge Date: [**2123-4-12**] Date of Birth: [**2055-7-29**] Sex: F Service: MICU CHIEF COMPLAINT: Dyspnea and weakness. HISTORY OF PRESENT ILLNESS: This is a 67-year-old woman with lupus scleroderma, chronically on steroids, with multiple past pneumonias; who, two days prior to admission started feeling extremely fatigued. On the morning of admission she was unsteady on her feet. Her husband noted her temperature at home to be up to 103 degrees. He brought her to the Emergency Department for evaluation where she developed respiratory distress and was intubated. She denied not have any nausea, vomiting, or cough while at home. She has had multiple pneumonias in the past; usually levofloxacin-sensitive streptococcus pneumoniae and has had multiple sputums with Mycobacterium avium intracellulare. She has had sputum smears taken ever since a positive purified protein derivative dating back to [**2101**]. She does not have a history of tuberculosis. PAST MEDICAL HISTORY: 1. Lupus. 2. Migraine headaches. 3. Autoimmune hepatitis. 4. Severe gastroesophageal reflux disease. 5. Status post colectomy (atonic colon as a complication of lupus). 6. In [**2108**], rheumatoid arthritis. 7. Status post appendectomy. 8. Status post hysterectomy. 9. She also had revealed endoscopic retrograde cholangiopancreatography on [**2123-3-9**] for pancreatitis; at which time she received sphincterotomy of a stenosis in the major papilla. MEDICATIONS ON ADMISSION: Medications at home included prednisone 15 mg p.o. q.d., Prevacid 30 mg p.o. b.i.d., folic acid 1 mg p.o. q.d., Celexa 20 mg p.o. q.d., Vioxx 25 mg p.o. q.d., Dilantin 200 mg p.o. b.i.d., Vivelle patch (estrogen) two times per week, Keppra 500 mg p.o. b.i.d. (antiepileptic), Estrace cream 0.01% q.d., Procardia 10 mg p.o. t.i.d. p.r.n. for migraine headaches, Imitrex 25 mg p.o. p.r.n. for migraine headaches, verapamil 180 mg p.o. q.d. (migraine prophylaxis), Vicodin 5/500 p.o. b.i.d. p.r.n. ALLERGIES: A rash with NAPROXEN (she reports no problems with ibuprofen), METHOTREXATE causes nausea, CODEINE causes nausea. She is allergic to PENICILLAMINE (note that she is not allergic to PENICILLIN). PLAQUENIL causes visual disturbances. SOCIAL HISTORY: Immigrated from [**Country 22965**] in the [**2070**]. She is a retired nurse. She has three daughters who are nurse anesthetizes and a son who is [**Initials (NamePattern4) **] [**Name (NI) 33963**] film maker. REVIEW OF SYSTEMS: She has fair exercise tolerance at baseline. She can walk eight flights of stairs without dyspnea, although she gets occlusion fatigue. She takes some oral food, but her nutrition is mostly Vital high nitrogen 1 liter every night. She has had chronic diarrhea since her colectomy in [**2108**]. PHYSICAL EXAMINATION ON PRESENTATION: Temperature of 99.9, pulse of 106, blood pressure of 81/55, respiratory rate of 18. In general, a thin woman who was intubated and sedated, occasionally moved four extremities. Chest revealed coarse breath sounds on the right but with good air movement. The left side was clear. Cardiovascular was tachycardic, normal first heart sound and second heart sound. No murmurs. The abdomen was soft, nontender, and nondistended, with positive bowel sounds. She had a jejunostomy tube present in the left upper quadrant. Extremities were warm and well perfused with 2+ dorsalis pedis pulses. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission revealed a white blood cell count of 7.7, hematocrit of 35.6, platelets of 251. Differential revealed neutrophils of 52%, bands of 31%. PT was 12.8, PTT was 24.5, INR was 1.1. Sodium of 136, potassium of 4.2, chloride of 108, bicarbonate of 19, blood urea nitrogen of 18, creatinine of 0.5, glucose of 121. ALT of 83, AST of 87, LDH of 297, creatine kinase of 108, alkaline phosphatase of 143, total bilirubin of 0.5, lipase of 31, albumin of 3.9. Calcium of 8.7, phosphate of 2.2, magnesium of 2.3. Arterial blood gas prior to extubation (on 15 liters of oxygen) was 7.31/42/45. Arterial blood gas was 7.35/33/92 on assist control 16 X 600. Gram stain showed 3+ gram-positive cocci in pairs. Immunoglobulin levels showed severe immunoglobulin A deficiency. RADIOLOGY/IMAGING: A chest x-ray showed right-sided multifocal pneumonia. A chest CT angiogram showed no evidence for pulmonary embolus. A cardiac echocardiogram showed an ejection fraction of 55% to 60% on [**2123-1-30**]. HOSPITAL COURSE: Assessment and plan revealed a 67-year-old woman with a history of frequent streptococcus pneumoniae who now comes in with complaints of cough, fever, and respiratory difficulty. The patient was intubated in the Emergency Department on [**2123-3-30**] because of impending respiratory failure. 1. CARDIOVASCULAR: She was initially hypotensive and required Levophed pressor in order to maintain her blood pressure. She also received frequent boluses of normal saline. The Levophed was stopped on [**2123-4-1**]. She initially required fluid boluses after the Levophed was stopped but did not require any further use of pressors while in the Medical Intensive Care Unit. 2. NEUROLOGY: She has a history of seizure disorder; and per her online outpatient notes, it appeared that her neurologist had been trying to transition her from Dilantin to Keppra. Therefore, her dose of Dilantin had been getting gradually reduced while as an outpatient. Her Dilantin level was 3.7 on admission. We opted to load her with Dilantin and to maintain her at a therapeutic level given our concerns about a possible seizure in the setting of acute illness. 3. ENDOCRINE: She was on oral prednisone daily at home for her lupus scleroderma. She was started on stress-dose steroid of hydrocortisone 100 mg intravenously t.i.d. which was, in subsequent days, converted to p.o. prednisone as the patient takes at baseline. 4. PULMONARY: The patient's chest x-ray on admission revealed a large right-sided multilobar pneumonia. Follow-up x-rays during the hospitalization initially demonstrated some involvement of the left lung as well, followed by eventual clearing of the right lung. She was extubated without incident on [**2123-4-11**]. Given that she has a history of frequent recurrent pneumoniae, the Allergy/Immunology team was consulted, and they found her to be profoundly immunoglobulin A deficient. This was likely the source of her frequent pneumonias, her immune system dysfunction. 5. INFECTIOUS DISEASE: She had a pan-sensitive streptococcus pneumoniae and was therefore started on levofloxacin 500 mg q.d. She continued to be febrile. Her arterial line tip was positive for methicillin-resistant Staphylococcus aureus, and she also had [**1-1**] blood culture bottles that grew methicillin-resistant Staphylococcus aureus. Therefore, she was stated on vancomycin on [**2123-4-4**]. With the administration of the vancomycin her fever and white blood count began to fall. She has a history of chronic sinusitis. A head CT was performed which showed evidence of chronic sinusitis as well as multiple sinus surgeries. She was started on ceftazidime and Flagyl on [**2123-4-10**] (as recommended by the Infectious Disease team). 6. GASTROINTESTINAL: She continued to be fed through her jejunostomy tube while she was here. She had a gradual increase of pancreatic enzymes, amylase and lipase, to close to 300 before they started decreasing on [**2123-4-9**]. Her primary gastroenteritis (Dr. [**Last Name (STitle) **] who had performed endoscopic retrograde cholangiopancreatography on her last month advised that she simply needed an elective repeat endoscopic retrograde cholangiopancreatography after she was extubated and more stable. 7. HEMATOLOGY: She required 1-unit transfusions of packed red blood cells while she was her. Per her family, she is believed to have chronic gastritis and to have a certain baseline blood loss through the presumed slow gastrointestinal bleeding. 8. PULMONARY: She was very slowed weaned off the ventilator on a pressure support trial. She was extubated on the morning of [**2123-4-11**] and appeared to be in good spirits. NOTE: This Discharge Summary is dictated through the morning of [**2123-4-12**]. An Addendum to this Discharge Summary will follow. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-207 Dictated By:[**Name8 (MD) 4123**] MEDQUIST36 D: [**2123-4-12**] 01:56 T: [**2123-4-13**] 08:23 JOB#: [**Job Number 109057**] Name: [**Known lastname 17884**], [**Known firstname **] [**Doctor First Name 3625**] Unit No: [**Numeric Identifier 17885**] Admission Date: [**2123-3-30**] Discharge Date: [**2123-4-21**] Date of Birth: [**2055-7-29**] Sex: F Service: RobinsonIM DISCHARGE SUMMARY ADDENDUM: This is an addendum to the previous discharge summary completed on [**2123-4-12**]. HOSPITAL COURSE: 1. Infectious Disease - The patient was administered pneumococcal vaccine upon being transferred to the medicine floor. A tetanus booster was also administered. A PICC line was inserted for administration of long term IV antibiotics. By the time of discharge, the patient had already completed her 14 day course of Vancomycin and will need to complete just three more days of Ceftazidine. 2. Gastrointestinal - After the patient's tube feeds were started through her J tube, the patient felt abdominal pain with elevation of amylase and lipase. The biliary service was consulted. They recommend the patient be kept NPO until her abdominal pain resolved. She should then follow up with gastroenterologist, Dr. [**Last Name (STitle) **] for an ERCP. After the patient was made NPO her amylase and lipase trended downward and her abdominal pain steadily improved daily. Her single lumen PICC line was then replaced with a double lumen PICC line for TPN administration. Because the patient stated that her J tube was due for replacement we attempted to notify her surgeon Dr. [**Last Name (STitle) 1180**] for his recommendations. However at the time the discharge summary was completed, we have not been able to contact him. [**Name2 (NI) **] discharge to the rehabilitation facility will depend on his reply. MEDICATIONS: 1. Verapamil SR 180 milligrams po q day. 2. Phenytoin 200 milligrams po bid. 3. Lansoprazole 30 milligrams po bid. 4. Ceftazidine 1 gram q 12 hours until [**2123-4-23**]. 5. Prednisone 15 milligrams po q day. 6. Levetiracetam 500 milligrams po bid. 7. Cataloprim hydrobromide 20 milligrams po q day. 8. Heparin subcutaneous 5,000 units subcutaneous [**Hospital1 **]. FOLLOW UP: Follow up with your PCP in one week after being discharged from the hospital to review the events of this admission. Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of [**Hospital1 960**] Gastroenterology for scheduling of an ERCP. Follow up with Dr. [**Last Name (STitle) 12368**] in one month with [**Hospital1 1294**] Allergy and Immunology. INSTRUCTIONS: Return to the Emergency Department if you develop worsening abdominal pain, nausea or vomiting. DISCHARGED DIAGNOSIS: 1. Systemic lupus erythematosus. 2. Scleroderma. 3. History of multi pneumonias. 4. History of current sinusitis. 5. IGA deficiency. 6. Autoimmune hepatitis. 7. Migraine headaches. 8. GERD. 9. Status post colectomy secondary to atony. 10. Chronic diarrhea. 11. Seizure disorder. 12. PPD positive. 13. Anemia. 14. Osteoporosis. 15. J tube. 16. History of rotator cuff surgery. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 166**] Dictated By:[**Last Name (NamePattern1) 6853**] MEDQUIST36 D: [**2123-4-20**] 18:21 T: [**2123-4-21**] 09:45 JOB#: [**Job Number 17886**] cc:[**Location (un) 17887**]

[ "710.0", "518.81", "535.51", "279.01", "280.0", "482.30", "038.11", "780.39", "996.62" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "34.91", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

1531, 2274

9010, 10712

10724, 11961

2526, 4521

150, 173

202, 1019

1041, 1504

2291, 2506

12,588

191,265

45816

Discharge summary

report

Admission Date: [**2134-4-26**] Discharge Date: [**2134-4-28**] Date of Birth: [**2074-11-28**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 281**] Chief Complaint: transferred from OSH w/ hemoptysis Major Surgical or Invasive Procedure: bronchoscopy and microdebridement History of Present Illness: This is a 59 year old gentleman with a history of smoking and IVDU who presented with a two week history of cough and hemoptysis. The coughing came on suddenly two weeks ago and was severe. He noticed, when this started, blood in the sputum. This persisted for two weeks prompting him to go to an OSH where a chest X-ray appeared consistent with RLL pneumonia and was started on antibiotics. The patient showed no improvement and a repeat CXR showed perihilar mass. At this point, the patient was electively intubated for flexible bronchoscopy; this showed carinal mass with active slow bleeding that was refractory to cold saline and epinephrine. This prompted transfer to [**Hospital1 18**] for evaluation by Interventional Pulmonolgy. On [**4-26**], he underwent flexible bronchoscopy where a right middle lobe lesion was seen. Ablation and excision of the lesion was performed along with stenting. There was brisk bleeding at the site of excision necessitating maintenance of endotracheal intubation. Past Medical History: PMH: 1) Anxiety 2) History of heroin abuse Medications at home: 1) Methadone 40qd Medications in hospital: 1) Levofloxacin 500 IV daily 2) Metronidazole 500 IV TID 3) Metoprolol 5 mg IV q6 4) Methadone 50 mg daily 5) Combivent nebulizers 6) Heparin SC 5000 u TID 7) Protonix 40 IV daily Social History: Former smoker, quit 7 years ago. Previously had smoked for 20 years, three packs a day. Former IV heroin use, quit 20 years ago, on methadone Family History: non-contributory Physical Exam: VS: T 98 BP 160/69 P 103 RR 20 O2 99 on 10 L FM Gen: WD/WN Caucasian gentleman. NAD. Pleasant Eyes: Sclerae anicteric. Mouth: No lesions. Neck: Tracheal deviation. No LND Chest: Wheezes at L base, Rhonchi at R, good air movement. Cor: Tachycardic regular. Abd: Obese, no hepatosplenomegaly Ext: Trace pedal edema. Lymph: No cervical, axillary or supraclavicular lymphadenopathy appreciated. Brief Hospital Course: pt was admitted to the ICU intubated and sedated from OSH. Flex bronch was done on HD#1 and right mainstem and bronchus intermedius were found to be patent. Pt was weaned from sedationa nd extubated w/o difficulty. he will be evaluated by heme/rad onc as the frozen section on bx was NSCLC. Medications on Admission: Medications in hospital: 1) Levofloxacin 500 IV daily 2) Metronidazole 500 IV TID 3) Metoprolol 5 mg IV q6 4) Methadone 50 mg daily 5) Combivent nebulizers 6) Heparin SC 5000 u TID 7) Protonix 40 IV daily Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: right endobronchial lesion Discharge Condition: good-requires home oxygen at all times Discharge Instructions: Call Dr.[**Name (NI) 14680**] office [**Telephone/Fax (1) 10084**] if you develop chest pian, shortness of breath, fever, chills, or cough up blood. Followup Instructions: You have a follow up appointments with Dr. [**Last Name (STitle) **] on thursday [**2134-5-13**] at 2:30pm, and Dr. [**Last Name (STitle) 3274**] at 3:30pm and Dr. [**Last Name (STitle) **] at 4pm in the thoracic oncology clininc [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical Center. You will have a PET scan [**2134-5-6**] in [**Hospital Ward Name 23**] Clinical Center [**Location (un) 1385**] Rehab Services and a PET scan [**2134-5-6**] at 1:50pm in the [**Hospital Ward Name 23**] clinical center [**Location (un) **]. Pulmonary function test prior to this appointment. You will be contact[**Name (NI) **] with the dates and times of these tests. If you have any questions, please call [**Telephone/Fax (1) 170**]. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**] Completed by:[**2134-4-29**]

[ "304.01", "162.8", "300.00", "518.81" ]

icd9cm

[ [ [] ] ]

[ "40.11", "33.24", "32.28", "96.05", "96.71" ]

icd9pcs

[ [ [] ] ]

2909, 2965

2361, 2653

356, 391

3036, 3077

3274, 4136

1911, 1929

2986, 3015

2679, 2886

3101, 3251

1511, 1736

1944, 2338

282, 318

419, 1425

1447, 1490

1752, 1895

16,296

152,081

42995

Discharge summary

report

Admission Date: [**2196-1-26**] Discharge Date: [**2196-2-29**] Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Motrin / Ampicillin / Lactose / Latex / Adaptic / Amiodarone Attending:[**First Name3 (LF) 1515**] Chief Complaint: Confusion Major Surgical or Invasive Procedure: None History of Present Illness: The patient is an 86y/o F with a PMH of CAD s/p CABG 86F with CAD s/p CABG [**10/2189**] (SVG-OM, LIMA-LAD), AS s/p valvuloplasty [**11-3**], diastolic CHF, AF on coumadin, s/p R colectomy [**12-6**] admitted with generalized tonic clonic seizure. Her recent past medical history inculdes an admission [**11-3**] for a history of worsening DOE with AS with valve area of 0.56cm2. She underwent valvuloplasty with subsequent diameter of 0.98cm2. Her course was complicated by LGI bleed and on colonoscopy a precancerous 2cm cecal polyp was found. She was then admitted from 1/11-20/10 for right hemicolectomy. Low-grade T2N0M0 well or moderately differentiatedadenocarcinoma. Her hospital course ([**2195-12-7**]- [**2195-12-16**]) was complicated by hypercarbia requiring intubation and fluid overload requiring diuresis. Subsequent to this she developed C. difficile colitis, for which she has been on PO vancomycin since; she continued to complain of abdominal pain, with fevers post op and had a CT in [**2195-12-28**], that revealed slight increased fat stranding in the region of the sigmoid colon at sites of diverticula, representing a mild case of uncomplicated diverticulitis. The patient was admitted on [**1-26**] to Neurology service after tonic clonic seizure activity which resolved spontaneously. Her daughter and husband were visiting her and they noticed a self-limitted 5 minutes seizure, described as acute onset of LOC, followed by whole body stiffens and later shaking. She was brought to the [**Hospital1 18**] ED, and during her observation in the ED she another 30 seconds GTC seizure. To stop the cluster she received Ativan IV and later she was loaded with 1000mg of IV Keppra. No further seizures in the ED. She was admitted to the Neuro ICU for further management. She was initially treated with broad spectrum abx including vancomycin/cipro/bactrim and acyclovir for concern for meningitis/encephalitis. These were stopped after approx 24 hours. LP was not pursued given elevated INR on coumadin. CTA negative for CVA. She had no further seizure activity. [**Hospital1 4338**] head demonstrated a focal area with high signal intensity in the right superior parietal lobule. On evening of [**1-28**] the patient triggered for altered mental status and lethargy following head [**Date Range 4338**]. O2 sat found to be 84% and HR 130s, SBPs in 80s. Lasix 10mg IV given with no improvement. ABG 7.32/65/89/35. MICU consult was called and an additional 30mg IV lasix given with metoprolol 5mg IV. AMS felt most likely secondary to ativan given for head [**Date Range 4338**]. Repeat ABG this am 7.35/63/72/36. Given continued tachypnea and hypoxia requiring 4-5L NC, the patient was transferred to the CCU for further managment. Temp spiked to 101 and cultures sent. Past Medical History: 1. CAD status post CABG [**2189-9-26**] 2. Severe aortic stenosis, s\p recent valvuloplasty. 3. AFib on coumadin 4. HTN 5. Hyperlipidemia 6. Osteoarthritis - hip replacement spinal stenosis 7. Squamous cell carcinoma 8. Chronic venous stasis with ulceration 9. Hypothyroidism 10. peripheral neuropathy 11. Raynaud's synd 12. Right retinal vein clot with mild loss of vision 13. Diastolic heart failure 14. Shingles in [**2194-10-27**] 15. Status post right hemicolectomy in [**2195-12-7**] Social History: Has been staying at [**Hospital 100**] Rehab since her partial collectomy and C.diff. At baseline is awake, interactive with family but confused about dates, current events and prior conversations. Occupation: previously managed a store with her husband EtOH: Denies Drugs: Denies Tobacco: Denies Family History: Mother - CHF Father - [**Name (NI) 5290**] x ~6, starting in 60's Physical Exam: Admission examination (per admitting neurology resident) VS: Genl: obtuned CV: irregular rate Afib, Chest: CTA bilaterally, no wheezes, rhonchi, rales Abd: +BS, soft, mild dyscomfort to deep palpation Neurologic examination: Mental status: eyes closed. Not following verbal commands. Barely localizing pain. Cranial Nerves: Fundoscopic examination reveals sharp disc margins. Pupils equally round and sluggish reactive to light, 4 to 2 mm bilaterally. Extraocular movements intact bilaterally without nystagmus. Motor: Normal tone moving all extremities antigravity. Sensation: withdraw with noxious stimulation. Reflexes: decreased particularly in the lower extremities. Exam on ICU admission: VS: T=100.2 BP=123/66 HR= 87 RR= 21 O2 sat=95% on 4LNC GENERAL: responds to voice and painful stimuli, unable to follow commands. OPC/NC/AT/no LAD NECK: Supple with JVP of [**7-4**] cm in mid neck) CARDIAC: iirregularly irregular, [**3-1**] late peaking SEM heard, hear both S1 and S2 clearly, S2 may be fainter, throughout precordium, radiating to carotids. LUNGS: diffusely ronchorous, wheezing. ABDOMEN:+bs, soft, NT, obese. EXTREMITIES: 1+ pitting edema up to mid calf, bandages in place bilaterally in mid shin at site of presumed venous stasis ulcers. R/L DP/PT pulses weak,palpable, extremities WWP, good cap refill, skin turgor. Exam at time of discharge: Pertinent Results: Labs on admission: [**2196-1-26**] 12:30PM BLOOD WBC-12.1* RBC-4.30# Hgb-10.4*# Hct-36.4# MCV-85 MCH-24.1* MCHC-28.4* RDW-18.3* Plt Ct-602* [**2196-1-26**] 12:30PM BLOOD Neuts-80.4* Lymphs-12.2* Monos-5.2 Eos-2.2 Baso-0.2 [**2196-1-26**] 12:30PM BLOOD PT-26.7* PTT-31.4 INR(PT)-2.6* [**2196-1-26**] 12:30PM BLOOD Glucose-121* UreaN-24* Creat-0.8 Na-142 K-4.4 Cl-103 HCO3-32 AnGap-11 [**2196-1-27**] 04:27AM BLOOD ALT-6 AST-18 LD(LDH)-202 CK(CPK)-15* AlkPhos-62 TotBili-0.2 [**2196-1-26**] 12:30PM BLOOD cTropnT-0.02* [**2196-1-27**] 04:27AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2196-1-28**] 04:35AM BLOOD Albumin-2.8* Calcium-8.0* Phos-3.5 Mg-1.7 [**2196-1-27**] 04:28AM BLOOD %HbA1c-5.9 eAG-123 [**2196-1-27**] 04:27AM BLOOD Triglyc-98 HDL-26 CHOL/HD-3.1 LDLcalc-34 [**2196-1-27**] 04:27AM BLOOD TSH-6.8* [**2196-1-28**] 04:35AM BLOOD T3-PND Free T4-PND Imaging: CT head [**1-26**] - FINDINGS: There is no acute hemorrhage, edema, mass effect, or infarct. The ventricles and sulci are again prominent, consistent with age-related atrophy. Note is made of extensive [**Month/Day (2) 1106**] calcifications in the bilateral cavernous carotid, vertebral, and leptomeningeal arteries. The paranasal sinuses and mastoid air cells are clear. There are no fractures. The orbits and soft tissues are unremarkable. IMPRESSION: No acute intracranial process. CTA head and neck ([**2196-1-26**]) - IMPRESSION: 1. No acute infarction or hemorrhage. 2. Severe atherosclerotic narrowing of the distal right vertebral artery and moderate-to-severe narrowing of both cavernous internal carotid arteries. Small focus of calcification in the Basilar A. close to ithe tip. Given the extent of disease in the dominant right vertebral artery, associated vertebrobasilar insufficiency cannot be excluded. Further evlauation with MRA Neck with Gado can be considered for temporal info regarding the direction of flow, if there is no contra-indication to [**Month/Day/Year 4338**]. 3. Moderate microangiopathic ischemic white matter disease CXR [**1-26**] - IMPRESSION: Mild pulmonary edema. Opacity in the left lower lobe may represent atelectasis or infection. ECHO [**1-27**] - The left atrium is dilated. There is symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is a mild resting left ventricular outflow tract obstruction. The aortic valve leaflets are severely thickened/deformed. Significant aortic stenosis is present (not quantified). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. No vegetation seen (cannot definitively exclude). [**Month/Day (4) 4338**] Head ([**2196-1-28**]) - IMPRESSION: 1. Focal area with high signal intensity is demonstrated at the right superior parietal lobule, with no significant mass effect and may represent a chronic hemorrhagic area. 2. Subcortical areas with high signal intensity are identified on T2 and FLAIR sequences, likely consistent with chronic microvascular ischemic changes. 3. Tortuosity of the basilar artery, consistent with dolichoectasia, previously described by CTA on [**2196-1-26**]. CT Head ([**2196-2-4**]) - IMPRESSION: 1. No acute intracranial hemorrhage seen. Small ovoid hypodensity in right parietal lobe corresponds to area demonstrating old blood products seen on [**Month/Day/Year 4338**] of [**2196-1-28**]. 2. New opacification of left anterior ethmoid air cells and increased opacification of left mastoid air cells. Echo ([**2196-2-8**]) - The left and right atria are moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. There is no mitral stenosis. Mild to moderate ([**11-28**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Critical aortic valve stenosis. Pulmonary artery hypertension. Right ventricular cavity enlargement with free wall hypokinesis. Mild symmetric left ventricular hypertrophy with preserved global and regional systolic function. Compared with the prior study (images reviewed) of [**2195-11-6**], the [**Date Range **] across the aortic valve has increased and the right ventricular cavity is now dilated with free wall hypokinesis. The estimated PA systolic pressure and severity of mitral regurgitation are similar. [**Date Range 4338**] Head ([**2196-2-19**]) - IMPRESSION: 1. Severe tortuosity of the vertebrobasilar system without evidence of pontine infarction. 2. No evidence of large hemorrhage, edema, masses, mass effect, or infarction. 3. Unchanged small area of subacute blood products in the right parietal lobe. Brief Hospital Course: 1st NEURO ICU COURSE: 86 year-old woman with CAD s/p CABG, HTN, HL, R retinal vein occlusion and recently dx. colon cancer, s/p colectomy c/b C.Diff coilitis who now presented from NH with two episodes of GTC seizures. She was loaded with Keppra IV and was transferred to [**Hospital1 18**]. At [**Hospital1 18**] upon evaluation in the ED, she was found to be "obtunded" s/p Keppra load and given multiple hospitalizations, WBC and seizure, she was felt to be at risk for meningitis, thus was treated with Vancomycin IV, Bactrim IV and Acyclovir IV for possible meningitis. LP couldn not be performed due to requirement of remaining on coumadin and INR of 2.6. There was also concern for top of the basilar syndrome, thus she underwent a CTA of the neck, showing severe atherosclerotic narrowing of the distal right vertebral artery and moderate-to-severe narrowing of both cavernous internal carotid arteries along w/ a small calcification in the basilar artery. She was transfered out of neuro ICU on [**2196-1-28**] for further care. On HD#1 patient was noted to be arousable to voice, oriented to hospital and following simple appendicular and axial commands. Given sudden improvement and no menigismus the antibiotics were discontinued. She continued to improve in her mental status. The detailed neuro exam after she came back to Neuro floor showed subtle weakness on the left side and absent reflexes. To assess the etiology of the seizure (stroke vs. metastatic mass), pt. underwent an [**Date Range 4338**] of the head w/ and w/o contrast. Unfortunately she was agitated and was unable to complete the sequences with contrast. The Non contrast [**Date Range 4338**] showed a lesion in right parietal area, possibly infarct with hemorrhagic conversion, although mass or AVM could not be ruled out due to lack of contrast administration. Initially there was concern for endocarditis, TTE was performed and showed no vegetations. CV. s/p CABG and AV valvuloplasty. Patient was noted to have episodes of hypotension in setting of her home BB dose, this was decreased to 1/2 dose and her lasix was held x 1 day in this setting. TTE revealed EF of > 60%, LVH, mild LVOT and aortic valve leaflets are severely thickened/deformed as well as "significant aortic stenosis." She was continued on the remainder of her NH medications. We held lasix after transfer to floor as there was concerns about lowering her blood pressure in setting of possible ischemic stroke. PULM. Mild oxygen requirement in setting of b/l pleural effusions and mild volume overload, likely due to diastolic dysfunction. In setting of hypotension, the lasix was temporarily held but shortly resumed after concern for her tenuous fluid balance. GI. C. Diff infection. Per discussion w/ NH, it appears that the loose stools have been declining and the plan was to d/c Flagyl/Vanco on day of transfer. She has not had any more loose stools while in the SICU and last C.diff was [**1-13**] at NH and was neg. These were discontinued. 1st CCU COURSE: Pt was found to be in Afib with RVR on admission secondary to missing several doses of metoprolol on the floor. She was also found to be in acute pulmonary edema likely secondary to combination of afib with RVR and missing lasix doses. CXR also showed RLL lung collapse. She was febrile to 100.3 and given her worsened lung exam and MS [**First Name (Titles) **] [**Last Name (Titles) 4338**] it was thought that she had additional experienced silent aspiration. She was initially kept NP[**MD Number(3) **] her depressed mental status and her Afib with RVR was rate controlled with IV metoprolol. As her sensorium cleared she was transitioned to p.o metoprolol with effect. She was treated for HAP aspiration pneumonia with vanc/falgyll/cefepime. On ICU day 3 she spiked to 102 and was pancultured with urine analysis showing pyuria and positive leuk esterase. She was kept on broad spectrum coverage with culture data pending. She was noted to have some new anisocoria on exam on hospital day three felt likely [**12-29**] nebulizer treatment, given that her was still overall improved but should be followed with serial exam. The neurology service had recommended [**Month/Day (2) 4338**] with gadollinium once medically stable to evaluate hyperdensity noted on prior imaging. Currently this is believed to be [**Month/Day (2) 1106**] in nature (infarct) although metastatic disease cannot be ruled out given her history of colon cancer. Her INR was supratherapeutic on CCU admission, is now 1.4 with neurology recommending restarting low dose coumadin. Given her AS she was being judiciously diuresed with lasix drip, was running negative and was switched to her home lasix p.o dosing. Discussion is underway with Dr [**Last Name (STitle) **] regarding percutaneous Aortic valve replacement once she is medically stable. Oral vancomycin suppression for c.diff infection has been discontinued following a negative c.diff and the fact that she has not had any further diarrhea. She was seen by speech and swallow with recommendation made for tube feeding and an NGT was placed. As her mental status was not improving, she was started on continuous EEG monitoring. On the evening of [**2-3**] the patient was found to be in NCSE with generalized spikes in all leads at 2Hz on EEG. She was given ativan 0.5 mg x1, continued on keppra 1g [**Hospital1 **] and loaded with dilantin and was no longer in status. She was transferred to the neuro ICU for further care. 2nd NEURO ICU COURSE: Neurology; The patient remained on continuous video EEG monitoring. Her EEG remained active with generalized sharp waves at a rate of approximately 2 Hz, and on [**2-7**] was found to be back in subclinical status. Her keppra was increased to 1500 mg [**Hospital1 **] and her dilantin was adjusted for goal levels 15-20. Her EEG remained active on [**2-8**] AM. She also had worsening renal function. Therefore, she was given ativan 1 mg x1, her keppra was decreased to 500 mg q12h, and she was loaded with phenobarbital at 15 mg/kg with maintenance dose of 1 mg/kg. An [**Month/Year (2) 4338**] with and without contrast was unable to be performed due to the patient's instability. Her EEG has slowly become less active, currently consistent with encephalopathy and occasional GPEDs with less sharp activity. Her keppra was discontinued [**2-13**], and phenobarbital was decreased to 60 mg [**Hospital1 **] [**2-15**]. Her phenytoin is continued with goal level of 8 (which corresponds to free dilantin level 1.9 as per [**2-8**] draw). Trough levels are requested for dilantin and free dilantin levels on [**2-15**]. Clinically, she does not open eyes to noxious stimuli or follow any commands. Respiratory; The patient had worsening respiratory status [**2-7**], requiring intubation. ID; The patient completed a seven-day course of vancomycin and cefepime [**2-9**] for a presumed pneumonia. She spiked a low grade fever [**2-7**] and urinalysis revealed a likely UTI, but culture grew yeast. She received a three-day course of ciprofloxacin. CV; The patient continued to have a tenuous fluid balance. She was continued on aspirin, lasix, digoxin, lopressor, and statin. She required pressors to maintain her SBP (phenylephrine). A bedside TTE showed an aortic valve area of 0.6 cm2. She is on coumadin for goal INR [**12-30**]. Renal; The patient has had worsening renal failure with minimal urine output. This was presumed to be due to cardiorenal syndrome. She is being followed by nephrology and is considered to be a poor dialysis candidate. Goals of care; multiple family meetings have been held regarding goals of care. The patient's husband and son still wish for all aggressive measures at this time. 2nd CCU COURSE: The patient was transferred back to the CCU service on [**2196-2-14**]. At this time, she was intubated and unresponsive. She was also grossly fluid overloaded and in renal failure. Attempts at diuresis with IV lasix, diuril, and bumex were all unsuccessful. On transfer to the CCU service, the patient was on pressors; however, these were able to be weaned off. The neurology service continued to follow the patient and provided recommendations for weaning down her phenobarbital and dilantin. Per neurology recommendations, the patient underwent [**Date Range 4338**] of his head, which did not reveal any acute changes from prior MRIs. The patient was continued on EEG monitoring, which did not reveal any active seizure activity. The prospect of dialysis was brought up; however, it was felt that the patient was not a candidate for dialysis at that time. After multiple family meetings, the patient's family decided that she was unlikely to awaken from her coma. They decided to make the patient DNR/DNI with a focus on comfort. They decided not to escalate the patient's care any further but also not to deescalate. The patient remained stable until [**2196-2-29**] when she started to desat and look dusky. The family was notified of her clinical deterioration. On [**2196-3-1**] the patient expired. Medications on Admission: HOME MEDICATIONS: 1. Furosemide 60mg daily 2. Levothyroxine 75mg daily 3.Latanoprost 0.005% drop daily 4. Timoptic 0.5% drop daily 5. Lipitor 40mg daily 6. Gabapentin 300mg [**Hospital1 **] 7. Coumadin 4mg [**Last Name (un) **] . MEDICATIONS ON TRANSFER: Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Insulin SC (per Insulin Flowsheet) Acetaminophen 325-650 mg PO/NG Q6H:PRN pain\fever Ipratropium Bromide Neb 1 NEB IH Q6H Aspirin 81 mg PO/NG DAILY Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS Atorvastatin 40 mg PO/NG DAILY Levothyroxine Sodium 75 mcg PO/NG DAILY Bacitracin-Polymyxin Ointment 1 Appl TP Q6H:PRN wound LeVETiracetam 750 mg IV Q12H Collagenase Ointment 1 Appl TP DAILY Lidocaine 5% Patch 1 PTCH TD DAILY Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Digoxin 0.0625 mg PO/NG DAILY Metoprolol Tartrate 25 mg PO/NG TID Famotidine 20 mg IV Q24H FoLIC Acid 1 mg PO/NG DAILY Nystatin Oral Suspension 5 mL PO QID:PRN [**Female First Name (un) **] Gabapentin 100 mg PO/NG [**Hospital1 **] Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY . ALLERGIES: penicillin and erythromycin with rash and GI upset from Motrin Discharge Medications: Pt expired Discharge Disposition: Expired Discharge Diagnosis: Pt expired Discharge Condition: Pt expired Discharge Instructions: Pt expired Followup Instructions: Pt expired Completed by:[**2196-3-1**]

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Discharge summary

report

Admission Date: [**2158-12-12**] Discharge Date: [**2158-12-19**] Date of Birth: [**2074-12-4**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4679**] Chief Complaint: Right lower lobe lung nodule Major Surgical or Invasive Procedure: [**2158-12-12**] OPERATIONS: 1. Right video-assisted thoracic surgery (VATS) converted to right thoracotomy, superior segmentectomy of right lower lobe. 2. Mediastinal lymph node dissection. History of Present Illness: Mr. [**Known lastname 5066**] is an 84 year old gentleman who was admitted into the hospital for surgical management of a right lower lobe mass. He had a chest CT scan on [**9-14**] that showed a 24 x 28 mm noncalcified nodule in the superior segment of right lower lobe. He denied any shortness of breath prior to admission. He did admit to intermittent productive cough prior to admission, but no persistent hemoptysis. He was admitted following a right video assisted thoracostomy superior segmentectomy. Past Medical History: COPD (last PFTs [**2148**] FEV1/FVC 98%, FEV1 55) Coronary artery disease CHF (last echo [**2148**] showed preserved EF >55%, diastolic dysfunction) BPH Osteoarthritis bilateral hips s/p right total hip replacement Hypercholesterolemia atopic dermatitis cervical spondylosis s/p tonsillectomy Social History: Lives with his wife, retired plumbing/heating Tob: smoked x60yrs, quit [**2147**] EtOH: "very little" Illicits: denies Family History: Mother d. 56yrs MI, Father d. 71 MI, brothers with MI in 70s Physical Exam: Discharge Vital signs: T: 99.1 HR 68-70 BP: 110-116/58 20 93% on 3L of nasal cannula Wt: 104 kg Discharge Physical Exam: GEN: 84 year-old in no apparent distress HEENT: normocephalic, mucus membranes moist CV: RRR normal S1, S2 II-III/VI SEM RESP: decreased breath sounds with faint crackles right 1/3 up, left no crackles ABD: obese, bowel sounds positive, abdomen soft non-tender Extr: warm tr edema Incision: Right thoracotomy site with hematoma, no erythema, no discharge Neuro: awake, alert oriented. moves all extremities Pertinent Results: IMAGING: [**2157-12-19**]: The pre-existing opacity at the right lung base is smaller than on the previous examination. Areas of right basal atelectasis have clearly decreased in size. Overall, the right lung appears much better ventilated than before. Unchanged size of the cardiac silhouette. Mild decrease in extent of pre-existing left lower lobe atelectasis. No newly appeared parenchymal opacities. No pulmonary edema. No pneumothorax. Chest X-ray [**2158-12-16**] Impression: Two views. Comparison with the previous study done on [**2158-12-15**]. Bibasilar consolidation, more pronounced on the right and right pleural fluid and/or thickening persists. A very small right apical pneumothorax is redemonstrated. There is streaky density at the bases consistent with subsegmental atelectasis as before. The heart and mediastinal structures are unchanged. The bony thorax is grossly intact. Chest X-ray [**2158-12-15**] Impression: There is interval increase in right pleural effusion. There is small amount of right apical pneumothorax better appreciated on the current view and seen at the apex and along the mediastinum. The loculation of the air in the basal pleura is also seen. Mediastinum is at the central position. Left lung is essentially clear except for minimal basal atelectasis. Calcifications surrounding the right humeral head most likely located within the joint are redemonstrated and most likely consistent with synovial osteochondromatosis. CT chest scan [**2158-12-15**] Impression: 1. No evidence of pulmonary embolism. 2. Loculated right hydropneumothorax status post right lower lobe superior segmentectomy. 3. 2.9 cm low-density collection with multiple foci of air noted within the subcarinal space. Given its location, these findings likely represent the sequelae of mediastinal lymph node biopsy. However, differential diagnosis includes abscess. If the patient is stable, a followup chest CT in three months is recommended for further evaluation. If the patient is not stable, a repeat study may be obtained in one week for further assessment. 4. Bibasilar consolidations with marked secretions within the right bronchus intermedius and basal segmental bronchi. Findings are concerning for aspiration and atelectasis. However, superimposed infection cannot be excluded. 5. Mild enlargement of the mediastinal and right hilar lymph nodes, possibly reactive in nature. 5. Enlargement of the main pulmonary artery, consistent with pulmonary artery hypertension. ECHO [**2158-12-15**]: The left atrium is mildly dilated. The right atrium is moderately dilated. There is 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 70%). 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. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Labs: [**2158-12-18**] WBC-6.8 RBC-3.85* Hgb-10.8* Hct-33.8 Plt Ct-279 [**2158-12-15**] WBC-13.9* RBC-4.27* Hgb-11.9* Hct-37.2 Plt Ct-165 [**2158-12-12**] WBC-9.8# RBC-4.57* Hgb-13.2* Hct-39.1* Plt Ct-164 [**2158-12-19**] Glucose-115* UreaN-23* Creat-0.8 Na-136 K-5.0 Cl-98 HCO3-30 [**2158-12-12**] Glucose-149* UreaN-18 Creat-0.7 Na-136 K-4.0 Cl-101 HCO3-30 [**2158-12-15**] CK(CPK)-291 CK-MB-4 cTropnT-0.03* [**2158-12-19**] Calcium-8.8 Phos-3.4 Mg-2.2 Brief Hospital Course: Mr. [**Known lastname 5066**] was taken to the operating room by Dr. [**First Name (STitle) **] on [**2158-12-12**] where he underwent VATS converted to open right thoracotomy RLL superior segmentectomy for a right lower lung FDG avid lung nodule. The patient was kept intubated overnight in the ICU. POD 1 he was extubated. An epidural was placed by acute pain service which was discontinued POD 2. The following is a systems review of the hospital course: Neuro: The patient remained neurologically intact throughout his stay. He was sedated initially on propofol while intubated, then received paravertebral block with bupivacaine, along with IV Dilaudid. This was dc'd POD 1, and the patients pain was controlled well with ibuprofen, Tylenol and oxycodone. Pulmonary: Aggressive pulmonary toilet was encouraged. The chest tube was on wall suction, then to water seal POD 2, then dc'd POD 3. His oxygen requirements increased. A CTA was done on [**2158-12-15**] to rule out PE given rapid fib and need for oxygen. This was negative for PE, but revealed a pneumonia process. Aggressive pulmonary toilet, mucolytic nebs and incentive spirometer were continued. Oxygen saturations were 77-83% on room air, with ambulation, 93-95% on Liters via nasal cannula. CV: The patient remained hemodynamically stable until the eve of POD 2, at which time he went into rapid fib which was not converted after Lopressor 5mg IV x 2 and diltiazem 10mg IV push and 10mg/hr gtt. Cardiology consulted [**2158-12-15**] am, and recommended amiodarone, and echo (see report). Amiodarone 150mg IV bolus and gtt started, and the pt cardioverted around 1500 to NSR. He was converted to PO amiodarone 200 mg daily. On [**2157-12-18**] while ambulating he had another episode of Afib 140's which converted to SR with IV Lopressor and PO Lopressor was started. He was seen by cardiology again who recommended increasing his Amiodarone to 400 mg daily and stopping toprol and home with an event monitor. Dishcarge heart rhythm sinus 60-70. Blood pressure stable 100-120. ABD: Diet advanced and tolerated. Stool softeners given. GU: Foley was placed intra op and dc'd after paravertebral block dc'd on POD 2. He voided small frequent amounts. A bladder scan revealed 800 residual therefore a A Foley was placed. His home BPH medications were restarted the Foley was removed 24 hours later and he voided large amount without difficulty. POD 3 he was gently diuresed. His renal function remain within normal limits. Heme: Warfarin was started 5 mg [**2158-12-19**] for atrial fibrillation INR Goal 2.0-3.0 then 2 mg daily since on amiodarone and levofloxacin. PT/INR on Friday with VNA and call or fax results to his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 58**]. Endocrine: fingerstick blood sugars remained less than 200. ID: Vancomycin and Zosyn started empirically for a pneumonia seen on CT. Sputum cultures were unable to be obtained during his hospitalization and he was switched to Levaquin to empirically treat his pneumonia. Prophylaxis: Heparin SQ and SCD's placed for VTE prophylaxis. Dispo: The patient was evaluated by PT who recommended home with services for pulmonary rehab. He continue to make steady progress and was discharge to home on [**2158-12-19**] with his family, VNA, home oxygen and PT. He will follow-up with Dr. [**First Name (STitle) **], Dr. [**Last Name (STitle) **] and his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 58**] as an outpatient. Medications on Admission: Lipitor 10 mg a day, finasteride 5 mg daily, Advair 500/50 [**Hospital1 **], Lasix 20 mg daily, terazosin 5 mg daily, and Spiriva daily. Discharge Medications: 1. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 2. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*1* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks. Disp:*28 Capsule(s)* Refills:*0* 4. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. terazosin 5 mg Capsule Sig: One (1) Capsule PO once a day. 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation for 2 weeks. Disp:*24 Tablet(s)* Refills:*0* 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. oxycodone 5 mg Tablet Sig: .5 - 1 Tablet PO Q4H (every 4 hours) as needed for pain for 40 doses. Disp:*40 Tablet(s)* Refills:*0* 14. Home O2 Supplementation Please dispense home oxygen supplement and supplies. 15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day: take as directed to maintain INR 2.0-3.0. Disp:*100 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Right lower lobe lung nodule Aortic stenosis- moderate to severe on echo [**10-11**] Hyperlipidemia Hypertension BPH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough or chest pain -Incision develops drainage (soft hematoma at incision site stable) -Steri-strips remove in 10 days or sooner should they come off -Shower daily. Wash incision with mild soap and water, rinse, pat dry -Chest tube site with bandaid. Should site drain cover with a clean dressing and change as needed -No tub bathing or swimming for 6 weeks Daily weights: (wt:[**2158-12-19**] 229 lbs)keep a log. Call your Dr. [**Last Name (STitle) 58**] with 3-4 pounds weight gain Take amiodarone daily. Follow-up with your Cardiologist Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 5068**] regarding these medications. Call Dr. [**Last Name (STitle) **] should you have any questions regarding your heart rate or rhythm. Warfarin for atrial fibrillation. INR Goal 2.0-3.0 Take 2 mg nightly Followup Instructions: Followup with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**] Date/Time:[**2159-1-4**] 10:00 on [**Hospital Ward Name 23**] [**Location (un) **] [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center Chest X-ray 30 minutes prior to your appointment on the [**Location (un) **] radiology department 2. Please follow up with your cardiologist, [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD. [**2158-1-2**] at 10:00 [**Location (un) 5069**]. [**Telephone/Fax (1) 5068**] 3. Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 58**], in [**12-3**] week after discharge. [**Telephone/Fax (1) 3329**] Completed by:[**2158-12-19**]

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icd9cm

[ [ [] ] ]

[ "32.39", "40.3" ]

icd9pcs

[ [ [] ] ]

11233, 11291

5994, 6435

341, 540

11452, 11452

2174, 5971

12575, 13371

1546, 1608

9685, 11210

11312, 11431

9523, 9662

6453, 9497

11603, 12552

1623, 1722

273, 303

568, 1077

11467, 11579

1099, 1393

1409, 1530

1747, 2155

12,085

175,810

28232

Discharge summary

report

Admission Date: [**2151-12-22**] Discharge Date: [**2152-1-11**] Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 1973**] Chief Complaint: Cholangitis Major Surgical or Invasive Procedure: Transcutaneous Biliary Drain ERCP History of Present Illness: 83 y F with cholangitis due to pancreatic CA (end stage). Pt brought for ERCP (failed) treated with transcutaneous billiary drain. Pt worsened over admission, with recurrent tense ascites. Pt made DNR/DNI and to be transferred to hospice Past Medical History: Hypertension atrial fibrillation Social History: + TOB, - ETOH, - IVDU Lives with Son, also has daughter Family History: NC Physical Exam: Gravely ill woman, moaning in pain rales b/l ascites, NT/ND [**Last Name (un) **], S1/S2, - MRG 4+ edema Pertinent Results: [**2152-1-11**] 03:46AM BLOOD WBC-7.2 RBC-2.95* Hgb-8.4* Hct-26.3* MCV-89 MCH-28.5 MCHC-32.0 RDW-26.8* Plt Ct-61* [**2152-1-8**] 05:15AM BLOOD Neuts-87.6* Bands-0 Lymphs-5.3* Monos-4.8 Eos-2.2 Baso-0 [**2152-1-11**] 03:46AM BLOOD Plt Ct-61* [**2152-1-11**] 03:46AM BLOOD UreaN-73* Creat-2.2* Na-142 K-3.7 [**2152-1-11**] 03:46AM BLOOD TotBili-9.1* [**2152-1-9**] 05:14AM BLOOD ALT-49* AST-50* AlkPhos-357* TotBili-8.9* [**2151-12-25**] 04:17AM BLOOD CK-MB-4 cTropnT-0.02* [**2152-1-11**] 03:46AM BLOOD Albumin-1.9* Mg-2.3 cholangiogram:IMPRESSION: 1. Cholangiogram demonstrating biliary obstruction at the level of the common bile duct with moderate intrahepatic ductal dilatation. 2. Exchange of an 8 French biliary catheter over a wire. 3. Proper drainage of bile was demonstrated both visually via the external route and radiographically via the internal route into the duodenum. 4. Given severe narrowing of the common bile duct, if clinically indicated, a metallic stent could be placed by interventional radiology in the future. Brief Hospital Course: Patient now ready to go to hospice. Long family discussion, and medical futility of further treatment, decision to withdraw primary care, and move to comfort care and hospice. Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: Kinwell Discharge Diagnosis: Pancreatic Cancer Cholangitis Tense Ascites Discharge Condition: Critical Discharge Instructions: Hospice Care Followup Instructions: Hospice Care

[ "789.5", "799.02", "038.9", "537.3", "452", "401.9", "V10.3", "995.92", "211.1", "574.20", "427.31", "785.52", "996.59", "576.1", "157.0", "576.2", "293.0", "788.5", "428.30", "041.3", "041.04" ]

icd9cm

[ [ [] ] ]

[ "96.08", "38.93", "87.54", "51.98", "54.91", "00.14", "45.13", "97.05" ]

icd9pcs

[ [ [] ] ]

2343, 2377

1881, 2058

229, 264

2464, 2474

820, 1858

2535, 2550

676, 680

2081, 2320

2398, 2443

2498, 2512

695, 801

178, 191

292, 531

553, 587

603, 660

58,812

184,751

42604

Discharge summary

report

Admission Date: [**2113-11-23**] Discharge Date: [**2113-11-29**] Date of Birth: [**2071-9-27**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 598**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 42M with past medical hx of spina bifida, multiple shunts, pancreatitis and pseudocyst who presents to [**Hospital6 **] in [**11-22**] with signs/sxs and radiological findings consistent with a high grade obstruction. He was taken to the OR where he underwent small bowel resection with spilage and LOA. Shortly after the procedure he became hypotensive requirin pressors. He hct was stable, he received 11L of ressuscitation, however he continues to require pressors even with a CVP of 17. Due to his increasing ICU care he was transfered to [**Hospital1 18**] for further care. He was tranfered intubated on levophed and on arrival his BP was 95/60 and HR 130's Past Medical History: Past Medical History: Spina Bifida HTN Pancreatitis Past Surgical History: Multiple VP Shunt procedure Multiple pinnings of the hip as well as multiple laparatomies to fix various defects as well as mengeocele resection Social History: Social History: lives by himself, per hx no ETOH or tobacco Family History: NC Physical Exam: Physical Exam: upon admission [**2113-11-23**]: Vitals: 97.8 HR 130's BP 95/60 Sat 100% on the vent GEN: Intubated and sedated HEENT: anicteric sclera with ET tune in place CV: RRR, No M/G/R PULM: Clear to auscultation decrease BS at the bases with expiratory wheezing, Vent MMV 440x14 5,5 ABD: distented, NT, dressing c/d/i. Bladder PS 30 Ext: No LE edema, LE warm and well perfused At discharge: Vitals: 98.2 HR 98 BP 110/79 R 20 Sat 97% RA GEN: A&O, NAD CV: RRR, No M/G/R PULM: Clear to auscultation, decreased at b/l bases ABD: Soft, nondistended, appropriately tender at incision. Incision well-approximated with staples, minimal errythema, drainage. Retention sutures intact. Ext: No LE edema, LE warm and well perfused Pertinent Results: [**2113-11-28**] 06:03AM BLOOD WBC-7.4 RBC-3.32* Hgb-9.5* Hct-28.0* MCV-84 MCH-28.6 MCHC-33.9 RDW-13.0 Plt Ct-255 [**2113-11-26**] 05:00AM BLOOD WBC-6.3 RBC-3.26* Hgb-9.8* Hct-28.5* MCV-87 MCH-30.0 MCHC-34.3 RDW-12.9 Plt Ct-207 [**2113-11-23**] 03:33AM BLOOD WBC-16.0* RBC-4.63 Hgb-13.5* Hct-40.7 MCV-88 MCH-29.2 MCHC-33.2 RDW-12.8 Plt Ct-342 [**2113-11-25**] 02:13AM BLOOD Neuts-91.2* Lymphs-5.6* Monos-2.6 Eos-0.4 Baso-0.1 [**2113-11-23**] 03:33AM BLOOD Neuts-73* Bands-13* Lymphs-5* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-0 Plasma-1* [**2113-11-28**] 06:03AM BLOOD Plt Ct-255 [**2113-11-24**] 02:25PM BLOOD PT-19.7* PTT-32.1 INR(PT)-1.9* [**2113-11-28**] 06:03AM BLOOD Glucose-113* UreaN-3* Creat-0.5 Na-142 K-3.3 Cl-102 HCO3-37* AnGap-6* [**2113-11-27**] 09:15PM BLOOD Na-140 K-3.0* Cl-99 [**2113-11-27**] 05:09AM BLOOD Glucose-140* UreaN-4* Creat-0.5 Na-138 K-2.9* Cl-97 HCO3-35* AnGap-9 [**2113-11-23**] 03:33AM BLOOD Glucose-123* UreaN-11 Creat-0.8 Na-134 K-4.0 Cl-105 HCO3-23 AnGap-10 [**2113-11-25**] 02:13AM BLOOD ALT-15 AST-24 AlkPhos-67 TotBili-0.5 [**2113-11-28**] 06:03AM BLOOD Calcium-7.7* Phos-2.0* Mg-1.6 [**2113-11-23**] 03:33AM BLOOD Cortsol-109.9* [**2113-11-28**] 06:02AM BLOOD Vanco-14.3 [**2113-11-27**] 05:09AM BLOOD Vanco-13.6 [**2113-11-23**] 10:18PM BLOOD Lactate-1.1 [**2113-11-23**] 04:21AM BLOOD Glucose-112* Lactate-3.2* [**2113-11-23**] 09:44AM BLOOD freeCa-1.16 [**2113-11-23**]: ECHO: Conclusions The left atrium is normal in size. The left ventricular cavity is underfilled. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is dilated with normal free wall contractility. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The mitral valve leaflets are structurally normal. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Hyperdynamic LV systolic function without signs of regional wall motion abnormalities. The RV appears dilated but has good systolic function. RV systolic pressure cannot be determined without a TR jet. [**2113-11-24**]: ECHO: The left atrium is normal in size. Left ventricular wall thicknesses are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size is normal at the basal region, but appears to be dilated with an unusual shape in the mid ventricular region. This may be due to mechanical comprssion on the right atrium (please see description below). Right ventricular free wall contractility appears to be normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. The trisuspid valve is seen on some clips (12, 18) to potentially be compresed from external structure. No obvious loculated clot or other stucture seen compressing the right atrium or tricuspid valve, though. In addition, the pattern of tricuspid regurgitation is abnormal which support this concern. If clinically indicated, TEE or chest CT would be recommended. IMPRESSION: Preserved biventricular systolic function. Abnormal shape of the right ventricule. Concern for physical compression of the right atrium. Suboptimal images to exclude such compression Brief Hospital Course: 42 year old gentleman admitted to the acute care service from an OSH after undergoing a small bowel resection for an obstruction. He was reported to have spillage. He became hypotensive after the procedure requiring volume and pressor support and remained intubated. He was admitted to the intensive care unit for hemodynamic monitoring and pulmonary toilet. Neurosurgery was consulted regarding the possibility of CSF of his left ventricuatrial shunt. The shunt was tapped by ID and no white blood cells were indentified. He was started per Infectious disease on vancomycin, cefepime, and flagyl. Voriconazole was added for fungal prophalaxsis. An echocardiogram was done upon admission and 48 hours later which showed preserved biventricular systolic function and an abnormal shape of the right ventricle. His pressors were gradually weaned off and he was extubated on HD #2 maintaining adequate oxygenation. He had occasional bouts of tachycardia treated with metoprolol. His voriconazole was discontinued on HD #2. As his hemodynamic status improved, his foley catheter and [**Last Name (un) **]-gastric were discontinued on HD # 3. At this time, he had mild wheezing and was given a dose of lasix. After stabilization of his pulmonary status, he was transferred to the surgical floor on HD # 3. On HD #4, he was started on a regular diet. Bronchodilators were added to help alleviate his bouts of wheezing. His cefepime and vancomycin were discontinued on HD # 6. His cultures thus far have been negative. His WBC count is normal at 7.6. His vital signs are stable and he is afebrile. He has required frequent repletion of his electrolytes. He is tolerating a regular diet. His white blood cell count has decreased to 7.6 and his hematocrit is stable at 28. He was evaluated by physical therapy and recommendations made for discharge to a rehabilitation facility where he can further regain his strength and mobility. He will follow-up for removal of the stay sutures. Medications on Admission: Lisinopril 40 mg Qday Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: sepsis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair ( pt needs assistance to get into wheelchair) Discharge Instructions: You were admitted to the hospital after you had a small bowel resection at another hospital. After the procedure you had a large fluid requirement and required medication to support your blood pressure and there was a concern for sepsis. Because of this, you were transferred here for management. You were monitored in the intensive care unit where you had the breathing tube removed. Once your vital signs stabilized, you were transferred to the surgical floor. Followup Instructions: You are scheduled to follow up with your surgeon, Dr. [**Last Name (STitle) 8671**], from [**Location (un) 92162**] Hospital. You appointment is on [**2113-12-21**], at 1pm. The office is located at [**Last Name (un) 92163**], [**Location (un) 61553**], MA. Please call the office at [**Telephone/Fax (1) 92164**] if you need to reschedule. It is important you keep this appointment since your sutures (retension sutures) will most likely be removed at this time. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2113-11-29**]

[ "741.90", "998.02", "E878.6", "V45.2", "995.92", "038.9", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.91" ]

icd9pcs

[ [ [] ] ]

8401, 8473

5593, 7587

311, 318

8524, 8524

2125, 5570

9233, 9836

1356, 1360

7659, 8378

8494, 8503

7613, 7636

8745, 9210

1114, 1262

1390, 1761

1776, 2106

265, 273

346, 1017

8539, 8721

1061, 1091

1294, 1340

13,902

180,163

49580

Discharge summary

report

Admission Date: [**2112-3-11**] Discharge Date: [**2112-3-16**] Date of Birth: [**2038-11-21**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor / Zocor / Sulfamethoxazole/Trimethoprim / Plavix / Cortisone / Citalopram / Ticlid / Protonix / Lisinopril / Ranitidine / Pneumovax 23 Attending:[**First Name3 (LF) 1505**] Chief Complaint: DOE/CP Major Surgical or Invasive Procedure: [**2112-3-11**] Redo-Sternotomy, Coronary Artery Bypass Graft x 2 (SVG to LAD, SVG to Diag) History of Present Illness: Mr. [**Known lastname **] is a 73 year old male with prior CABG in [**2096**]. In [**2111-9-28**], he suffered a MVA secondary to a syncopal episode. Workup at that time showed native three vessel and vein graft disease. Prior to admission, he continues to have chest pain and dyspnea on exertion. Past Medical History: Coronary Artery Disease - s/p CABG [**2096**], Multiple PTCA/Stenting([**2105**]-[**2107**]) Hyperlipidemia Diabetes Mellitus Type II Rheumatic Fever as a child Cataracts - s/p surgery Glaucoma Appendectomy History of Bowel Obstruction - s/p Colectomy, s/p Reversal of Colectomy [**2110-12-29**] Social History: Social history: occasional drinks EtOH, 60 pack year smoking hx, stopped 25 years ago. Family History: Father MI at age 64. Brother died of MI at age 39. Physical Exam: 78 sr 14 146/78 GEN: WDWN in NAD SKIN: Warm, dry, no C/C/E HEENT: NCAT, R pupil dilated and pupils asymmetric, sclera anicteric, OP benign. Edentulous. NECK: FROM, No JVD, Supple LUNGS: Clear. STERNOTOMY: Well healed. ABD: Benign. Well healed midline incision. EXT: Warm, well perfused. [**12-30**]+ Pulses. R GSV harvested. L GSVappears suitable. NEURO: Nonfocal Pertinent Results: [**2112-3-11**] INTRAOP TEE PRE-BYPASS: 1. The left atrium is moderately dilated. No thrombus is seen in the left atrial appendage. 2. The interatrial septum is aneurysmal. A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present 3. Left ventricular wall thicknesses and cavity size are normal. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the aortic root. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Mitral valve area is reduced. Moderate (2+) mitral regurgitation is seen. 8. There is no pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is in sinus rhythm. 1. [**Hospital1 **]-ventricular function is preserved. 2. MR [**First Name (Titles) **] [**Last Name (Titles) 103703**], AI is unchanged. 3. Other findings are unchanged. 4. Aorta is intact post decannulation [**2112-3-16**] 05:25AM [**Month/Day/Year 3143**] WBC-8.6 RBC-3.17* Hgb-8.4* Hct-25.9* MCV-82 MCH-26.5* MCHC-32.5 RDW-13.6 Plt Ct-145* [**2112-3-11**] 10:50AM [**Month/Day/Year 3143**] WBC-9.1 RBC-3.18*# Hgb-8.5*# Hct-25.3*# MCV-80* MCH-26.7* MCHC-33.6 RDW-14.4 Plt Ct-124* [**2112-3-16**] 05:25AM [**Month/Day/Year 3143**] Plt Ct-145* [**2112-3-11**] 12:25PM [**Month/Day/Year 3143**] PT-13.5* PTT-36.0* INR(PT)-1.2* [**2112-3-11**] 10:50AM [**Month/Day/Year 3143**] Fibrino-186 [**2112-3-16**] 05:25AM [**Month/Day/Year 3143**] Glucose-143* UreaN-30* Creat-1.5* Na-137 K-4.5 Cl-95* HCO3-31 AnGap-16 [**2112-3-15**] 11:20AM [**Month/Day/Year 3143**] UreaN-30* Creat-1.7* [**2112-3-11**] 12:25PM [**Month/Day/Year 3143**] UreaN-25* Creat-1.1 Cl-112* HCO3-24 [**2112-3-14**] 05:30AM [**Month/Day/Year 3143**] Calcium-8.6 Phos-2.5* Mg-2.1 Brief Hospital Course: Mr. [**Known lastname **] was admitted and underwent redo sternotomy, and redo 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 maintained stable hemodynamics and transferred to the SDU on postoperative day one. He had [**Last Name (un) **] burst of atrial fibrillation that were converted with beta blockers, and has since remained in a normal sinus rhythm. Beta blockade was advanced as tolerated. Over several days, he continued to make clinical improvements with diuresis. His creatinine increased to 1.7 and diuretics were stopped. His creatinine then decreased and he was discharged home with services POD 5. Medications on Admission: Zetia 10 qd, Imdur 100 qd, Folate, Lopressor 125 [**Hospital1 **], Aspirin 325 qd, Centrum Silver, Sublingual Nitro 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:*40 Tablet(s)* Refills:*0* 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2 Post op atrial fibrillation PMH: a/p Coronary Arery Bypass Graft x 4 [**2096**] and s/p mulitple PTCA/Stenting Hyperlipidemia, Diabetes Mellitus, Glaucoma, Cataracts, Rheumatic fever as child, R shoulder torn rotator cuff 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 for redness or drainage from surgical wounds 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: [**Hospital Ward Name 121**] 6 for wound check in 2 weeks Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 2912**] in [**1-31**] weeks Completed by:[**2112-3-16**]

[ "427.31", "E878.2", "272.4", "414.01", "414.02", "250.00", "997.1" ]

icd9cm

[ [ [] ] ]

[ "36.12", "39.61" ]

icd9pcs

[ [ [] ] ]

6004, 6062

4126, 5001

417, 511

6389, 6396

1731, 4103

6719, 6903

1278, 1330

5167, 5981

6083, 6368

5027, 5144

6420, 6696

1345, 1712

371, 379

539, 838

860, 1157

1189, 1262

19,040

152,111

8401+55942

Discharge summary

report+addendum

Admission Date: [**2172-8-8**] Discharge Date: [**2172-8-18**] Date of Birth: [**2104-12-24**] Sex: F Service: CHIEF COMPLAINT: "Needs BiPAP." HISTORY OF PRESENT ILLNESS: The patient is a 67 year-old woman with very severe chronic obstructive pulmonary disease, FEV1 of 0.59, continues tobacco abuse on home O2 of 2 liters, bipolar disorder who now presents with increased dyspnea times one week requiring BiPAP. She is followed by Dr. [**Last Name (STitle) 29658**] for lung disease, last admitted from [**2-6**] to [**2-18**] with respiratory failure secondary to influenza infection. She has been steroid dependent for several years. The patient represents now with complaints of dyspnea at rest times one week, increased rhinorrhea, sore throat and cough, scant production of clear sputum with subjective fevers and chills, lower substernal chest tightness. PAST MEDICAL HISTORY: Chronic obstructive pulmonary disease, FEV1 0.59, PPD positive, multiple sputum negative for tuberculosis, bipolar, hypertension, hypercholesterolemia, osteoporosis, appendectomy, hiatal hernia repair, polycythemia. Echocardiogram in [**2172-2-7**] demonstrated left atrium of 4.4 cm, EF greater then 50%, mild left ventricular hypertrophy, decreased right ventricular function. ALLERGIES: Codeine, phenobarbital and Lithium. SOCIAL HISTORY: Married with three children. Husband cares for the patient at home. Tobacco use greater then two packs per day. The patient with bipolar disorder well controlled. She uses wheel chair at home. PHYSICAL EXAMINATION: Temperature 100. Heart rate 99. Blood pressure 122/65. 97% on 30% FIO2. HEENT extraocular movements intact. Pupils are equal, round and reactive to light and accommodation. Oropharynx dry. Pulmonary diffuse rhonchi, fine crackles at bases bilaterally. Decreased breath sounds throughout. Cardiovascular distant heart sounds, normal S1 and S2. Abdomen soft, nontender, nondistended. Extremities no clubbing, cyanosis or edema. Neurological alert and oriented times two. LABORATORY: White blood cell count 10.8, neutrophils 87, bands 3, lymphocytes 3, monocytes 6, atypicals 1. Hematocrit 49, platelets 297, sodium 142, potassium 3.9, chloride 103, bicarb 25, BUN 8, creatinine 1.3 at baseline, glucose 116, CK 54, troponin less then 0.3. Arterial blood gas 7.34, 52, 58, 29 on 2 liters nasal cannula. Chest x-ray slight upper zone redistribution. No infiltrate, blunting of the angles bilaterally. Electrocardiogram sinus tachycardia, left atrium enlargement, low limb lead voltages, wavy baseline, slight ST depression in V3 through V6. HOSPITAL COURSE: Ms. [**Known lastname **] was admitted to the [**Hospital Ward Name 332**] Intensive Care Unit for further management of her respiratory distress. She is maintained on BiPAP, although the patient had difficulty tolerating the machine. She was started on Solu-Medrol and continued on nebulizer treatments q 2 prn. She ruled out for myocardial infarction. The patient was started on Levofloxacin 500 mg q day. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Last Name (NamePattern1) 29659**] MEDQUIST36 D: [**2172-8-27**] 10:56 T: [**2172-9-2**] 07:17 JOB#: [**Job Number 29660**] Name: [**Known lastname 1223**], [**Known firstname **] K Unit No: [**Numeric Identifier 5179**] Admission Date: [**2172-8-8**] Discharge Date: [**2172-8-18**] Date of Birth: [**2104-12-24**] Sex: F Service: Continuation at hospital course: The patient was started on levofloxacin 500 mg q day. On [**8-10**], the patient was transferred to the floor for further management of her respiratory care. At that time the patient refused further treatment with BiPAP and maintained her DNR/DNI status. The patient was continued under treatment for one pulmonary nebulizer treatments q2 hours, levofloxacin, Solu-Medrol, Volmax, oral medication was added q hs. For anxiety, respiratory distress was also alleviated with Morphine 1-2 mg q2 hours prn. Anxiety helped controlled with Ativan 1-2 mg IV q4 hours prn. Patient's respiratory status slowly improved. When she arrived to the floor, she was maintained on rebreather face mask with frequent desaturations. At the time of discharge, she was able to maintain saturations in the low 90s on 3 liters nasal cannula. 2. Psych. The patient was continued on her outpatient medications including Tegretol, Norvasc, Serax, and Ativan. 3. Endocrine. Continued the outpatient Premarin dose. 4. GI. Prophylaxis with Protonix. 5. Code status. Discussions were initiated RE: Patient goals of care. The patient definite wishes to remain DNR/DNI. Discussion about hospice home services were initiated, however, patient liked to continue with VNA services at this time. 6. ID. Patient with the appearance of herpes zoster across the lumbar region. Treatment was initiated with acyclovir and Capsaicin cream as well as pain control with Morphine. CONDITION ON DISCHARGE: Good. Discharged to home with VNA services. DISCHARGE MEDICATIONS: 1. Combivent inhaler 3-4 puffs 4x a day. 2. Albuterol and Atrovent nebulizer treatments prn. 3. Flovent inhaler four puffs [**Hospital1 **]. 4. Volmax 4 mg q am. 5. Tegretol 200 mg tid. 6. Narvane 4 mg q hs. 7. Serax 10 mg one po qid. 8. Protonix 40 mg q day. 9. Colace 100 mg [**Hospital1 **]. 10. Tylenol 650 mg one q4 hours prn. 11. Aspirin 325 mg q day. 12. Multivitamins q day. 13. Premarin 0.625 mg q day. 14. Prednisone 30 mg q day x7 days and then 20 mg q day x7 days and then permanent dose is 15 mg q day. 15. Levofloxacin 500 mg q day x3 days. 16. Acyclovir 800 mg 5x a day x7 days. 17. Capsaicin cream applied to effected area 4x a day as needed. 18. Morphine IR 10 mg/5 cc every six hours as needed for pain x7 days with instructions not to take at the same time as Serax. If she becomes sleepy or confused, she may decrease the dose to 5 mg. 19. Senna one po q hs. Follow-up appointment arranged with Dr. [**Last Name (STitle) 5180**] in one week. [**Name6 (MD) 116**] [**Name8 (MD) 117**], M.D. [**MD Number(1) 118**] Dictated By:[**Last Name (NamePattern1) 2168**] MEDQUIST36 D: [**2172-9-22**] 15:05 T: [**2172-9-22**] 15:14 JOB#: [**Job Number **]

[ "296.7", "053.9", "305.1", "300.00", "289.0", "518.84", "263.9", "491.21" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

5142, 6351

3590, 5048

1574, 2629

145, 161

190, 884

907, 1337

1354, 1551

5073, 5119

31,541

179,612

900

Discharge summary

report

Admission Date: [**2108-3-8**] Discharge Date: [**2108-3-16**] Date of Birth: [**2047-10-22**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: CP and fatigue Major Surgical or Invasive Procedure: s/p CABGx3(LIMA->LAD, SVG->OM, PDA) [**2108-3-12**] History of Present Illness: This 60 y/o WF has had exertional angina and it has increased to having it at rest. She underwent cardiac cath at [**Hospital3 6101**] on [**2108-3-8**] which revealed 50-60% LM stenosis, 100% RCA and she was transferred on [**3-8**] for cardiac surgery. Past Medical History: CAD s/p MI PVD OA s/p cardiac thrombus obesity s/p carotid->carotid bypass s/p TAH ^chol. Social History: Lives with husband. [**Name (NI) 1403**] as a computer operator. Cigs: 20-30 pk. yr., quit in [**2094**] ETOH: denies Family History: F died of MI at age 53, brother +CAD Physical Exam: WDWNWF in NAD AVSS HEENT: NC/AT, PERLA, oropharynx benign Neck: FROM, supple, carotids without bruit Lungs: Clear to A+P CV: RRR without R/G/M Abd: +BS, soft, nontender, without masses or hepatosplenomegaly, obese Ext: without C/C/E, pulses Fem: 2+ bil., DP: 1+ bil., PT: 1+ bil., Rad: 2+ bil. Neuro: nonfocal Pertinent Results: [**2108-3-16**] 03:27AM BLOOD WBC-8.3 RBC-3.38* Hgb-10.3* Hct-30.4* MCV-90 MCH-30.4 MCHC-33.9 RDW-13.7 Plt Ct-144* [**2108-3-15**] 08:44PM BLOOD PT-12.9 PTT-29.8 INR(PT)-1.1 [**2108-3-16**] 03:27AM BLOOD Glucose-95 UreaN-15 Creat-0.9 Na-138 K-4.3 Cl-101 HCO3-29 AnGap-12 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2108-3-13**] 4:17 PM CHEST (PORTABLE AP) Reason: eval ptx s/p ct d/c [**Hospital 93**] MEDICAL CONDITION: 60 year old woman s/p CABG REASON FOR THIS EXAMINATION: eval ptx s/p ct d/c CHEST, AP PORTABLE SINGLE VIEW INDICATION: Status post bypass surgery. Discontinued lines and extubated. Evaluate for pneumothorax. FINDINGS: AP single view of the chest obtained with patient in sitting semi-upright position is analyzed in direct comparison with the next preceding chest examination of [**2108-3-12**]. During the interval, the patient has been extubated, and the NG tube has been removed. The same holds for the Swan-Ganz catheter and the sheath which has been replaced with a central venous line seen to terminate overlying the SVC at the level 2 cm below the carina. No pneumothorax has developed, and no new infiltrates are seen. _____ on previous examinations, the noted parenchymal densities in the upper lobe areas have resolved. They were interpreted as representing edema. IMPRESSION: Satisfactory chest findings after instrument removal, no evidence of pneumothorax. DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 6102**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 6103**] (Complete) Done [**2108-3-12**] at 1:31:43 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2047-10-22**] Age (years): 60 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Chest pain. Coronary artery disease. Shortness of breath. ICD-9 Codes: 786.05, 786.51, 440.0 Test Information Date/Time: [**2108-3-12**] at 13:31 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 #: 2008AW1-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 45% to 55% >= 55% Aorta - Ascending: 3.1 cm <= 3.4 cm Findings LEFT ATRIUM: Mild LA enlargement. Good (>20 cm/s) LAA ejection velocity. Cannot exclude LAA thrombus. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Normal LV cavity size. Mild regional LV systolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Simple atheroma in ascending aorta. Simple atheroma in aortic arch. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. Conclusions PRE-CPB:1. The left atrium is mildly dilated. A left atrial appendage thrombus cannot be excluded. 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. There is mild regional left ventricular systolic dysfunction with anterior mid and apical hypokinesis. 3. . Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7. There is a trivial/physiologic pericardial effusion. POST-CPB: On infusion of phenylephrine. Episode of transient RV dysfunction secondary to air visible in RCA. Epi 8-10 mcg given with prompt resolution. Preserved biventricular systolic function. Trace MR. Aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2108-3-12**] 16:17 Brief Hospital Course: The patient was transferred from [**Hospital6 5016**] on [**3-8**]. She had a preop vascular evaluation regarding her previous carotid surgery and she was cleared. Carotid doppler showed a patent graft. On [**2108-3-12**] she underwent CABGx3(LIMA->LAD, SVG->OM, PDA). The cross-clamp time was 50 mins., total bypas time was 66 mins. She tolerated the procedure well and was transferred to the CVICU in stable condition on Neo and Propofol. She was extubated on the post op night and continued to progress. She was on neo and eventually weaned off. Her chest tubes were d/c'd on POD#1 and wires were d/c'd on POD#3. She continued to progress and was discharged to home in stable condition on POD#4. Medications on Admission: Metformin 1000 mg PO BID Avandia 4 mg PO daily Fosamax 70 mg PO q week Verapamil SR 240 mg PO BID Lipitor 80 mg PO daily Isordil 140 mg PO TID Toprol XL 25 mg PO daily Lisinopril 10 mg PO daily Folic acid 1 mg PO daily ASA 81 ng PO daily Nitro spray PRN Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Rosiglitazone 8 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. Disp:*4 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: CAD PVD OA s/p MI s/p cardiac thrombus obesity ^chol. Discharge Condition: Good Discharge Instructions: Follow medications in discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office with sternal drainage, temp>101.5 Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 6104**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 4783**] for 2-3 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Wound check on [**Hospital Ward Name 121**] 6 on [**3-26**] at 11AM. Call [**Telephone/Fax (1) **] with any changes. Completed by:[**2108-3-16**]

[ "401.9", "715.90", "722.10", "458.29", "278.00", "412", "435.2", "443.9", "250.00", "413.9", "285.9", "272.0", "V15.82", "414.01", "270.4" ]

icd9cm

[ [ [] ] ]

[ "93.90", "38.93", "39.64", "39.61", "88.72", "36.13" ]

icd9pcs

[ [ [] ] ]

9164, 9213

6929, 7636

336, 390

9311, 9318

1322, 1717

9646, 10010

939, 977

7940, 9141

1754, 1781

9234, 9290

7662, 7917

9342, 9623

992, 1303

282, 298

1810, 6906

418, 675

697, 788

804, 923

13,549

119,605

43209

Discharge summary

report

Admission Date: [**2148-2-29**] Discharge Date: [**2148-2-29**] Date of Birth: [**2069-3-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: J-tube displacement Major Surgical or Invasive Procedure: G-J tube placement by interventional radiology History of Present Illness: HPI: 78M with ESRD on HD, CHF (EF 15%), s/p trach with chronic vent-dependence, s/p G-tube and J-tube placement, admitted after J-tube was accidentally pulled out by the patient and attempts at replacing it were unsuccessful. Per HRC notes, patient had his G-tube and J-tubes placed at the [**Hospital **] Hospital for gastroparesis in [**12-5**]. The G-tube is for drainage (very high-output per HRC), J-tube is for tube feeds. . In the ED, VS were T 99.6, HR 110, BP 121/86, RR 16, 95% on AC 550x14/5/0.40. Blood cultures were drawn and reinsertion of the J-tube was unsuccessful again. Surgery was consulted and they were also unable to replace the tube. He was sent for a G-J tube study which showed the G-tube in appropriate position. BP dropped to 80s-90s systolic. He was started on D5NS at 50cc/hr. He was admitted to the MICU with the plan to replace the J-tube in IR the following day. . Past Medical History: PMH: 1. DM type 2 2. ESRD- started HD [**12-5**] 3. CAD- s/p MI x 4, last MI in [**2135**] 4. CHF- EF 15% [**First Name8 (NamePattern2) **] [**Hospital1 882**] notes, s/p AICD placement 5. s/p multiple CVAs 6. Paroxysmal atrial fibrillation- not on AC, previously on rate control w/ BB, held for episodes of hypotension 7. History of multiple GI bleeds 8. SMA syndrome 9. GERD 10. s/p cardiac arrest [**2-10**], preceded by respiratory arrest, resuscitated with epi in ETT 11. H/o Boerhaave's syndrome--> esophageal stricture 12. VRE colonization 13. Seizure disorder 14. Hypertension 15. Gastroparesis s/p G-tube/J-tube placement 16. H/o EtOH abuse 17. AAA- 7cm on recent imaging at [**Hospital1 882**] 18. Recent Pseudomonal pna- treated with ceftaz/tobra, completed course today 19. C. diff colitis- treated with Flagyl with persistent toxin in stool, po vanco added to po Flagyl Social History: SH: lives at [**Hospital6 459**] MACU, history of EtOH abuse, niece [**Name (NI) 2270**] [**Name (NI) 2523**] is involved in care Family History: NC Physical Exam: Vitals- T 95.3, HR 94, 108/55, O2 sat 98% on AC 550x14/50/0.40 General- asleep but arousable to name, did not cooperate with further questions or exam HEENT- NCAT, sclerae anicteric, Neck- trach to vent Chest- R SC portacath Pulm- coarse breath sounds throughout anteriorly CV- broad and laterally displaced PMI, RRR, difficult to auscultate murmur Abd- G-tube in place draining yellowish-brown liquid, no surrounding erythema/induration or discharge, + BS, soft, no response to palpation Extrem- LEs in protective boots b/l . Pertinent Results: [**2148-2-29**] 05:51AM GLUCOSE-106* UREA N-19 CREAT-1.8* SODIUM-139 POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-30 ANION GAP-13 [**2148-2-29**] 05:51AM CK(CPK)-11* [**2148-2-29**] 05:51AM CK-MB-NotDone cTropnT-0.32* [**2148-2-29**] 05:51AM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-1.8 [**2148-2-29**] 05:51AM WBC-10.8 RBC-3.21* HGB-9.4* HCT-29.6* MCV-92 MCH-29.3 MCHC-31.7 RDW-18.0* [**2148-2-29**] 05:51AM PLT COUNT-313 [**2148-2-29**] 05:51AM PT-15.6* PTT-29.4 INR(PT)-1.4* [**2148-2-28**] 06:32PM LACTATE-1.3 [**2148-2-28**] 06:20PM GLUCOSE-98 UREA N-15 CREAT-1.4* SODIUM-137 POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-29 ANION GAP-11 [**2148-2-28**] 06:20PM estGFR-Using this [**2148-2-28**] 06:20PM CK(CPK)-12* [**2148-2-28**] 06:20PM CK-MB-NotDone cTropnT-0.27* [**2148-2-28**] 06:20PM WBC-10.4 RBC-3.28* HGB-9.9* HCT-29.8* MCV-91 MCH-30.3 MCHC-33.3 RDW-17.6* [**2148-2-28**] 06:20PM NEUTS-83.7* LYMPHS-8.4* MONOS-5.0 EOS-2.7 BASOS-0.2 [**2148-2-28**] 06:20PM HYPOCHROM-2+ ANISOCYT-1+ MACROCYT-1+ [**2148-2-28**] 06:20PM PLT COUNT-312 [**2148-2-28**] 06:20PM PT-15.5* PTT-30.4 INR(PT)-1.4* * Admission G tube check INDICATION: 78-year-old man with reposition of G-tube. No prior studies for comparison. FINDINGS: A single image of the abdomen demonstrates a tube overlying the pyloric junction. Contrast is seen within the abdomen. There is no evidence of extravasation on this single film. There are degenerative changes of the lower lumbar spine. Bowel gas pattern is unremarkable. IMPRESSION: 1. G-tube overlying pylorus. No evidence of extravasation on this single radiograph. * Brief Hospital Course: A/P: 78M with DMI, ESRD, CAD, CHF (EF 15%), admitted after J-tube displacement. . # The patient had a G-J tube placed by interventional radiology. Per Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] of inteventional radiology the G tube is directly above the pylorus and his output should be closely monitored. Should the tube have decrased output or should the patient develop abdominal pain then the patient may need an open surgery to replace the tube. The tube was also placed through the stoma of the old site without anesthesia or sedation per IR. The tube feeds can be administered through the J tube immediately but tube feeds should only begin on [**2148-3-1**] one day after the placement of the J-G tube. . # ESRD: On HD M/W/F . # CAD: The patient was noted to have an elevated troponin of 0.32. Serial CKs were 11 and 12 respectively. Given his hemodyamic stability and unchanged ECG this was thought to be chronic or a troponin leak in the setting of his ESRD. . # C. diff colitis: He was continued on po vancomycin and flagyl. . # DMII: FS qid and SSI. . # CHF: No current signs of hypervolemia. AICD in place. - continue to monitor . # Atrial fibrillation: Currently under good control, no anticoagulation. - continue to monitor . # FEN: - His K repletion was continued. He was continued on . # Ppx: - PPI - SC heparin . # Access: R SC . # Code status: DNR [**First Name8 (NamePattern2) **] [**Hospital 882**] Hospital d/c summary, however pt has AICD . # Communication: niece [**Name (NI) 2270**] [**Name (NI) 2523**] ([**Telephone/Fax (1) 93096**] (h), ([**Telephone/Fax (1) 93097**] (w) . Medications on Admission: Metronidazole 500mg po TID Vancomycin 250mg po Q6H Lansoprazole Oral Disintegrating Tab 30 mg G TUBE [**Hospital1 **] Acetaminophen 325-650 mg PO Q4-6H:PRN Levetiracetam 250 mg PO BID Albuterol-Ipratropium 6 PUFF IH Q6H Mirtazapine 15 mg PO HS Albuterol [**1-2**] PUFF IH Q4H:PRN Aspirin 81 mg PO DAILY Simvastatin 40 mg PO HS Heparin 5000 UNIT SC TID Humalog SSI (completed ceftaz/tobra today) Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: J- tube displacement Secondary: 1. DM type 2 2. ESRD 3. CAD 4. CHF- EF 15% [**First Name8 (NamePattern2) **] [**Hospital1 882**] notes, s/p AICD placement 5. s/p multiple CVAs 6. Paroxysmal atrial fibrillation 7. History of multiple GI bleeds 8. SMA syndrome 9. GERD 10. s/p cardiac arrest [**2148-2-10**] 11. H/o Boerhaave's syndrome--> esophageal stricture 12. VRE colonization 13. Seizure disorder 14. Hypertension 15. Gastroparesis s/p G-tube/J-tube placement 16. H/o EtOH abuse 17. AAA- 7cm 18. Pseudomonal pna 19. C. diff colitis Discharge Condition: Good,G-J tube working well. Discharge Instructions: Please seek urgent medical attention should you develop abdominal distension, nausea, vomiting, diarrhea, pain at the G-J tube site, fevers or chills. You G-J tubes were replaced with a combined G-J tube. Please seek urgent medical attention should you develop abdominal distension, nausea, vomiting, diarrhea, pain at the G-J tube site, fevers or chills. You G-J tubes were replaced with a combined G-J tube. Completed by:[**2148-3-2**]

[ "536.3", "250.60", "345.90", "403.91", "008.45", "585.6", "427.31", "569.62", "V44.0", "V45.02", "428.0", "250.40", "V46.11" ]

icd9cm

[ [ [] ] ]

[ "44.32", "96.71" ]

icd9pcs

[ [ [] ] ]

6667, 6733

4595, 6221

334, 382

7322, 7352

2955, 4572

2388, 2392

6754, 7301

6247, 6644

7376, 7817

2407, 2936

275, 296

410, 1317

1339, 2224

2240, 2372

28,063

121,936

184

Discharge summary

report

Admission Date: [**2125-2-9**] Discharge Date: [**2125-2-16**] Service: MEDICINE Allergies: Zocor / Lescol Attending:[**Doctor Last Name 1857**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Central venous line insertion (right internal jugular vein) History of Present Illness: Mr. [**Known lastname 1858**] is an 84 yo man with moderate aortic stenosis (outside hospital echo in [**2124**] with [**Location (un) 109**] 1 cm2, gradient 28 mmHg, moderate mitral regurgitation, mild aortic insufficiency), chronic left ventricular systolic heart failure with EF 25-30%, hypertension, hyperlipidemia, diabetes mellitus, CAD s/p CABG in [**2099**] with SVG-LAD-Diagonal, SVG-OM, and SVG-RPDA-RPL, with a re-do CABG in [**9-/2117**] with LIMA-LAD, SVG-OM, SVG-diagonal, and SVG-RCA. He also has severe peripheral arterial disease s/p peripheral bypass surgery. He presented to [**Hospital 1474**] Hospital ER this morning with shortness of breath and chest pain and was found to be in heart failure. He states he was in his usual state of health until 10:30 last evening when he woke up feeling cold; 1 hour later he developed moderate to severe sharp chest pain radiating across his chest associated with nausea, diaphoresis, and dypsnea. The pain was fairly constant and did not resolve until he was given sL NTG at 6 am by EMS. He has been pain free since. Presenting vitals BP 109/66, HR 71, O2 sat 88% on RA. CXR showed congestive heart failure; initial troponin-I was mildly elevated at 0.4, CK 70. He given aspirin and furosemide 80 mg IV (with ~600cc diuresis), Nitropaste [**1-3**]", and Lovenox 80 mg SQ. During the ambulance transfer to the [**Hospital1 18**], he also received ~500 cc IVF for ? low BP). On further questioning, Mr. [**Known lastname 1858**] has very poor exercise tolerance due to knee pain that he attributes to osteoarthritis. But he says that he gets chest pain (similar to pain he had last night) with fairly minimal exertion (picking up his 11 lb cat, carrying 1 gallon jug of water, first getting up from sitting to walk outside or to walk to the bedroom). The pain is associated with dyspnea and is relieved with few minutes rest. His symptoms occur about every day to every other day and have been stable over the past year. He denies orthopnea, paroxysmal nocturnal dyspnea, but does endorse exertional dyspnea (he cannot identify the amount of exertion required). Currently, he is dyspneic and feels somewhat better sitting up; he reports no chest pain. ROS is also positive for a nose bleed requiring ED visit several months ago (and cessation of Plavix for a few days), and currently gross hematuria after Foley placement and Lovenox. Past Medical History: 1. Coronary artery disease s/p CABG twice (vide infra). 2. Hypertension. 3. Diabetes mellitus. 4. Hyperlipidemia. 5. Peripheral arterial disease with occluded left common iliac artery, S/P right iliac artery stenting and femoral-to-femoral bypass, further angioplasty to the right profunda. 5. Ischemic cardiomyopathy and chronic LV systolic heart failure, reported LVEF 25-30%. 6. Moderate-severe aortic stenosis. 7. Osteoarthritis. CAD: Diabetes, Dyslipidemia, Hypertension Cardiac History: CABG in [**2099**] (SVG-LAD-Diagonal, SVG-OM, and SVG-RPDA-RPL), with a re-do CABG in [**9-/2117**] (LIMA-LAD, SVG-OM, SVG-diagonal, and SVG-RCA) Percutaneous coronary intervention, in [**2120**] anatomy as follows: Patent SVG to OM1, patent SVG to PDA which filled the distal PDA as well as the R-PL via a jump segment. Stump occlusion of a graft presumably to the right system as well as one stump that could be documented of a graft to the left. Other SVG's were not able to be selectively engaged. Supravalvular aortography demonstrated no other patent grafts. Patent LIMA to mid-LAD, which also back-perfused the diagonal via a patent jump graft that was interposed between the LAD and the diagonal. Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is extensive family history of early coronary disease (father died of MI at 44, one brother died in 40's, one in 50's, sister had stroke). Physical Exam: Gen: Elderly white male in NAD. Oriented x3. VS T 101 BP 88/54 HR 122 in A-Fib RR 27 O2 sat 97 % on 100 % NRB. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: JVP of near angle of the jaw. CV: PMI diffuse and laterally displaced. Rate irregular, normal S1, S2 with mid-late peaking 3/6 systolic murmur heart throughout precordium, loudest at apex. No gallop. Chest: Appear tachypneic, some accesorry muscle use. No chest wall deformities, scoliosis or kyphosis. Lungs with crackles [**1-3**] way up L>R. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No femoral bruits, could not palpate DP or TP pulses but Dopplerable. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [**2125-2-10**] 03:44AM BLOOD WBC-8.1# RBC-4.11* Hgb-13.3* Hct-37.9* MCV-92 MCH-32.4* MCHC-35.0 RDW-14.1 Plt Ct-111* [**2125-2-10**] 08:00PM BLOOD Neuts-74.3* Lymphs-21.9 Monos-3.0 Eos-0.7 Baso-0.1 [**2125-2-10**] 03:44AM BLOOD Plt Ct-111* LPlt-2+ [**2125-2-10**] 08:00PM BLOOD Fibrino-760*# [**2125-2-9**] 09:15PM BLOOD Glucose-195* UreaN-30* Creat-1.4* Na-133 K-4.6 Cl-96 HCO3-25 AnGap-17 CK 257* --> 189* --> 192* --> 193* --> 176 --> 82 [**2125-2-10**] 08:00PM BLOOD ALT-38 AST-46* AlkPhos-66 TotBili-1.0 DirBili-0.3 IndBili-0.7 [**2125-2-9**] 09:15PM BLOOD CK-MB-10 MB Indx-3.9 cTropnT-0.66* proBNP-[**Numeric Identifier 1859**]* [**2125-2-10**] 03:44AM BLOOD CK-MB-7 cTropnT-0.69* [**2125-2-10**] 11:40AM BLOOD CK-MB-8 cTropnT-0.67* [**2125-2-10**] 04:55PM BLOOD CK-MB-7 cTropnT-0.65* [**2125-2-10**] 08:00PM BLOOD CK-MB-7 cTropnT-0.64* [**2125-2-11**] 05:41AM BLOOD CK-MB-63* MB Indx-6.3* cTropnT-2.61* [**2125-2-9**] 09:15PM BLOOD calTIBC-334 Ferritn-93 TRF-257 [**2125-2-10**] 08:00PM BLOOD TSH-5.4* ECG [**2125-2-9**] 9:36:38 PM Rhythm is most likely sinus rhythm with frequent ventricular premature beats with occasional ventricular bigeminal pattern. There are also frequent atrial premature beats. Intraventricular conduction defect. Left ventricular hypertrophy. ST-T wave changes most likely related to left ventricular hypertrophy. Compared to the previous tracing of [**2124-4-9**] ventricular premature beats are more frequent, as are atrial premature beats. Clinical correlation is suggested. CXR [**2125-2-9**]: The patient is after median sternotomy and CABG. The heart size appears slightly enlarged compared to the previous study. Bilateral perihilar haziness continues toward the lower lungs is new consistent with new moderate- to-severe pulmonary edema. Bilateral pleural effusion is present, also new, most likely part of the heart failure. Left and right retrocardiac opacities consistent with atelectasis. ECHO [**2125-2-11**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with akinesis of the basal half of the inferior and inferolaterl walls. There is mild hypokinesis of the remaining segments (LVEF = 25-30 %). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with moderate global free wall hypokinesis. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area 0.6 cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-3**]+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior report (images unavailable of [**2119-5-8**], left ventricular systolic function is now depressed and the severity of aortic stenosis has increased. Brief Hospital Course: Patient is a 84 yo man with CAD s/p CABG twice with daily angina, presenting with chest pain, dyspnea, and congestive heart failure. # CAD: The patient was transferred to [**Hospital1 18**] for further workup and treatment of chest pain. A chest X-ray performed on admission showed moderate-severe pulmonary edema. He did have a stably elevated troponin thought to be related to acute heart failure or demand ischemia. He was started on a Lasix drop at 10 mg/hr for initiation of diuresis. He initially tolerated this well, however at approximately 8 pm on [**2125-2-10**], Mr. [**Known lastname 1858**] was transferred from the floor to the CCU after complaining of chest pain when he was sitting in bed after dinner. As he was being evaluated by the housestaff, he became unresponsive and developed pulseless electrical arrest. Chest compressions were started, but within approximately 2 minutes, he became responsive and regained a palpable pulse. His rhythm appeared to be atrial fibrillation with ventricular rate initially in the 50s but rising to the 110's. Review of his telemetry showed that he had developed atrial fibillation earlier in the evening without obvious ventricular arrhythmias immediately prior to his arrest (which was attributed to a vasovagal episode in the setting of heart failure and aortic stenosis). On transfer to the CCU, he was started on levophed for hypotension and amiodarone IV for AFib. Chest x-ray on [**2125-2-10**] showed interval worsening of pulmonary edema, bilateral pleural effusions and bibasilar atelectasis. At this time his cardiac enzymes became very elevated with EKG changes consistent of a NSTEMI with a CK to 1006 and troponin to 3.82. On [**2125-2-11**], he had a transthoracic echocardiogram which showed moderate regional left ventricular systolic dysfunction with akinesis of the basal half of the inferior and inferolateral walls. LVEF was 25-30 %, with severe aortic stenosis and [**1-3**]+ mitral regurgitation. He was aggressively diuresed with an IV Lasix drip with improvement in his oxygen requirement and chest x-ray. Levophed was discontinued on [**2-12**], and blood pressures remained stable off pressors with MAP's 60 - 70. On [**2125-2-13**], he was transferred back to the floor team on PO amiodarone. He remained in normal sinus rhythm on telemetry on po amiodarone, and diuresis was continued with a Lasix drip with good urine output and improvement of renal function. He remained asymptomatic with no shortness of breath or chest pain after transfer. He was maintained on a heparin drip bridging to Coumadin for paroxysmal atrial fibrillation. His metoprolol was held for hypotension in the ICU and relative hypotension with SBP in 90s and low 100s upon transfer to the floor. ACE-inhibitor was held due to relative hypotension and renal insufficiency with Creat 1.7. A cardiac surgery consult deemed him an acceptable candidate for a 3rd open heart surgery for aortic valve replacement pending re-assessment of his coronary anatomy. The intermediate-term plan was to allow recovery from the current episode and discussion as an outpatient with his primary cardiologist regarding the risks and benefits of aortic valve replacement. On [**2-16**], the patient became hypotensive to SBPs to 60s-70s after getting into a chair after breakfast. He was given 1L NS with no response in BP. The patient was mentating but became short of breath with IVF. He had worsening EKG changes. He was started on Levophed without improvement in his blood pressure. He was brought to the catherization laboratory for potential emergent aortic valvuloplasty and was intubated. At that point, he suffered a PEA arrest and could not be resuscitated. He was pronounced deceased at 12:33pm. # Pump: As above. The patient had severe pulmonary edema with initial exam revealing crackles throughout his lung fields. He was treated with a Lasix drip which was transitioned on [**2-16**] to po Lasix 80 mg po twice daily. # Rhythm: Patient was in NSR on admission. On HD #2, he had chest pain, then went into PEA arrest as described above. Telemetry showed atrial fibrillation prior to the event. In the CCU, he was started on amiodarone 400 mg po tid to be tapered over the subsequent weeks. # Acute renal failure: Renal function initially declined (creatinine to 2.1), then improved on Lasix gtt, but stayed 1.7 - 1.9 (above baseline of 1.3). # Hematuria: He had hematuria (no clots) after traumatic Foley placement at the outside hospital. The catheter was removed on [**2-16**] with gradual resolution of hematuria. # Diabetes: Due to acute renal failre, metformin was discontinued and the patient was maintained on a Humalog sliding scale with 30 units of Lantus at bedtime. # Hematoma. The patient developed a small hematoma at the site of his right internal jugular venous access after catheter removal. This was treated with local compression. Medications on Admission: Aspirin 81 mg Plavix 75 mg Atenolol 50 mg Isordil 5 mg [**Hospital1 **] HCTZ 25 mg daily Lisinopril 40 mg Gemfibrozil 600 mg Simvastatin 20 mg Glipizide 5 mg XL daily Metformin unknown dose Protonix 40 mg Thiamine, B12, B6, folate Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1) Severe aortic stenosis 2) Coronary artery disease with non-ST segment myocardial infarction 3) Cardiogenic shock requiring pressor support 4) Atrial fibrillation 5) Pulseless electrical activity arrest, twice 6) Severe acute on chronic left ventricular systolic and diastolic heart failure 7) Acute on chronic renal failure 8) Traumatic hematuria 9) Diabetes mellitus 10) Hypertension 11) Peripheral arterial disease 12) Hyperlipidemia Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, MSC 12-339

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icd9cm

[ [ [] ] ]

[ "38.93", "99.60", "00.17" ]

icd9pcs

[ [ [] ] ]

13370, 13379

8147, 13060

232, 293

13861, 13871

5081, 8124

13924, 14070

4083, 4229

13341, 13347

13400, 13840

13086, 13318

13895, 13901

4244, 5062

182, 194

321, 2718

2740, 3942

3958, 4067

1,801

133,616

9816

Discharge summary

report

Admission Date: [**2179-4-14**] Discharge Date: [**2179-4-20**] Date of Birth: [**2101-9-22**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1781**] Chief Complaint: Bilateral leg weakness Major Surgical or Invasive Procedure: [**4-15**]: Abdominal aortogram with Left lower extremity run off, PTA of PT artery times two with completion of angiogram [**2179-4-19**]: Abdominal aortogram with right lower extremitiy run off, recanalization of tibioperoneal trunk with PTA and completion angiogram History of Present Illness: 77 yo Female who complains of 6 year of bilateral leg heaviness an weakness especially with ambulating and prolonged standing. Denies frank pain but states legs will have some paresthesias and numbness at times. These sympoms have progressively worse over these 6 years. No history of foot or leg ulcers. No history of venous stasis or leg cellulitis. No distal extremity surgeries in past aside from Right total knee replcement. Patient states both leg bother her equally. No history of CVA, TIA. No SOB, no chest pain/hypothyroid. Past Medical History: Type 1 Diabetes Hypertension Glaucoma history of sarcoma Right total knee replacement Removal of Left upper back sarcoma Social History: no tobacco no ETOH Family History: noncontributory Physical Exam: Temperature 99.1, Pulse 80, Blood pressure 166/84, Respiraroy rate 20, Oxygen saturation 93% Alert and oriented times three, No apparent distress Regular rate and rhythm\ clear to auscultation bilaterally Abdomen: soft nontender and nondistended Extremities: wamrm, cap refil less than 2 seconds, no erythema, no cellulitis Pulses: Right: 2+ radial, 2+ femoral, 2+ brachial,. 2+carotid, No popliteal, triphasic DP, bibphasic PT [**Name (NI) 2325**]: 2+ Radial, 2+ femoral, 2+ brachial, 2+ carotid, no poplitieal, biphasic DP, biphasic PT Pertinent Results: Discharge labs: [**2179-4-20**] WBC-6.7 RBC-3.95* Hgb-11.7* Hct-35.0* MCV-89 MCH-29.6 MCHC-33.4 RDW-13.0 Plt Ct-197 Glucose-98 UreaN-17 Creat-0.9 Na-140 K-4.1 Cl-106 HCO3-23 AnGap-15 Calcium-8.8 Phos-3.7 Mg-1.9 Brief Hospital Course: The patient was admitted to the vascular surgery service for preoperative hydration prior to angiogram. The patient had an angiogram/angioplasty on [**4-15**] with angioplasty of thge left PT artery (see op note for details). Because it was felt that it would be in the patients best interest to split up the dye load, the patient was hydrated until [**4-18**] when she got a right lower extremity angiogram( see full report for details). She tolerated both procedures well and remained hemodynamically stable throughout her hospital stay. The patient's hematocrit and creatinine were stable after both procedures. On a screening UA, the patient had a urinary tract infection with e coli. She was treated with 3 days of ciprofloxacin. She had no evidence of groin hematoma. On post operative days [**4-4**] the patient was ready for discharge to home on asprin and plavix. Medications on Admission: novalin insulin 6 units AM, 8 units PM regular insulin 2 units 5 pm Trosopt 1 drop [**Hospital1 **] HCTZ 37.5/25 daily asa 81 daily Vit E Xalatan 1 drop daily Tylenol prn Coreg 6.25 daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 2. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Urinary tract infection Peripheral vascular disease status post angiogram x 2 Diabetes hypertension history of sarcoma glaucoma Discharge Condition: Good Discharge Instructions: [**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) 152**] fevers, increase in lower extremity pain, numbness or neurologic changes to feet, swelling, redness or dishcarge from your groin. You should resume your preoperative medications. Take medications as prescribed You may resume your preprocedure diet Followup Instructions: You should follow up with Dr. [**Last Name (STitle) **] in [**1-7**] weeks. Call the office for an appointment

[ "V10.89", "443.9", "V43.65", "599.0", "041.4", "401.9", "250.01" ]

icd9cm

[ [ [] ] ]

[ "88.48", "39.50" ]

icd9pcs

[ [ [] ] ]

4004, 4010

2194, 3075

337, 608

4182, 4188

1958, 1958

4563, 4678

1368, 1385

3313, 3981

4031, 4161

3101, 3290

4212, 4540

1974, 2171

1400, 1939

275, 299

636, 1172

1194, 1316

1332, 1352

29,048

117,238

529

Discharge summary

report

Admission Date: [**2150-2-3**] Discharge Date: [**2150-2-16**] Service: CARDIOTHORACIC Allergies: Promethazine/Codeine Attending:[**First Name3 (LF) 1267**] Chief Complaint: Chest pain and syncope Major Surgical or Invasive Procedure: s/p AVR(19mm Mosaic porcine valve)/Aortic endarterctomy [**2-3**] s/p pacer placement [**2-10**] History of Present Illness: This 84WF presented to [**Hospital1 18**] [**Location (un) 620**] [**2150-1-19**] with CP and was in AF. She was treated with Lopressor and Dilt and became asystolic. She was resuscitated and transferred to [**Hospital1 18**]. She was found to have aortic stenosis and is now admitted for AVR. Past Medical History: Aortic stenosis recent Afib HTN Pseudogout of R knee Hypothyroidism GERD, EGD [**2144**] Breast Cancer [**2102**] s/p left mastectomy s/p Hysterectomy Osteoporosis on Evista Aortic Stenosis DJD Hand Iron Deficiency Anemia [**2146**] Left Shoulder Impingement Syndrome Spinal Stenosis: MRI [**10-26**] showed severe stenosis of spinal canal and recesses at L4-L5 Osteoarthritis: Right lower extremity pain and lower back pain Paronychia Actinic keratosis on R face Social History: Social history is significant for the absence of current tobacco use. She previously smoked 1 ppd, but quit 40 years ago. There is no history of alcohol abuse. She lives at home with a boarder. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Elderly WF in NAD AVSS HEENT: NC/AT, oropharynx benign Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+ bilat. with rad murmur Lungs: Clear to A+P CV: RRR w/ III/VI SEM Abd: +BS, soft, nontender, without masses or hepatosplenomegaly Ext: without C/C/E, pulses 2+= bilat. throughout Neuro: nonfocal Pertinent Results: [**2150-2-14**] 07:15AM BLOOD WBC-13.2* RBC-3.61* Hgb-11.0* Hct-32.2* MCV-89 MCH-30.4 MCHC-34.0 RDW-14.0 Plt Ct-294 [**2150-2-14**] 09:04AM BLOOD PT-24.2* INR(PT)-2.4* [**2150-2-14**] 07:15AM BLOOD Glucose-99 UreaN-19 Creat-1.1 Na-139 K-4.1 Cl-99 HCO3-34* AnGap-10 RADIOLOGY Preliminary Report CHEST (PA & LAT) [**2150-2-13**] 6:12 PM CHEST (PA & LAT) Reason: eval for pleural effusions [**Hospital 93**] MEDICAL CONDITION: 84 year old woman s/p AVR REASON FOR THIS EXAMINATION: eval for pleural effusions CHEST HISTORY: AVR. Two views. Comparison with the previous study done [**2150-2-11**]. Small bilateral pleural effusions and subsegmental atelectasis or scarring at the right base are again demonstrated. The patient is status post median sternotomy and AVR as before. A bipolar transvenous pacemaker remains in place. Aorta is mildly tortuous and calcified. Mediastinal structures are unchanged. The bony thorax is grossly intact. There are degenerative arthritic changes in the spine. IMPRESSION: Small pleural effusions. Status post AVR. No significant change. DR. [**First Name (STitle) **] [**Doctor Last Name 4391**] DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**] Brief Hospital Course: The pt. was admitted [**2150-2-3**] and underwent elective AVR(19mm Mosaic porcine valve)/Aortic endarterectomy. The cross-clamp time was 52 mins., total bypass timewas 72 mins. The pt. tolerated the procedure well and was transferred to the CVICU in stable condition on Propofol and Neo. She had a stable post op night and was extubated on POD#1. She was quite lethargic but eventually was more alert. Her chest tubes were d/c'd on POD#2 and was transferred to the floor on POD#4. She had intermittent AF and was treated with beta blockers. On POD#5 she had a 10 second pause and was paced with her temporary epicardial wires. EP was consulted and on POD#7 she underwent permanent pacer placement. She was restarted on coumadin for afib. She continued to have intermittent rapid a fib and her beta blocker was increased. Her INR became supratherapeutic and her coumadin was held. Her INR came down and she was discharged on 1 mg daily. She was discharged to rehab in stable condition on POD#11. Medications on Admission: Thyroid 15mg PO 5x/week. ASA 81 mg PO daily Ascorbic acid 500 mg PO BID Calcium carbonate 1500mg PO TID Vitamin D3 400 mg PO daily Raloxifene 60 mg PO daily Prilosec 20 mg PO daily Lopressor 12.5 mg PO daily Hexavitamin 1 PO daily Simvistatin 40 mg PO daily Lisinopril 5 mg PO daily Discharge Medications: 1. 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. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily (). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3 times a day). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. 10. Thyroid 30 mg Tablet Sig: 0.5 Tablet PO 5X/WEEK ([**Doctor First Name **],MO,WE,TH,SA). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 12. CefazoLIN 1 g IV Q12H pacer Duration: 3 Days 13. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 3 days: Then decrease dose to 400 mg PO daily for 7 days, then decrease to 200 mg PO daily. 16. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Check daily PT, dose for INR goal of [**2-21**].5. 17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Aortic stenosis HTN hypothyroidism GERD s/p breast ca, s/p L mastectomy s/p TAH osteoporosis iron deficiency anemia spinal stenosis Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs for 2 months. After pacer dressing is off (7 days), shower daily, let water flow over wounds. Do not use lotions, powders, or creams on wounds. Call our office for temp. >101.5, sternal drainage. Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2150-2-17**] 9:00 Make an appointment with Dr. [**Last Name (STitle) 4390**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Completed by:[**2150-2-14**]

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icd9cm

[ [ [] ] ]

[ "37.83", "35.21", "37.72", "38.14", "00.40", "39.61" ]

icd9pcs

[ [ [] ] ]

6029, 6108

3071, 4077

256, 355

6284, 6292

1829, 2223

6637, 6918

1396, 1478

4410, 6006

2260, 2286

6129, 6263

4103, 4387

6316, 6614

1493, 1810

194, 218

2315, 3048

383, 680

702, 1167

1183, 1380

46,668

177,510

14305

Discharge summary

report

Admission Date: [**2112-9-15**] Discharge Date: [**2112-9-21**] Date of Birth: [**2039-9-28**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Staging laparoscopy and liver biopsy History of Present Illness: Patient is a 72M w/ h/o CAD and DM2 who presents to [**Hospital1 18**] with a 1 month h/o decreased energy, abdominal bloating and intermittent dizziness. The patient states that his bloating sensation feels like "gas pains" but has not limited his PO intake. He notes difficulty sleeping but nothing else exacerbating or alleviating the discomfort. He notes moving bowels regularly but over the past week notes a "tan color" to stools. He reports occasional blood in toilet bowl after bowel movements but attributes this to known "fissures". He reports dizziness upon standing from recumbency and experience an episode today while seeing endocrinologist at [**Last Name (un) **]. He was found to be hypotensive to SBP 80's and was sent to ED for further workup. Past Medical History: PMH: CAD s/p coronary stent x4 years, CKD (? diabetic nephropathy), HTN, hypercholesterol, BPH, gout, obesity PSH: c-scope x10 years [**Last Name (un) 1724**]: Levemir 24U/day, plavix 75', atenolol 50', amaryl 4", lisinopril 20', Diltia XT 180', lipitor 80', ASA 325', allopurinol 300' Social History: No ETOH/Tob or illicits Family History: Noncontributory Physical Exam: (On Discharge) VS 98.3 98.3 63 90/54 18 92RA Gen: NAD A&Ox3 Card: RRR Lungs: CTAB Abd: Soft, NTND, -guarding/rebound Wound: CDI, steris in place Brief Hospital Course: Pt was seen in the ED for dizziness/hypotension as described in the above HPI. CT, US and labs were consistent with obstructive jaundice [**12-21**] a pancreatic head mass and the patient was admitted to the pancreaticobiliary service for further management in the intensive care unit. The patient had an ERCP that showed a 2.5 cm strictured in the intrapancreatic portion of the common bile duct and a stent was placed. The patients total bilirubin on admission was 7.9 and this trended down following stent placement. Blood cultures were sent, and final cultures were negative. Following ERCP the patient returned to the unit for an uncomplicated recovery and was transferred to the floor. He was restarted on clears and advanced to general diet. EUS was planned and obtained and final results are pending. The patient was taken to the OR on hospital day 6 for a staging laparoscopy and biopsy of his pancreatic head mass in preparation for a whipple procedure on [**9-29**]. This was performed without complication and the patient had an uneventful recovery from anesthesia. After discussion with the patients cardiologist, it was decided that his aspirin and plavix should be held until after his whipple. Medications on Admission: Levemir 24U/day, plavix 75', atenolol 50', amaryl 4", lisinopril 20', Diltia XT 180', lipitor 80', ASA 325', allopurinol 300' Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain for 7 days. Disp:*50 Tablet(s)* Refills:*0* 2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain for 1 weeks. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pancreatic Mass Discharge Condition: Good Discharge Instructions: Your operation is scheduled with Dr. [**Last Name (STitle) **] on Thursday, [**9-29**]. Please return to the hospital as instructed by the clinic. Do not eat or drink anything after midnight the night before your procedure. Do not take your aspirin or plavix (clopidogrel) between the time you are discharged and when you return to the hospital. Continue to take the remainder of your medications. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**3-27**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Followup Instructions: Please return to the hospital as above. The remainder of your follow up will be scheduled after your operation.

[ "274.9", "278.00", "576.2", "403.90", "565.0", "V45.82", "285.1", "276.52", "585.9", "414.01", "272.0", "584.9", "250.40", "157.0", "600.00" ]

icd9cm

[ [ [] ] ]

[ "52.11", "45.13", "51.87", "52.98", "50.14" ]

icd9pcs

[ [ [] ] ]

3409, 3415

1730, 2941

328, 367

3475, 3482

5223, 5338

1527, 1544

3117, 3386

3436, 3454

2967, 3094

3506, 5200

1559, 1707

274, 290

395, 1160

1182, 1470

1486, 1511

386

111,584

2385

Discharge summary

report

Admission Date: [**2159-7-9**] Discharge Date: [**2159-7-16**] Date of Birth: [**2111-4-4**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 4223**] is a 48-year-old male resident at Rentham Developmental Center, who has a problem with chronic severe aspiration. This problem was first noticed around eight years ago. He had a gastrostomy tube placed in [**2150**]. He continued to have reflux, however, with aspiration and recurrent pneumonia. In [**2159-6-12**], he developed right pleural effusion. He had a thoracoscopy and chest tube placement. The fluid was an exudate with no infection or malignancy. Due to the recurrent nature of the problem, he was scheduled for a tracheoesophageal separation by total laryngectomy with Dr. [**Last Name (STitle) 1837**] on [**2159-7-9**]. PAST MEDICAL HISTORY: 1. Chronic aspiration. 2. Pulmonary fibrosis secondary to Macrodantin. 3. Chronic constipation. 4. Acne. 5. Pre-procedural anxiety. 6. Contractures. 7. Hypothyroidism. 8. Hypothermia. 9. Atypical psychosis/frontal lobe syndrome. 10. Seizure disorder. 11. Dysphagia. 12. History of urinary tract infections. 13. Mental retardation. HOSPITALIZATIONS: 1. [**Date range (3) 12357**] at [**Hospital3 934**] Hospital for respiratory distress, pleural effusions, Pseudomonas urinary tract infection. 2. On [**2159-4-8**] returned to [**Hospital **] Hospital for vomiting with respiratory distress. ALLERGIES: Ampicillin that causes swelling and rash. MEDICATIONS: 1. Calcium carbonate 1250 mg q day. 2. Dilantin 300 mg q day. 3. Keflex 500 mg q6h. 4. Metronidazole 250 mg q8h. 5. Olanzapine 2.5 mg q day. 6. Senna four tablets daily. 7. Levothyroxine 25 mcg q day. 8. Milk of magnesia 60 cc daily. 9. Topamax 250 mg [**Hospital1 **]. 10. Fludrocortisone 0.1 mg q day. 11. Albuterol/ipratropium nebulizers qid. 12. Dulcolax suppository qod. 13. Fleet's enemas q2-3 days prn. DIET: His diet includes 3/4 strength 2-cal HN 70 cc/G tube q hour with 1/4 strength Jevity Plus x12 hours q day along with two tablespoons of ProMod [**Hospital1 **]. FAMILY HISTORY: Maternal parents colon cancer. Paternal parents significant cardiac disease. Father died of transient ischemic attack and stroke. Mother developed diabetes in her 60s. Brother and maternal aunt diagnosed with multiple sclerosis. On examination, [**2159-5-16**] preoperative: In general, this is a 48-year-old male with multiple physical handicaps, who is alert, nonverbal, and cooperative. Skin: Good turgor, scattered scars including permanent scar in right hip. Eyes: Left exotropia. Pupils are equal, round, and reactive to light. Visual acuity appears intact. Fundoscopic examination limited, but grossly normal. Ears normal, hearing acuity with bilateral cerumen. Nose: Nares patent. Dental hygiene fair. No abnormal tongue movements. Neck is supple, no thyromegaly or lymphadenopathy. Cyst noted at base of the skull. Lungs: Occasional rhonchi, decreased breath sounds at bases. Heart: Normal sinus rhythm, no audible murmurs. Abdomen is soft, protuberant, bowel sounds active in all quadrants, no hepatosplenomegaly, no tenderness or masses. G tube in place mid abdomen. G site clean. Rectal examination deferred. Extremities: Light contractures of right upper extremity. Significant contractures of the left upper extremity with left hand flexed. No skin breakdown. All four limbs can be extended left greater than right. Neurologic: Mental status: Alert, minimally verbal, follows simple requests. Cranial nerves II through XII intact except for exotropia. Deep tendon reflexes hyperreflexive lower extremities, normal reflexes upper extremities. PREOPERATIVE CHEST X-RAY: Showed pleural thickening with no acute consolidation or change. PREOPERATIVE ELECTROCARDIOGRAM: Within normal limits, rate 80, normal sinus rhythm, no change since previous electrocardiogram in [**2154**]. Patient underwent a total laryngectomy on [**2159-7-9**] with Dr. [**Last Name (STitle) 1837**]. There were no complications. He received 4800 cc of crystalloid. Urine output 425 cc, 200 cc estimated blood loss. He was transferred to the Intensive Care Unit postoperatively. HOSPITAL COURSE AND TREATMENT: 1. Otolaryngology: The patient had bacitracin applied to his wounds [**Hospital1 **] throughout his stay. They continued to heal well. Staples were removed prior to discharge. He received humidified O2 by trache collar which was gradually weaned to 35% FIO2. He was on aspiration precautions throughout his stay to prevent reflux. Postoperative laboratories included a white count of 6.9, hematocrit of 29.7, which subsequently rose to 31.9. He continued to improve throughout his stay. His ionized calcium postoperatively was 1.15, which dropped to 0.97 and returned to 1.15 prior to discharge. He was transferred to the floor on postoperative day three, [**2159-7-12**]. His drains were originally to wall suction with high output around 100 cc a day until [**7-13**] and 2nd when they are switched to bulb suction, and the output came down to between 50-70 cc a day. JP #2 was removed on [**2159-7-15**] after putting out 30 cc over 24 hours. JP #1 was removed on [**7-16**] prior to discharge. 2. Neurologic: The patient's Dilantin level postoperatively was 4.3. He was loaded with 500 mg IV x1 and then placed on a maintenance dose of 100 mg tid. He did have seizure activity during his stay. His Dilantin level rose to 12.9, which was in the therapeutic range, and he was continued on the maintenance dose. His atypical psychosis and MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] throughout his stay. 3. GI: Immediately, postoperatively the G tube was placed to gravity. His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him. He had very low residuals and no problems with aspiration into the oropharynx. 4. Infectious Disease: The patient was afebrile throughout his stay. He was on Ancef and Flagyl after the surgery. He had a urinalysis that was positive and was placed on Cipro throughout the length of his stay. 5. Respiratory: He continued to have thick secretions requiring frequent suctioning and chest PT. He received respiratory care multiple times a day. Wheezing was controlled with albuterol and Atrovent nebulizers. 6. Endocrine: He had a TSH of 0.78 postoperatively. He received his normal dose of Synthroid. No changes were made. He was on an insulin-sliding scale throughout his stay. On [**7-16**], staples and drains were discontinued. The patient was in good condition with continuing needs for frequent suctioning. He was discharged to Rentham with antibiotics, pain medication, and instructed to followup with Dr. [**Last Name (STitle) 1837**] in [**12-14**] weeks. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 6152**], M.D. [**MD Number(1) 6153**] Dictated By:[**Last Name (NamePattern1) 12358**] MEDQUIST36 D: [**2159-7-16**] 08:23 T: [**2159-7-16**] 08:25 JOB#: [**Job Number 12359**]

[ "318.1", "530.81", "244.9", "787.2", "V44.1", "599.0", "780.39", "515" ]

icd9cm

[ [ [] ] ]

[ "30.3", "96.6" ]

icd9pcs

[ [ [] ] ]

2111, 3485

158, 831

3501, 7125

853, 2094

29,998

190,217

51504+59354

Discharge summary

report+addendum

Admission Date: [**2147-11-7**] Discharge Date: [**2147-11-13**] Date of Birth: [**2081-10-19**] Sex: M Service: CARDIOTHORACIC Allergies: Tetracyclines Attending:[**First Name3 (LF) 1267**] Chief Complaint: Exertional angina Major Surgical or Invasive Procedure: [**11-7**] Aortic Valve Replacement with 21mm [**Company 1543**] Porcine Valve History of Present Illness: 66 y/o male with known aortic stenosis. Serial echocardiograms have shown progressively worsening aortic stenosis. Currently admits to exertional angina. Past Medical History: Hypercholesterolemia, Hypertension, Hemochromatosis, Rosacea, Gout, Hemorrhoids, s/p Mole removal, s/p Anal fistula, s/p Tonsillectomy, s/p Dental implants, s/p Liver biopsy Social History: Quit smoking [**2116**]. Denies ETOH. Family History: Non-contributory Physical Exam: VS: 58 14 135/67 Gen: WDWN male in NAD Skin: Unremarkable HEENT: Poor dentitian Neck: Supple, FROM, -JVD Chest: CATB -w/r/r Heart: RRR 3/6 sem Abd: Soft, NT/ND +BS Ext: Warm, well-performed, 1+ edema Neuro: A&O x3, MAE, non-focal Pertinent Results: [**11-7**] Echo: PRE-BYPASS: 1. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild symmetric left ventricular hypertrophy. 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. 4. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta 5. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). Mild to moderate ([**1-17**]+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. 7. The tricuspid valve appears structurally normal with mild (1+) tricuspiid regurgitations. 8. There is no pericardial effusion. POST-BYPASS: 1. A mechinal prosthetic valve is seen in the aortic valve position. It is well seated without evidence of paravalvular leaks or aortic regurgitation. Mean gradient across the valve is 9.4 mmHg and peak gradient is 21mmHg. 2. Biventricular function is preserved post-bypass. 3. Aortic contours are intact post-decannulation. [**2147-11-7**] 10:15AM BLOOD WBC-10.6# RBC-3.09*# Hgb-10.0*# Hct-27.6*# MCV-89 MCH-32.5* MCHC-36.4* RDW-13.7 Plt Ct-123* [**2147-11-9**] 06:15AM BLOOD WBC-10.6 RBC-3.56* Hgb-11.0* Hct-32.4* MCV-91 MCH-30.9 MCHC-34.0 RDW-14.0 Plt Ct-92* [**2147-11-7**] 10:15AM BLOOD PT-14.4* PTT-36.5* INR(PT)-1.3* [**2147-11-8**] 04:08AM BLOOD PT-13.2* PTT-30.3 INR(PT)-1.1 [**2147-11-7**] 11:23AM BLOOD UreaN-16 Creat-0.8 Cl-115* HCO3-24 [**2147-11-9**] 06:15AM BLOOD Glucose-94 UreaN-21* Creat-1.0 Na-136 K-4.5 Cl-103 HCO3-30 AnGap-8 Brief Hospital Course: Mr. [**Known lastname 1557**] was a same day admit after undergoing all pre-operative work-up as an outpatient. On day of admission he was brought to the operating room where he underwent a aortic valve replacement. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later that day he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics and gently diuresed towards his pre-op weight. He was transferred to the SDU on post-op day two. Chest tubes were removed on this day and epicardial pacing wires were removed on post-op day three. Pt progressed with PT. He is stable for home with VNA Medications on Admission: Crestor 10mg qd, Allopurinol 300mg qd, Minocycline 5mg [**Hospital1 **], Metrogel oint, Aspirin 325mg qd, MV, Folate, B6, B12, Fish Oil Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation for 7 days. Disp:*7 Suppository(s)* Refills:*0* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. Disp:*8 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Packet Sig: One (1) PO twice a day for 4 days. Disp:*8 Potassium Chloride (Oral) 20 mEq* Refills:*0* 11. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) **] area VNA Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement PMH: Hypercholesterolemia, Hypertension, Hemochromatosis, Rosacea, Gout, Hemorrhoids, s/p Mole removal, s/p Anal fistula, s/p Tonsillectomy, s/p Dental implants, s/p Liver biopsy Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) **] in [**2-18**] weeks Dr. [**Last Name (STitle) 106784**] in [**1-17**] weeks Completed by:[**2147-11-12**] Name: [**Known lastname 10**],[**Known firstname 33**] Unit No: [**Numeric Identifier 17427**] Admission Date: [**2147-11-7**] Discharge Date: [**2147-11-13**] Date of Birth: [**2081-10-19**] Sex: M Service: CARDIOTHORACIC Allergies: Tetracyclines Attending:[**First Name3 (LF) 4551**] Addendum: Pt. refused to be discharged on [**11-12**] due to anxiety, and was cleared for discharge to home with services on POD #6. Pt. is to make all followup appts. as per discharge instructions. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*1* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*2* 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation for 7 days. Disp:*7 Suppository(s)* Refills:*0* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. Disp:*8 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Packet Sig: One (1) PO twice a day for 4 days. Disp:*8 Potassium Chloride (Oral) 20 mEq* Refills:*0* 11. folate Sig: One (1) 400 mcg tablet once a day. Disp:*30 * Refills:*1* Discharge Disposition: Home With Service Facility: [**Location (un) 17428**] area VNA [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**] Completed by:[**2147-11-13**]

[ "512.1", "300.00", "424.1", "274.9", "401.9", "695.3", "411.1", "275.0", "272.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8445, 8666

3018, 3783

300, 380

5606, 5612

1114, 2995

6354, 7076

831, 849

7099, 8422

5360, 5585

3809, 3946

5636, 6331

864, 1095

243, 262

408, 563

585, 760

776, 815

19,018

165,988

25925

Discharge summary

report

Admission Date: [**2116-12-29**] Discharge Date: [**2116-12-31**] Date of Birth: [**2083-4-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: CC:[**CC Contact Info 64457**] Major Surgical or Invasive Procedure: Right subclavian [**12-29**] Left arterial line [**12-29**] History of Present Illness: HPI: 33 y/o female with PMH significant for a past suicide attempts and ETOH abuse transferred from [**Hospital6 33**] following a multidrug overdose. Pt was in her normal state of health until approximately 4:30 this afternoon when she took an overdose of propranolol, seroquel, hydroxyzine, camprel, and lexapro. She had also been drinking heavily. Pt took an unknown amount of medication but most of her medications were refilled on [**12-9**]. Pt called her mother and reported that someone was in her home then dropped her phone. Her mother called 911 at that time who went to the pt's home to evaluate the situation. Pt was initially drowsy when EMS arrived but she was alert and oriented x3. Per report, the pt was emotionally distraught. Her SBP was in the 80s to 90s. On arrival to the [**Hospital3 **] ED, the pt was only responsive to painful stimuli and her SBP had decreased into the 60s and 70s. Pt was intubated for airway depression and she was given 50 grams of charcoal. Pt then recieved 10 mg of IV glucagon followed by 5 mg per minute of glucagon. She was bolused with 35 units of regular insulin then started on an insulin drip at 30 units per hour. Pt received 1 amp of D50 then started on a D10 drip at 200 cc/hour. She received 4 gm of calcium gluconate, 1 amp of IV epinephrine, and 3 mg of IV atropine. Pt remained hypotensive and was started on three pressors including dopamine at 1400 mcg per minute, Neo synephrine at 100 mcg per minute, and epinephrine at 1 mcg with an improvement of her SBPs only into the 80s. Studies at the OSH included a CXR which showed the ET tube and orogastric tube in good position. No acute process was seen. ECG was sinus at 60 to 70 beats per minute with a QRS of 116 milliseconds and a QTC of 499 milliseconds. Pt's pregnancy test was negative. Urine tox screen was negative. Her ETOH level was 234. Pt was then sent to [**Hospital1 18**] for further care. Past Medical History: PMH: 1. Past overdose- Per pt's family, pt attempted to overdose on various medications approximately four months ago. She was stopped by her fiance at that time who reports scooping a handfull of pills out of her mouth. She had her stomach pumped and was given charcoal but never lost conscousness. Pt was then hospitalized at a psychiatric hospital for a short time. Her family repoports that she did very well for a couple of weeks following this hospitalization but then went off her prescribed medications and began drinking ETOH again. 2. Bipolar disorder 3. S/P tubal ligation 4. S/P right ovarian cyst 5. S/P kidney donation to her brother in [**1-/2115**] 6. [**Name (NI) 64458**] Pt's family reports that she has been doing well from this prospective for quite some time. 7. ETOH abuse- Pt's family reports that she has never had any withdrawl seizures. Social History: SH: Pt has a fiance. No information is available about drug, tobacco, or ETOH use. Family History: Significant for bipolar d/o, h/o suicide attempts in pt's mother and GM Physical Exam: PE (on admission): 97/55 62 100% CVP 26 AC 600/12/.100/PEEP 8 Gen- Sedated. Minimal response to painful stimuli. Intubated. HEENT- NC AT. Dilated pupils at approximatly 6 mm which are sluggishly reactive R < L. MMM. Intubated. Cardiac- Bradycardic. No m,r,g. Pulm- CTAB. No wheezes, rales, or rhonchi. Abdomen- Soft. NT. ND. Positive bowel sounds. Extremities- Cool. No c/c/e. 2+ DP pulses bilaterally. Neuro- Sedated. Minimally responsive to pain. Downgoing toes bilaterally. Pertinent Results: CXR- No acute cardiopulmonary process. ET tube in position. Right IJ in good position. . ECG- Sinus bradycardia at 60 beats per minute. Normal axis. QRS 108. QTC 462. Brief Hospital Course: A/P: 33 y/o female with PMH significant for a past suicide attempts and ETOH abuse transferred from [**Hospital6 33**] following a multidrug overdose. . 1. [**Name (NI) 64459**] Pt overdosed on multiple drugs. Toxicollogy following and appreciate their input. Also called and discussed the case with poison control who was aware. - over [**2034-12-28**], pt HR and BP stabilized, with levophed off at 3 am on [**12-30**] - weaned off glucagon drip yesterday [**12-30**] - off Ca gluconate gtt as hypercalcemic on [**12-30**] -> receiving NS, which brought Ca from 18 to 10 - EKGs stable over last 12 hours - extubated successfully yesterday morning - will add valium q6 as pt will need it for agitation and per psych recommendations - LFTs and labs stable over last 2 days - Concern for propranolol for seizures given its high lipophilicity. Maintain seizure percautions. Will give IV benzos if seizes -> no seizures thus far, and it has been 48 hours since overdose, so likelihood for seizures is very low - pt medically stable, and will benefit from an inpatient psych admission with evaluation and treatment of bipolar disorder . 2. Bipolar disorder/suicide attempt- Pt without adequate treatement for her bipolar disorder and a recent suicide attempt three months ago. Psych consulted, will admit to inpatient psych. On suicide precautions and one-to-one sitter . 3. FEN- Tolerating po well, replete lytes as need. On maintenance IVF -> can d/c if UOP>30 cc/hr and as she takes in adequate po 4. Proph- SC heparin; PPI; bowel regimen . 5. Code status- Full code. . 6. [**Name (NI) 2638**] With pt's mother and fiance. Medications on Admission: Pt's family reports that she is receives multiple medications from mulitple physicians and they are not sure what she is really supposed to be taking. Medications in her possession included: 1. Hydroxizine 50 mg [**Hospital1 **] 2. Campral 33 mg taking 2 tabs [**Name (NI) 21852**] Pt's family reports that she has not been taking this. 3. Lexapro 10 mg QAM 4. Propranolol 39 mg TID 5. Seroquel 50 mg TID PRN then 300 mg QHS 6. Ibuprofen 800 mg Q8H PRN Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 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,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Diazepam 5 mg/mL Syringe Sig: Two (2) Injection Q6H (every 6 hours). Discharge Disposition: Extended Care Discharge Diagnosis: Primary - s/p Suicide attepmt, bipolar disease Discharge Condition: Medically stable Discharge Instructions: -discharge to Inpatient Psych -continue with medications as prescribed Followup Instructions: Inpatient psych admission [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2116-12-31**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6788, 6803

4142, 5766

347, 409

6894, 6912

3950, 4119

7031, 7214

3362, 3435

6269, 6765

6824, 6873

5792, 6246

6936, 7008

3450, 3931

278, 309

437, 2358

2380, 3246

3262, 3346

40,273

124,821

211

Discharge summary

report

Admission Date: [**2159-4-6**] Discharge Date: [**2159-4-10**] Date of Birth: [**2120-1-29**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: Blurry vision Major Surgical or Invasive Procedure: None History of Present Illness: This is a 39 year old male with a history of hypertension (on beta blockade, lasix, hydralazine, imdur, metolazone) complicated by chronic kidney disease (stage IV), EF of 25-30%, obesity, and tobacco abuse. He presented today to the emergency room after [**Hospital 2081**] clinic noted severe bilateral papilledema; opthomology suggested this was secondary to either elevated intracranial pressure in the setting of malignant hypertension or pseudotumor cerebri. He has been symptomatic with blurry vision over the past month in the absence of headaches or other central symptoms. He has noted some gait instability. In the ED, his blood pressure was noted to be 180/118. He took his usual dose of one of his blood pressure meds (unknown) and his BP improved to 160 systolic. He was transferred to the MICU for management of hypertensive emergency. Past Medical History: Hypertension, hypertensive chronic kidney disease stage IV, systolic heart failure, last ejection fraction from [**Hospital 2082**] between 25 and 30%, obesity, and tobacco abuse. Social History: The patient continues to smoke cigarettes about ten per day. He has cut down recently on the amount that he smokes, but still is precontemplative about quitting at this time. Family History: No history of hypertension, heart disease, or cancer. Physical Exam: ADMISSION EXAM: VS: HR 80 BP 170/100 RR 18 96% on RA Gen: Obese. NAD. HEENT: Dilated fundoscopic exam revealed bilateral papilledema without evidence of flame hemorrhages or distinct cotton whool spots. Mucous accumulation in canthal folds. Mild proptosis apprecaited. Otherwise MMM without any cervical LAD apprecatied. PERRLA. CV: Faint heart sounds. [**1-5**] pansystolic murmur best apprecaited in mitral region. No carotid bruits apprecaited. No rubs or gallops. Lungs: CTABL throughout all lung fields. Abd: Obese. Nontender throughout. NBS. No appreciable organomegaly. Ext: 1+ DPP with no appreciable edema. NeurO: AOX3. NO focal neurologic deficits appeciated on focused cranial nerve exam or on brief gross motor exam. DISCHARGE EXAM: VS: 98.0 BP 129-155/96-117 HR 75-96 RR 20 Satting 100% on RA. GENERAL - well-appearing morbidly obese man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD seen, no carotid bruits LUNGS - CTA bilat HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-5**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Pertinent Results: ADMISSION LABS: [**2159-4-6**] 03:50PM BLOOD WBC-7.3 RBC-4.07* Hgb-12.5* Hct-37.0* MCV-91 MCH-30.7 MCHC-33.7 RDW-13.6 Plt Ct-219 [**2159-4-6**] 03:50PM BLOOD Neuts-61.7 Lymphs-29.3 Monos-5.3 Eos-2.8 Baso-0.9 [**2159-4-6**] 03:50PM BLOOD PT-11.5 PTT-27.2 INR(PT)-1.1 [**2159-4-6**] 03:50PM BLOOD Glucose-84 UreaN-41* Creat-3.8* Na-142 K-3.4 Cl-100 HCO3-27 AnGap-18 [**2159-4-6**] 03:50PM BLOOD Calcium-9.4 Phos-4.0 Mg-1.8 dischcarge labs: [**2159-4-10**] 06:20AM BLOOD WBC-8.6 RBC-4.24* Hgb-13.4* Hct-38.8* MCV-91 MCH-31.7 MCHC-34.6 RDW-13.3 Plt Ct-195 [**2159-4-10**] 06:20AM BLOOD Glucose-93 UreaN-53* Creat-4.1* Na-138 K-2.9* Cl-94* HCO3-26 AnGap-21* [**2159-4-10**] 06:20AM BLOOD Calcium-9.5 Phos-5.9*# Mg-2.0 [**2159-4-10**] 06:20AM BLOOD ALDOSTERONE-PND [**2159-4-10**] 06:20AM BLOOD RENIN-PND OTHER LABS: [**2159-4-7**] 01:46AM BLOOD ALT-14 AST-20 AlkPhos-42 TotBili-0.4 [**2159-4-7**] 01:46AM BLOOD TSH-1.1 IMAGING: CT Head w/o contrast [**2159-4-6**]: 1. No acute intracranial pathology. 2. Bilateral proptosis. renal u/s [**2159-4-9**]: Both kidneys show increased echogenicity consistent with chronic kidney disease. Two simple cysts in the right kidney, one at the upper pole and one at the lower pole. Doppler evaluation of both renal arteries and of the arcuate/segmental vessels in the renal parenchyma was within normal limits. No ultrasound/Doppler evidence for renal artery stenosis. tte [**2159-4-10**]: The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is at least 15 mmHg. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with depressed free wall contractility. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: #Hypertensive Emergency: Pt presented with HTN systolics >200 and blurry vision, found to have papilledema. The patient's blood pressure was markedly elevated with systolic blood pressures ranging from 160-210 during ICU stay. Review of prior notes outlines a longstanding history of poorly controlled blood pressures. His home isosorbide and carvedilol were discontinued. Labetalol was uptitrated to 200mg TID, Hydral downtitrated to 50mg TID, clonidine 0.3mg weekly patch started, and furosemide/metolazone continued as is. MAP >120 was goal. On leaving the ICU SPB was in 130s. TSH was within normal limits. It was felt that this patient needed a full workup for secondary causes of hypertension. In the meantime renal artery ultrasound done here showed no renal artery stenosis but did show chornic bilateral changes consistent with CKDD. He should likely have a workup for hyperaldosteronism (see hypokalemia below) and workup including urine metanephrines and dexamethasone suppression test, as he is quite young for this degree of hypertension and seems to be compliant with his medications. He was initially started on spironolactone given report of EF 25-30% and thought that it may help with hypokalemia, however after 3 days (3 doses) this was discontinued so that pt could ideally have a renin/aldosterone level drawn prior to discharge (which is now pending), several days after discontinuation. Would recommend restarting this medication after the appropriate studies have been done. It is more than likely this patient has sleep apnea as well; in the ICU he was noted to have desats during sleep with very loud snoring. Desats resolved instantly on waking. Pt is also smoking and quite obese both of which are likely worsening his hypertension. Would recommend outpatient sleep study as well. . #hypokalemia - pt was noted to be hypokalemic with potassium 2.9-3.2. Concern for hyperaldosterone state given concommittant resistant hypertension. Pt required >160meq potassium repletion per day while in the [**Hospital Unit Name 153**] and still remained with K below 4.0. Outpatient records demonstrate history of low potassium. Pt also had been started on spironolactone, and while it was low dose, it did not appear to help with potassium retention. This was also unusual in the setting of elevated creatinine/chronic renal failure, which emphasized concerns for hyperaldosterone state. Spironolactone was DCd temporarily so that he could have renin/[**Male First Name (un) 2083**] levels drawn. #Intracranial hypertension: Likely secondary to systmemic hypertension. Neurology evalauted patient in ED and suggested potential LP if BP controlled to assess for pseudotumor cerebrii, though this can be deferred to outpatient setting if papilledema does not improve with improved BP control. . #Chronic kidney disease: The patient's creatinine was elevated at 3.6-3.7, which is baseline. CKD likely secondary to hypertensive nephropathy. Continued sevalamer and nephrocaps. . #Chronic systolic CHF: No echo in the system, but OSH records per Dr.[**Name (NI) 2084**] note states TTE showed increased wall thickness, estimated LVEF 25-30% and global hypokinesis without focal wall motion abnormality, as well as increased [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1934**], with estimated PA systolic pressure 32mm. The patient appeared euvolemic on exam, without evidence of an acute sCHF exacerbation. His blood pressure control was adjusted as above, including the addition of spironolactone to his regimen. Despite his renal impairment, he may benefit from the addition of an ACEi/[**Last Name (un) **] and should discuss this with his PCP, [**Name10 (NameIs) 2085**], and nephrologist. He was continued on a beta blocker (though switched from metoprolol/carvedilol to labetalol), lasix, and metolazone. His EF on the TTE here showed an EF of 55%. TRANSITIONAL ISSUES: -Has PCP, [**Name10 (NameIs) 2086**], and nephrology follow-up scheduled -Needs outpatient sleep study -Would benefit from work-up for secondary hypertension if not already done at another facility - follow up renin/[**Male First Name (un) 2083**] ratio, may draw urine metaneprhines, dex suppression testing -Patient was a Full Code during this admission -Would benefit from nutrition consult - Has Cr and K ordered as outpt on Thursday which needs f/up Medications on Admission: B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - (Prescribed by Other Provider) - Dosage uncertain CARVEDILOL - 25 mg Tablet - 1 Tablet(s) by mouth twice a day FUROSEMIDE - 20 mg Tablet - 3 Tablet(s) by mouth twice a day HYDRALAZINE - 100 mg Tablet - 1 Tablet(s) by mouth three times a day ISOSORBIDE MONONITRATE - 120 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth Qday METOLAZONE - 5 mg Tablet - 1 Tablet(s) by mouth Qday METOPROLOL TARTRATE - 100 mg Tablet - 1 Tablet(s) by mouth twice a day POTASSIUM CHLORIDE - 20 mEq Tablet, ER Particles/Crystals - 1 Tablet(s) by mouth Once a day SEVELAMER HCL - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 2. hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 3. metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 6. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patches Transdermal QSAT (every Saturday). Disp:*4 Patch Weekly(s)* Refills:*2* 7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO once a day. Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*0* 9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive emergency Secondary Diagnoses: Chronic kidney disease Chronic systolic heart failure Tobacco abuse Obesity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 2087**], You were admitted to the intensive care unit at [**Hospital1 771**] with very high blood pressures and blurry vision. Your blurry vision was likely caused by your high blood pressure. When your blood pressure is this high, you are at risk for serious complications including further kidney damage and possible stroke. We monitored you closely and changed some of your blood pressure medications to help better control your blood pressures. We made the following changes to your medications: STOPPED: -Carvedilol -Metoprolol -Isosorbide mononitrate DECREASED: -Hydralazine from 100 mg three times a day to 50 mg three times a day INCREASED: -Potassium chloride 20 meq chrystals increased from one dose once a day to two doses once a day STARTED: -Clonidine patch 0.3 mg once a week -Labetalol 400 mg three times a day -Lisinopril 2.5mg once a day We did not make any other changes to your medications. Please continue to take them as you have been doing. It is very important that you take your blood pressure medications and monitor your blood pressure. If your blood pressure is persistently higher than 190/110, you should contact your doctor. Also, if you develop any worsening blurry vision, headache, chest pain, shortness of breath, slurred speech, or weakness on one side of the face or body, you should seek medical attention immediately. We are concerned you may have a condition called obstructive sleep apnea, and we recommend you have a sleep study after you leave the hospital. We also recommend that you see a nutritionist and work on continuing to lose weight. Please eat a low salt diet. We also strongly encourage you to stop smoking. Please also note that you will need to get your creatinine and potassium checked on Thursday, [**2159-4-12**]. Followup Instructions: Department: [**Hospital3 249**] When: THURSDAY [**2159-4-12**] at 2:15 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: MONDAY [**2159-4-23**] at 9:40 AM With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2159-5-30**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

[ "585.4", "425.8", "305.21", "404.01", "377.01", "305.1", "428.0", "278.01", "327.23", "428.22", "276.8", "V15.81", "437.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11564, 11570

5558, 9443

318, 325

11754, 11754

3191, 3191

13746, 14734

1625, 1680

10632, 11541

11591, 11591

9946, 10609

11905, 12408

1695, 2435

11655, 11733

2451, 3172

9464, 9920

12437, 13723

265, 280

353, 1211

3207, 3993

11610, 11634

11769, 11881

1233, 1415

1431, 1609

4005, 5535

28,304

140,434

45783

Discharge summary

report

Admission Date: [**2171-8-20**] Discharge Date: [**2171-8-27**] Date of Birth: [**2100-5-11**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: arterial cannuation, foley placement History of Present Illness: 71 with [**First Name3 (LF) 499**] cancer s/p resection with diverting ileostomy and 2 cycles of chemo (currently between cycles), brought in by family for lethargy, malaise over the past few days; found to have acute renal failure with Cr 6.3 up from 1.6, hyperkalemia to 8.3. . According to family, had not been "feeling herself" past two days, with generalized weakness, decreased po intake, and somnolence. Ileostomy output has been constant, with her needing to empty the ileostomy bag two-three times a day. There has been some decreased urine output. She denies fevers, chills, headaches, blurry vision, chest pains, shortness of breath, or dysuria. Did endorse vague LLQ pain. . In ED, vitals 96.9 145/81 95 16 100%RA, peaked T waves on EKG. Placed foley, patient put out 1L urine. Received calcium gluconate, insulin + glucose, started bicarb drip. Renal evaluated patient and did not initiate dialysis as patient was making urine. Past Medical History: - Stage III rectal cancer s/p neo-adjuvant chemotherapy and colectomy with low anterior resection and proximal diverting ileostomy; currently s/p 1 cycle of capecitabine chemotherapy - Chronic depression- requiring multiple psychiatric hospitalizations with ECT; question of schizoaffective disorder - HTN - diabetes mellitus - mild dementia - history of UTIs - history of peripheral vascular disease Social History: She is married and lives with husband in [**Name (NI) 1474**]. She is retired, but prior to retirement worked at [**Last Name (un) 6058**] for 20 years. . Smoking: never EtOH: never Illicits: never Family History: Two sons [**Name (NI) 97544**] for SI/?SA "depression and paranoia" several other family members. [**Name (NI) **] was vague. . sister with [**Name2 (NI) 499**] cancer, died at age 80 Physical Exam: 96.5 128/46 114 19 100% RA GEN: pale elderly female, shivering on arrival to MICU HEENT: PERRL but sluggish, EOMI, OP clear, MM dry NECK: jugular veins flat CHEST: clear to auscultation bilaterally CV: s1, s2, III/VI mid systolic murmur ABD: ileostomy in RLQ, obese, soft, nontender EXT: no c/c/e, cool to touch SKIN: no rashes or ecchymoses NEURO: AAO x3 with prompting Pertinent Results: [**2171-8-20**] 08:45PM WBC-10.9 RBC-4.07* HGB-13.0 HCT-37.3 MCV-92 MCH-31.9 MCHC-34.8 RDW-17.6* [**2171-8-20**] 08:45PM NEUTS-94.0* BANDS-0 LYMPHS-4.1* MONOS-1.5* EOS-0.2 BASOS-0.2 [**2171-8-20**] 08:45PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-NORMAL [**2171-8-20**] 08:45PM PLT SMR-NORMAL PLT COUNT-334 [**2171-8-20**] 08:45PM GLUCOSE-258* UREA N-129* CREAT-6.3*# SODIUM-125* POTASSIUM-8.3* CHLORIDE-94* TOTAL CO2-9* ANION GAP-30* [**2171-8-20**] 10:30PM POTASSIUM-8.7* [**2171-8-20**] 11:53PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2171-8-20**] 11:53PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2171-8-20**] 11:53PM URINE OSMOLAL-415 [**2171-8-20**] 11:53PM URINE HOURS-RANDOM CREAT-117 POTASSIUM-51 TOT PROT-26 PROT/CREA-0.2 EKG on presentation: Sinus rhythm. Inferolateral ST-T wave abnormalities which are non-specific. Compared to the previous tracing of [**2171-5-27**] the heart rate is significantly faster. Inferolateral ST-T wave abnormalities persist. Peaked T waves. CXR: The cardiomediastinal silhouette is within normal limits. The pulmonary vasculature is normal. The lungs are clear without focal consolidation, pneumothorax, or pleural effusion. The osseous structures are unremarkable. Renal Ultrasound: The right kidney measures 11.8 cm. Left kidney measures 10.5 cm. Bilateral simple appearing renal cysts are identified measuring up to 1.6 x 1.7 x 1.4 cm on the right. The bladder is decompressed by a Foley catheter. IMPRESSION: Simple-appearing renal cysts identified. Otherwise, the kidneys are unremarkable. . Labs over hospital course: [**2171-8-22**] 06:58AM BLOOD WBC-2.4* RBC-2.47* Hgb-7.9* Hct-22.1* MCV-89 MCH-32.0 MCHC-35.9* RDW-18.6* Plt Ct-131* [**2171-8-25**] 06:20AM BLOOD WBC-4.7 RBC-2.81* Hgb-8.7* Hct-24.8* MCV-88 MCH-30.8 MCHC-35.0 RDW-17.8* Plt Ct-134* [**2171-8-20**] 08:45PM BLOOD Glucose-258* UreaN-129* Creat-6.3*# Na-125* K-8.3* Cl-94* HCO3-9* AnGap-30* [**2171-8-21**] 05:50AM BLOOD Glucose-90 UreaN-110* Creat-4.8* Na-138 K-4.0 Cl-98 HCO3-21* AnGap-23* [**2171-8-25**] 06:20AM BLOOD Glucose-113* UreaN-29* Creat-2.1* Na-139 K-4.8 Cl-107 HCO3-25 AnGap-12 [**2171-8-25**] 06:20AM BLOOD Calcium-7.8* Phos-1.7* Mg-1.4* Brief Hospital Course: 71F with depression and rectal cancer s/p resection with diverting ileostomy and chemotherapy, now with acute renal failure . # acute renal failure: etiology of ARF was unclear but was likely multifactorial, with post-renal, as patient voided 1L after placement of foley in ED; prerenal, as dry on exam at admission, has increased volume loss with ostomy and had volume-responsive hypotension; and intrinsic, as creatinine was slightly elevated at 1.6 3 weeks pta. Sediment was bland, but could not rule out ATN. Foley removed on [**8-23**] and patient able to avoid with no post-void residual. This suggested that obstruction was only one, perhaps more minor, contributing factor. Of note, the renal ultrasound the patient had was after decompression with Foley catheter and given possibility of post-XRT scarring may not have shown hydroureter. Creatinine on discharge is 2.2. She should have nephrology follow-up as an outpatient. . # altered mental status: likely secondary to uremia; avoided benzos and initially held antidepressants, but added them back without significant sedation or delirium. At discharge she was noted to have a flat affect, with cogwheel rigidity, raising the question of Parkinsonism secondary to ziprasidone (Parkinson's disease less likely as patient does not have tremor). This should be followed up by her outpatient psychiatrist. She was also given the number for the [**Hospital1 18**] psychiatry department as she has not seen her outpatient psychiatrist for several years. Alternatively flat affect may be due to schizoaffective disorder. . # lactic acidosis: lactate 6.5; normotensive without leukocytosis or overt signs of infection; suspect most likely due to metformin use with marked decrease in renal function. Metformin held during admission and should not be restarted at rehab given impaired renal functinon. . # colorectal cancer: s/p one cycle Xeloda, last before [**8-2**] appointment with Dr. [**Last Name (STitle) **] per patient. Stooling significantly from both ileostomy and rectum. Discussed with surgery, who confirmed that patient's GI tract is intact, with anastomosis; ileostomy was planned to temporarily decrease stool passing new anastomosis. Gastrograffin enema study showed normal/healthy anastomosis; patient to follow up with Dr [**Last Name (STitle) **] for reversal of ileostomy. Second cycle of Xeloda should be scheduled once patient is finished with rehab. . # depression: initially held outpatient Effexor, Geodon, & Klonopin. Restarted effexor and geodon after mental status cleared, but holding klonopin as patient became very sedated after receiving single dose of this. Once creatinine is stabilized, rehabillitation facillity or psychiatrist should consider a renal dosing of Effexor. . # diabetes: Bld glc mildly elevated (258) on admission, with no ketones in urine, so not c/w ketoacidosis. After receiving amp of D50 and bicarb in D5W, glc up to 400s. Briefly on insulin drip for euglycemic control, transitioned to sliding scale insulin. Holding metformin given lactic acidosis in the setting of elevated creatinine; can re-evaluate and likely restart this after renal function has normalized. When transferred to floor, maintained on 10units glargine qHS plus humalog sliding scale which was titrated for good blood sugar control. . # HTN: now normotensive, likely due to dehydration. Held metoprolol initially but restarted at 12.5mg [**Hospital1 **]. This can be uptitrated to home dose of 25mg [**Hospital1 **]. Olmesartan (Benicar) can also be restarted once renal function stabilized. Currently does not need from a HTN point of view, but would be helpful from a diabetes standpoint. . # pancytopenia: WBC, Hct, and Plts all down on HD 2. Likely from recent chemo. Will change H2blocker to PPI in case this is contributing to thrombocytopenia. Supportive transfusion (1 unit given in MICU) to keep Hct >24. HCT on discharge is 26.1 . # FEN: - hyperkalemia: QRS slightly widened and T waves peaked on presentation, after calcium/insulin + D50/bicarb, QRS has normalized and T wave peaking less marked. K is slightly elevated at 5.2 at discharge. This should be followed at rehab and kayexelate given if it increases. Mild hyperkalemia may be due to diabetic hyporeninemia and hypoaldosteronemia. - hyponatremia: improved with volume resuscitation, c/w hypovolemic hyponatremia . # ? OSA: patient with labored breathing and snoring during sleep, but does not carry diagnosis of OSA. Needs outpatient sleep study. Medications on Admission: Metoprolol Tartrate 25 mg [**Hospital1 **] Oxycodone-Acetaminophen 5-325 mg Metformin 1000 mg [**Hospital1 **] Clonazepam 0.5 mg DAILY Ziprasidone HCl 80 mg [**Hospital1 **] Venlafaxine 150 mg DAILY Olmesartan 20 mg Daily Discharge Medications: 1. Ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). 3. Insulin Lispro 100 unit/mL Solution Sig: ASDIR units Subcutaneous ASDIR (AS DIRECTED): 2 units for Bld Sugar 151-200, and 2 additional units for every 50 of Bld Sugar over 200. 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: acute renal failure stage 3 rectal cancer depression . Secondary: Diabetes Mellitus Discharge Condition: Good Discharge Instructions: You were admitted with acute renal failure, which is resolving after placement of a Foley catheter to decompress your bladder. We have held the medications benicar and metformin, as these are not safe to take until the kidney function returns to normal. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern1) 21**], M.D. Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2171-9-6**] 9:00 (oncology) Call Dr. [**Last Name (STitle) **] when you get home for a follow-up appointment. See your primary care doctor after you are discharged from Rehab. [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 35276**]

[ "284.1", "154.0", "403.90", "276.1", "V44.2", "295.70", "294.8", "250.00", "584.9", "585.9" ]

icd9cm

[ [ [] ] ]

[ "38.91" ]

icd9pcs

[ [ [] ] ]

10218, 10290

4952, 5902

336, 374

10427, 10434

2596, 4309

10736, 11127

2003, 2189

9740, 10195

10311, 10406

9493, 9717

4327, 4929

10458, 10713

2204, 2577

275, 298

402, 1345

5917, 9467

1367, 1771

1787, 1987

72,608

112,790

36434

Discharge summary

report

Admission Date: [**2131-4-13**] Discharge Date: [**2131-4-26**] Date of Birth: [**2071-8-13**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2131-4-16**] Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending and saphenous vein grafts to diagonal and posterior descending artery History of Present Illness: Mr. [**Known lastname **] is a 59 year-old male who presented to [**Hospital1 25157**] with 3 week history of chest pain radiating to his left arm with exertion. A subsequent EKG revealed NSR with ST elevation in V1-5 with Q waves and a troponin was found to be 1.16. He was cathed and found to have severe two vessel coronary artery disease. An echo revealed moderate to severe mitral regurgitation with an LVEF of 15-20%. He was subsequently transferred to [**Hospital1 18**] for surgical revascularization. Past Medical History: Remote Bronchitis/Pneumonia History of Kidney Stones Denies previous surgeries Social History: Denies tobacco. Occasional alcohol use. Married, employed as a truck driver. Family History: Father with coronary arery disease, requiring stent at age 65, then bypass surgery. Passed away 1 yr after surgery. Physical Exam: Pulse:83 Resp: 16 O2 sat: 95 RA B/P Right: 95/67 Height: 5'5" Weight: 147 lbs General: No acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur III/VI SEM 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 intactX Pulses: Femoral Right: 1+ Left:1+ DP Right: 1+ Left:1+ PT [**Name (NI) 167**]: 1+ Left:1+ Radial Right: 2+ Left:2+ Carotid Bruit Right: - Left:+ Pertinent Results: [**2131-4-13**] BLOOD WBC-6.0 RBC-3.79* Hgb-12.3* Hct-37.4* MCV-99* MCH-32.3* MCHC-32.8 RDW-13.2 Plt Ct-617* [**2131-4-13**] BLOOD PT-15.5* PTT-34.4 INR(PT)-1.4* [**2131-4-13**] BLOOD Glucose-106* UreaN-13 Creat-1.0 Na-139 K-4.5 Cl-107 HCO3-25 [**2131-4-13**] BLOOD ALT-27 AST-23 LD(LDH)-307* CK(CPK)-85 AlkPhos-55 Amylase-46 TotBili-0.4 [**2131-4-13**] BLOOD CK-MB-4 cTropnT-0.88* [**2131-4-14**] BLOOD CK-MB-NotDone cTropnT-0.98* [**2131-4-13**] BLOOD Albumin-3.2* [**2131-4-13**] BLOOD %HbA1c-5.5 [**2131-4-26**] 05:10AM BLOOD WBC-7.1 RBC-3.41* Hgb-10.7* Hct-32.5* MCV-95 MCH-31.3 MCHC-32.8 RDW-14.7 Plt Ct-718* [**2131-4-23**] 03:50AM BLOOD PT-15.3* PTT-32.8 INR(PT)-1.3* [**2131-4-26**] 05:10AM BLOOD Glucose-86 UreaN-22* Creat-1.0 Na-136 K-5.3* Cl-102 HCO3-24 AnGap-15 [**2131-4-19**] 04:48AM BLOOD LD(LDH)-343* TotBili-1.3 [**2131-4-23**] 03:50AM BLOOD Calcium-8.2* Mg-2.5 [**2131-4-16**] Carotid Ultrasound: On the LEFT systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 388/167, 135/65, 32/17 cm/sec. CCA peak systolic velocity is 52/13 cm/sec. ECA peak systolic velocity is 82 cm/sec. The ICA/CCA ratio is 7.5. These findings are consistent with 80-99% stenosis. On the RIGHT systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 99/39, 100/34, 68/25 cm/sec. CCA peak systolic velocity is 75/21 cm/sec. ECA peak systolic velocity is 98 cm/sec. The ICA/CCA ratio is 1.3. These findings are consistent with < 40%stenosis. [**2131-4-16**] Intraop TEE: PREBYPASS - 1. The left atrium is mildly dilated. No spontaneous echo contrast is seen in the body of the left atrium. No atrial septal defect of PFO is seen by 2D or color Doppler. 2. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %) with akinesia of the apex and anterior wall. The anterior septum and inferior septum are moderately hypokinetic. 3. Right ventricular chamber size and free wall motion are normal. 4. 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. 6.The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. POST BYPASS - 1. Patient is in sinus rhythm receiving an infusion of milrinone and norepinephrine. 2. LVEF slightly improved post revascularization. LVEF 25- 30%. 3. Aorta is intact post decannulation. 4. Mitral regurgitation is mild to moderate. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the cardiac surgical service. He was maintained on intravenous Heparin and Nitro and remained pain free. Preoperative echocardiogram showed LVEF 20-25% with 2-3+ mitral regurgitation - see result section for additional detail. Preoperative carotid ultrasound revealed severe left internal carotid artery stenosis - see result section for further detail. Vascular surgery was consulted and recommended left carotid endarterectomy six to eight weeks after cardiac surgery. Preoperative course was otherwise uneventful. Just prior to surgical revascularization, an IABP was placed given his severely depressed left ventricular function. On [**4-16**], Dr. [**First Name (STitle) **] performed coronary artery bypass grafting surgery. Given inpatient stay was greater than 24 hours prior to surgery, Vancomycin was given for perioperative antibiotic coverage. For surgical details, see 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. The IABP was weaned and removed on postoperative day one without complication. Due to persistent hypotension, he was slow to wean from pressor support. Midodrine was initiated. Hemodynamics gradually improved and he was eventually transferred to the telemetry floor on postoperative day seven. Over next couple of days he received further medical management and remained stable without any complications. He worked with physical therapy for strength and mobility and on post-operative day ten he was discharged home with VNA services and the appropriate follow-up appointments. Patient was unable to be started on ACE-inhibitor due to hypotension post-operatively. He will follow-up with his cardiologist for possible addition of an ACE. Medications on Admission: None Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. 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:*1* 6. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*1* 7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary Artery Disease status post Coronary Artery Bypass Graft Ischemic Cardiomyopathy, Ejection Fraction 15-20% Preoperative Myocardial Infarction Mitral Regurgitation Carotid Disease Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**First Name (STitle) **] in [**4-8**] weeks, call for appt Dr. [**First Name (STitle) **] in [**2-6**] weeks, call for appt Dr. [**Known firstname **] [**Last Name (NamePattern1) **] in [**2-6**] weeks, call for appt [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2131-4-26**]

[ "458.29", "397.0", "414.8", "414.01", "433.10", "428.0", "428.23", "410.11", "424.0" ]

icd9cm

[ [ [] ] ]

[ "37.61", "36.15", "36.12", "39.61" ]

icd9pcs

[ [ [] ] ]

7777, 7836

4595, 6448

331, 534

8066, 8072

2076, 4572

8583, 8927

1287, 1404

6503, 7754

7857, 8045

6474, 6480

8096, 8560

1419, 2057

281, 293

562, 1075

1097, 1177

1193, 1271

21,645

184,867

4687

Discharge summary

report

Admission Date: [**2104-2-1**] Discharge Date: [**2104-2-7**] Date of Birth: [**2023-5-29**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 783**] Chief Complaint: Melena Major Surgical or Invasive Procedure: None History of Present Illness: 80 y/o French/Creole-speaking female with a hx of GI bleed, fairly recent diagnosis of HepC cirrhosis c/b grade I esophageal varices and ascites, who within the 2-3 days prior to admission had been having SOB and melanotic stools. On presentation the patient was noted to be lethargic. Her Hct was 32.3. Vitals were noteworthy for a HR 67, BP 125/47. The patient was seen in the ED by hepatology who recommended an EGD with possible intubation (given the patient's mental status). The patient's daughter opted for conservative management, because she was fearful that the patient may not be able to be extubated. . Of note the patient had been recently discharged from [**Hospital1 18**] on [**2104-1-12**]. Her presenting diagnosis was new ascites. During that time, she had an EGD which showed grade I varices. Colonoscopy was limited due to poor prep, but no obvious sites of bleeding were noted. Hep C VL at that time was noted to be 428K. The patient was discharged on Nadolol, Lasix, and Spironolactone. Past Medical History: HTN CVA DM (on oral hypoglcemics) COPD urinary retention (recent indwelling foley) GI bleeding requiring transfusion Social History: Lives with daughter. Is Creole speaking. No tobacco. Family History: NC Physical Exam: V: Tm 97.7 HR 55 BP 127/98 R12 O2sat 100%RA Gen: elderly female who appears lethargic in NAD HEENT: no conjunctival pallor, dried blood in nares, MM dry, OP clear CV: Normal S1, S2, RRR, II/VI HSM along LUSB Pulm: CTA-anteriorly Abd: +BS, no guarding, no rebound tenderness, no fluid wave Ext: 2+DP b/l, no cce Pertinent Results: CXR [**2103-2-1**] CHEST AP: Small bilateral pleural effusions are unchanged. Upper zone redistribution of pulmonary vasculature is seen with hilar congestion and mild cardiomegaly representing persistent failure. . EKG Sinus bradycardia at 50bpm, TWF V4-V6 (unchanged from prior), poor R wave progression (unchanged from prior) . ECHO The left atrium is dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 11-15mmHg. 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%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Suboptimal image quality - patient unable to cooperate. Brief Hospital Course: 80 year old female with MMP including Hep C, GIB, who presents with GIB. The following issues were investigated during this hospitalization: . 1. GIB: Likely upper GI bleed given melena and probably from esophageal varices. Daughter elected conservative management out of fear that once intubated, her mother may not be able to be extubated. The patient was admitted to the intensive care unit where she was monitored with serial Hcts and vitals were checked for hemodynamic instability. The patient remained stable and was thus transferred to the floor where another conversation was held with the daughter who fully understood the consequences of declining an EGD, but still declined. The patient's vitals remained stable. She was maintained on a PPI and Ciprofloxacin and once her blood pressure became stable, she was restarted on Nadolol. She never required a transfusion. She was discharged with instructions to follow up in [**Company 191**] for Hct monitoring and additional care. . 2 HTN: Antihypertensives were initially held given the GIB, however after being transferred to the floor, the patient was noted to be hypertensive frequently with SBPs in the 170s. She was restarted on Amlodipine which she had been taking as an outpatient. Additionally, Nadolol for the esophageal varices and Lasix for ascites were added on. Careful attention was paid to not only the blood pressure but the patient's heart rate while on these medications as she was noted to have asymptomatic bradycardia while sleeping. The patient was able to tolerate them all well and was discharged on her outpatient regimen of all the aforementioned medications. . 3. UTI: The patient was noted to have a UTI on urinalysis which was treated with Levofloxacin. This was continued on discharge for a total of 14 days, since it was associated with a foley. . 4. Hep C: Patient with known cirrhosis and grade 1 varices, viral of 428,000. While patient was admitted previously for ascites, there was no evidence of ascites on exam during this hospitalization. Once her blood pressure became stable, she was restarted on her outpatient dose of Lasix. Otherwise, no active issues for Hepatitis C during this hospitalization. . 5. DM2: The patient's diabetes was monitored and treated with QID fingersticks and an Insulin sliding scale. . 6. COPD: Patient was maintained on her outpatient dose of nebulizers/inhalers. Medications on Admission: Lasix 60mg daily Albuterol Protonix 40mg IV BID Xalatan Ferrous Sulfate 325 daily Norvasc 5mg daily Nadalol 20mg daily Lactulose 20mg daily Procrit 20,000U qweekly Magnesium Oxide 400mg daily KCl 10meq TID Ciloxin eyedrops TID ISS Prandin 0.5mg TID Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:*1 bottle* Refills:*2* 2. Ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic TID (3 times a day). Disp:*1 bottle* Refills:*0* 3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 5. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Outpatient Lab Work Please draw a CBC to evaluate Hct and Chem 10 to evaluate electrolytes given diuretics. 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 10. Lactulose 10 g/15 mL Solution Sig: Thirty (30) mL PO once a day. Disp:*qs * Refills:*2* 11. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation q4-6 hours PRN as needed for shortness of breath or wheezing. Disp:*qs * Refills:*0* 12. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. Prandin 0.5 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 14. Procrit 20,000 unit/mL Solution Sig: One (1) mL Injection once a week. Disp:*qs * Refills:*2* Discharge Disposition: Home With Service Facility: nurses R us Discharge Diagnosis: Primary GIB . Secondary Hepatitis C associated liver cirrhosis Renal insufficiency Urinary Tract Infection Ascites History of lower GI bleed Gastritis Grade I esophageal varices Type 2 diabetes mellitus Hypertension Chronic obstructive pulmonary disease CVA DM2 Discharge Condition: Stable with appropriate follow-up. Discharge Instructions: You were seen and evaluated for concern of bleeding in your digestive tract. An option of having endoscopy (placing a camera down into your stomach to look for a source of bleeding) was offered, but given your initial unstable state and a risk of having to be intubated (having a breathing tube placed into your throat and lungs) per the request of your daughter, the decision was made to hold off on endoscopy. Your blood count remained stable during this hospitalization, however since no source of bleeding was found, it will be important for you to continue to follow-up with your doctor [**First Name (Titles) **] [**Last Name (Titles) **] to evaluate your blood count. * Take all of your medications as directed. * Keep all of your follow-up appointments. * Call your doctor or go to the ER for any of the following: vomiting blood, blood in your stool or dark, black stools, lightheadedness, palpitations, chest pain, shortness of breath, fevers/chills, nausea/vomiting or any other concerning symptoms. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19779**], MD (Internal Medicine) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2104-2-11**] 10:30 (You will be given a prescription to give to this doctor to have your blood drawn) Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Liver) Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2104-2-12**] 3:00 Provider: [**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) **], MD (Internal Medicine) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2104-3-11**] 1:30 [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "250.00", "280.0", "571.2", "789.5", "599.0", "070.54", "456.20", "401.9", "496" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7609, 7651

3293, 5688

276, 283

7957, 7994

1904, 3270

9062, 9805

1553, 1557

5988, 7586

7672, 7936

5714, 5965

8018, 9039

1572, 1885

230, 238

311, 1326

1348, 1466

1482, 1537

25,297

100,294

18692

Discharge summary

report

Admission Date: [**2117-8-26**] Discharge Date: [**2117-8-29**] Date of Birth: [**2051-11-8**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 65-year-old male who was previously hospitalized in [**2117-6-1**] for a large right sided subdural hematoma, which developed while he was on Coumadin on atrial fibrillation with no history of trauma. The patient underwent bedside drainage of subdural hematoma without complication, and was discharged off Coumadin. Patient had a four week followup CT which showed a left sided subdural hematoma with 5 mm rightward shift. The patient denies any current symptoms. However, his wife noted difficulty with gait and occasional tripping prior to admission. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Hypertension. 3. Hypercholesterolemia. 4. Anxiety. 5. Questionable pulmonary embolus on [**7-4**]. 6. Status post IVC filter in the right groin. Patient neurologically was awake, alert, and oriented times three and slightly anxious with equal pupils and full extraocular motions on initial exam. Patient had a questionable right pronator drift with a slight facial droop, but motor strength was [**4-5**] throughout upper and lower extremities on admission. Patient was admitted to the floor and preoped for craniotomy and left subdural evacuation, which he underwent on [**2117-8-27**] without complication. Subdural drain was placed. The patient was transferred to the PACU status post procedure. Patient was placed on fluid restriction on [**8-28**] for a sodium of 132. Patient's repeat head CT showed some postoperative air in the left subdural space and some layering of fluid. Drain was placed. There is scant drainage in the subdural drain since OR. Drain was flushed on [**10-1**], and [**8-29**] without significant change in the amount of drainage. Patient continued to neurologically remain intact postoperatively. Patient's drain was D/C'd on [**8-29**] without sequelae. The patient was transferred to the floor. Patient had no complaints at the time of discharge. Was neurologically stable at time of discharge. DISCHARGE MEDICATIONS: 1. Zolpidem tartrate 5 mg p.o. q.h.s. 2. Phenytoin 100 mg p.o. t.i.d. 3. Lisinopril 10 mg p.o. q.d. 4. Atorvastatin 10 mg p.o. q.d. 5. Lorazepam 1 mg p.o. q.4-6h. prn. 6. Peroxetine 40 mg p.o. q.d. FOLLOW-UP INSTRUCTIONS: The patient was instructed to followup with Dr. [**Last Name (STitle) 1327**] in the office in two weeks with prior head CT. Again, the patient is neurologically stable at time of discharge. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Last Name (NamePattern1) 27454**] MEDQUIST36 D: [**2117-8-29**] 23:51 T: [**2117-8-31**] 08:25 JOB#: [**Job Number 51255**]

[ "300.00", "272.0", "401.9", "432.1", "427.31" ]

icd9cm

[ [ [] ] ]

[ "01.31" ]

icd9pcs

[ [ [] ] ]

2133, 2332

155, 721

2357, 2814

743, 2110

6,299

108,422

47257

Discharge summary

report

Admission Date: [**2132-12-10**] Discharge Date: [**2133-1-23**] Date of Birth: [**2071-9-13**] Sex: M Service: SURGERY Allergies: Penicillins / Ivp Dye, Iodine Containing Attending:[**First Name3 (LF) 1556**] Chief Complaint: Fever, chills, left leg pain, redness and swelling Major Surgical or Invasive Procedure: -Left hip disarticulation. -Diverting descending colostomy. -Splenic flexure mobilization of the colon. -Gastrostomy tube placement. -Repair of incisional hernia. -Debridement of subcutaneous tissue including muscle of the left pelvis and gluteus. -VAC dressing -IVC filter [**2133-1-2**] -Primary Wound Closure [**2133-1-6**] History of Present Illness: 61 yo male with history of rectal carcinoma who presents after a fall one week ago and BRBPR; now with fevers, chills, left leg pain, redness and swelling. Past Medical History: Rectal cancer s/p resection w/ ileostomy & s/p ileostomy takedown Bilateral Knee arthroscopies s/p Ventral hernia repair Social History: Married, owns men's clothing store in [**Location (un) 86**] Family History: Noncontributory Physical Exam: Vs upon admission: 97.2 HR 100 BP 99/56 RR 18 Gen- Disoriented Cor- Tachy Chest- Decreased breath sounds Abd- soft, NT,ND, surgical scar Rectum- guaiac positive, normal tone Extr- left thigh & calf swollen w/ dependent erythema, warmth Pertinent Results: [**2132-12-10**] 11:52PM TYPE-ART PO2-161* PCO2-33* PH-7.33* TOTAL CO2-18* BASE XS--7 INTUBATED-INTUBATED [**2132-12-10**] 09:31PM GLUCOSE-73 UREA N-49* CREAT-2.5*# SODIUM-138 POTASSIUM-5.1 CHLORIDE-111* TOTAL CO2-16* ANION GAP-16 [**2132-12-10**] 09:31PM ALT(SGPT)-89* AST(SGOT)-185* ALK PHOS-32* TOT BILI-1.5 [**2132-12-10**] 09:31PM CALCIUM-7.5* PHOSPHATE-7.6*# MAGNESIUM-1.2* [**2132-12-10**] 09:31PM WBC-3.6* RBC-3.79* HGB-11.9* HCT-32.1* MCV-85 MCH-31.3 MCHC-37.0* RDW-13.9 [**2132-12-10**] 09:31PM PLT COUNT-131* [**2132-12-10**] 09:31PM PT-16.2* PTT-37.3* INR(PT)-1.8 UNILAT LOWER EXT VEINS LEFT [**2132-12-10**] 12:49 PM UNILAT LOWER EXT VEINS LEFT Reason: LOWER EXTREMITY EDEMA AND PAIN [**Hospital 93**] MEDICAL CONDITION: 61 year old man with L lower extremity edema and pain REASON FOR THIS EXAMINATION: assess for dvt DOPPLER ULTRASOUND STUDY OF LEFT LOWER LIMB VEINS. FINDINGS: Evaluation for DVT. FINDINGS: The left lower limb veins are patent and compressible along their length, there is normal phasic venous flow and increased venous return with calf compression on color Doppler. Some generalized edema noted in the subcutaneous tissues. No collection. CONCLUSION: 1. No DVT 2. Mild generalized subcutaneous edema noted. Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 100046**],[**Known firstname **] [**2071-9-13**] 61 Male [**-5/4324**] [**Numeric Identifier 100047**] Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif SPECIMEN SUBMITTED: FASCIA LEFT LEG, NECROTIC GLUTEUS LEFT, LEFT LEG & LEFT PROXIMAL HEAD FEMUR. Procedure date Tissue received Report Date Diagnosed by [**2132-12-10**] [**2132-12-11**] [**2132-12-18**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma?????? Previous biopsies: [**-5/3647**] GI BX'S, 2. [**Numeric Identifier 100048**] HERNIA SAC. [**Numeric Identifier 100049**] PORTA CATH GROSS ONLY, DISTAL ILEOSTOMY STOMA. [**-3/3178**] PROCTECTOMY, PROXIMAL DONUT, DISTAL DONUT. (and more) DIAGNOSIS 1. Fascia, left leg (A-B): - Necrotic fascia and fat with minimal inflammation. - Necrotic skeletal muscle with acute inflammation. 2. Necrotic gluteus, left (C-D): - Necrotic fascia and fat with acute inflammation. - Skin with necrosis of subcutis. 3. Left leg (E-K): - Skin and soft tissue (fascia, skeletal muscle, fat) with extensive necrosis and acute inflammation; proximal margin is focally involved. - Viable bone at resection margin. - Patent large vessels with mild-moderate atherosclerosis. 4. Left proximal femoral head (L-N): - Necrotic soft tissue. - Unremarkable bone. Clinical: Necrotizing fascitis. Gross: The specimen is received fresh in four parts, each labeled with "[**Known lastname **], [**Known firstname **]" and the medical record number. Part 1 is additionally labeled "fascia left leg" and consists of a portion of necrotic muscle and fascia measuring 2.4 x 2.0 x 0.2 cm. A portion of this is submitted for frozen section. Frozen section diagnosis by Dr. [**Last Name (STitle) **]. Brown is: "Necrotic muscle and fascia with acute and chronic inflammation." The specimen is represented as follows: A = frozen section remnant, B = remainder of tissue. Part 2 is additionally labeled "necrotic gluteus and leg muscles" and consists of a 1200 gram aggregate of skin and necrotic muscle measuring 14 x 14 x 13 cm. In certain areas the specimen is liquified and the necrosis extends to 0.5 cm of the epidermal surface. There are no discrete masses identified. The specimen is represented in C-D. Part 3 is additionally labeled " left leg" and consists of a leg resected within the femur, measuring 80 cm long. The foot measures 22 cm long with white skin over the entire surface. There are no skin lesions over the foot. There is a linear surgical defect at the lateral leg, starting 10 cm proximal to the lateral malleolus extending up to the soft tissue resection margin. This surgical defect extends down deep to the fascia. There is a portion of brown, necrotic appearing skeletal muscle and fascia starting 14 cm from the proximal resection margin, measuring 13 x 11 cm. The fascia here has been incised previously. There is viable tissue apparent adjacent to the tibia and femur, however the tissue is necrotic deep to the fascia. The vessels are dissected and there are mild atherosclerotic changes visible within the popliteal vessels. The dorsalis pedis appears grossly unremarkable. The soft tissue resection margin does appear involved by necrotic muscle, however, the skin and the bone appear grossly unremarkable. The specimen is represented as follows: E-F = femur resection margin after decal, G-H = soft tissue and skin resection margin, I = necrotic appearing muscle, J = necrotic appearing fascia, K = representative sections through popliteal and dorsalis pedis vessels. Part 4 is additionally labeled "left proximal head, femur" and consists of a portion of femur with attached femoral neck and femoral head measuring 14 x 9 x 3 cm. Attached to the femur, the portion of skeletal muscle and fascia measuring 9 x 8 x 6 cm. There is focal necrosis within the muscle, particularly adjacent to bone. The articular cartilage of the femoral head appears focally eroded over an area measuring 1.7 x 0.8 cm. The necrotic soft tissue is represented in L. The head of the femur is hemisected to reveal a grossly unremarkable cortical bone, with no areas of necrosis or cyst formation within the bone. The area of articular erosion is represented in M after decal. The femur and femoral neck are sectioned in the area adjacent to the necrotic soft tissue to reveal grossly unremarkable bone, with necrotic adjacent soft tissues. Section of bone adjacent to necrotic soft tissue is submitted in N after decal. CT PELVIS W/CONTRAST [**2132-12-16**] 6:14 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: eval for fistula Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 61 year old man s/p left hip disarticulation for nec [**Hospital **]. with stool from wound REASON FOR THIS EXAMINATION: eval for fistula CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: History of rectal cancer, now status post left hip disarticulation for necrotizing fasciitis, with stool from the wound. Evaluate for fistula. COMPARISON: Study from [**2132-7-2**]. TECHNIQUE: MDCT-acquired contiguous axial images were obtained from the lung bases to the pubic symphysis. Multiplanar reconstructions were performed. CONTRAST: Oral contrast and 145 cc of IV Optiray contrast were administered due to the rapid rate of bolus injection required for this study. CT OF THE ABDOMEN WITH IV CONTRAST: Tiny bilateral pleural effusions are noted. No parenchymal consolidation or pulmonary nodules are identified. An NG tube is seen positioned within the stomach. The liver, gallbladder, adrenal glands, spleen, right kidney, and pancreas are normal in appearance. The left kidney demonstrates a hypodensity which is too small to characterize. There is diastasis of the anterior abdominal wall rectus muscles. Scattered retroperitoneal lymph nodes are noted which do not pathologically enlarge by CT criteria. The stomach and small bowel are normal in appearance, without any evidence of bowel wall dilatation or thickening. No free fluid or free air is seen. CT OF THE PELVIS WITH IV CONTRAST: Foley catheter is seen within the bladder. The sigmoid and descending colon are normal in appearance. Within the left pelvic soft tissues, changes are seen from recent hip disarticulation. There is fluid, soft tissue gas, and soft tissue stranding from recent surgery. Additionally, within the distal most portion of the femoral veins at the site of amputation, there is a filling defect, consistent with occlusion. Within the rectum, in the presacral space there is again noted a soft tissue thickening, which is seen on the prior study from [**2132-7-2**], and may reflect change from prior surgery or therapy for rectal cancer. Additionally, on more inferior images, there is a possible focal outpouching on the left adjacent to the coccyx, but this is not clearly defined. Additionally, in the soft tissues, there is extensive stranding, and soft tissue gas extending from surgery in that area. More inferiorly, there is a focal second outpouching which contains gas and fluid, which may be in the ischiorectal space, and may represent focal outpouching versus a sinus tract. There is not a significant amount of inflammatory stranding adjacent to this, making an abscess less likely. BONE WINDOWS: Changes are seen from recent surgery within the left hip. No other suspicious lytic or sclerotic lesions are identified. CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in delineating the anatomy and pathology. IMPRESSION: 1. There are extensive changes within the soft tissues adjacent to the left acetabulum, where there has been recent surgery for left hip disarticulation. There is extensive soft tissue gas and defect in this area. 2. Within the rectum, there is soft tissue thickening within the presacral space, which was seen on the prior study, and may represent changes from prior therapy for rectal cancer. Additionally, within the rectum, there is a focal area of outpouching on the left. No definite fistulous tract is identified. Inferior to this, there is a second area of focal outpouching which appears to be adjacent to the lower rectum/anal canal. This study does not definitely identify a fistula, and cannot exclude the presence of a fistula. Further evaluation is recommended. 3. Tiny bilateral pleural effusion. CT ABDOMEN W/CONTRAST [**2133-1-14**] 2:55 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: assess for abscess or fluid collection Field of view: 38 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 61 year old man s/p left hip disarticulation for nec [**Last Name (LF) **], [**First Name3 (LF) **] pus in JP output REASON FOR THIS EXAMINATION: assess for abscess or fluid collection CONTRAINDICATIONS for IV CONTRAST: None. CT ABDOMEN AND PELVIS There is comparison from [**2132-12-16**]. CLINICAL HISTORY: Status post left hip disarticulation for necrotizing fasciitis, pus in JP drain, evaluate for abscess or fluid collection. TECHNIQUE: Axial MDCT images of the abdomen and pelvis were obtained with IV and barium based contrast placed through the stoma. FINDINGS: Images of the lower thorax demonstrate an increased size of the right pleural effusion. There is trace left pleural effusion, which is decreased in size since the previous exam. The heart size is normal. The liver, spleen, pancreas, adrenal glands, and kidneys are normal. The gallbladder is present. A gastrostomy tube is present with its tip in the lumen of the stomach. An IVC filter is present with its tip below the renal veins. The patient is status post left hemicolectomy. In the bed of the left colon tracking caudally and medially and terminating in the mid pelvis, there is an enhancing fluid collection. CT PELVIS FINDINGS: In the soft tissues of the left hemipelvis, there is a large multiloculated fluid and gas collection present. There is heterotopic ossification in this region. Several drains are seen coursing through this fluid collection. There is liquefaction of the adjacent pelvic muscles. Thrombus is seen in the left superficial and deep femoral veins. The largest diameter of this fluid collection is 15 cm. It extends from the obturator foramen superiorly to the left iliac crest. The osseous structures of the left hemipelvis look intact on this study. There is ulceration of the skin of the left buttock which is likely related to infection and debridement. IMPRESSION: 1. Large abscess in the region of the disarticulated left hip, which extends over the superior aspect of the iliac crest to the obturator foramen. 1. Additionally, there an abscess or seroma in the left abdomen in the region of the left colon bed with dependent accumulation in the pelvis. 2. Thromboses in the left superficial and deep femoral veins. 3. Liquefaction of the left pelvic musculature in the region of the abscess. 4. These findings were communicated to the clinical service on [**2133-1-14**]. Brief Hospital Course: Patient admitted to the trauma service; he was transferred to the intensive care unit secondary to sepsis. Orthopedics consulted because of his necrotizing fascitis; he was taken to the operating room for left hip disarticulation. Micro: [**1-15**] Cdiff neg [**1-12**] JP drain GNRs (heavy growth ID & S P), GPC in p, GPRs, G variable; Cdiff neg [**1-11**] Cdiff neg [**12-10**] bld cx. pan S E. coli. RADS: [**1-15**] CT abd abscess drained spont [**1-14**] CT abd abscess iliac crest to the obturator foramen. abscess/seroma left colon bed. Thromboses in the left superficial and deep femoral veins. Liquefaction of the left pelvic musculature in the region of the abscess. [**1-10**] KUB no obs [**1-5**] gastrograffin/ KUB neg closure/debridement per plastics. [**12-17**] -OR for colostomy dressing change [**12-24**] transfer to floor, TF's cycled [**12-27**]- tube feeds held, erythema @ G-tube site, stoma dusky, +TTP R abdomen [**12-29**] - OR for woundvac to L stump [**12-31**] - OR for wound vac change, washout [**1-2**] - IVC filter, f/u [**Hospital **] clinic PRN for removal [**1-6**] - OR s/p I&D, local flap closure, [**Doctor Last Name **] x4: 2 posterior-deep, 2 anterior - superficial. [**1-7**] - DAT, pain control [**1-8**] - Rehab screen. [**1-9**] - SW for coping, bowel regimen restarted. [**1-10**] - N/V-> switched to IV flagyl and IV vanco, d/c clinda. lg amt emesis. [**1-11**] - NGT placed, GT to gravity, NPO. SBO vs narc ileus, Cdiff neg. [**1-12**] - Improved clinically, clamped GT, NPO. + purulent drainage from JPs, Cx GNR. [**1-13**] -Started TF cycle PM/clears. Accepted at [**Hospital1 **]. c-diff neg x2. f/u with PRS about opening wound. [**1-14**] -CT abd/pelvis-large fluid collection in L hip and bed of L colon. PRS will likely not drain. [**1-15**] -hip collection drained spontaneously, NTD on by IR (fluid collection resolved on CT) [**1-16**] -JP Cx repeat. Plan is [**Hospital1 **] next week if stable. No acute issues over the weekend. Pt c/o mild intermittent "gnawing" abd pain. [**1-19**] - Pt remains stable. Attending plastics note confirms that they will not intervene on LLE stump and he is cleared for d/c from their perspective. [**2133-1-20**] - comfirmed klebsiella and entercoccus in jp drainage, pt remains afebrile and stable off abx. [**2133-1-22**] - LLE stump continues to ooze; JP drains remain in place with decreased output. Plan is for follow up in [**Hospital 3595**] clinic 1 week from next Tuesday; likely may d/c drains at that time. Medications on Admission: Percocet Hydrocortisone Ativan Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Zinc Sulfate 220 mg Tablet Sig: One (1) Capsule PO once a day. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain/fever. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 6. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for heartburn. 7. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. Morphine 15 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO Q12H (every 12 hours). 9. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Necrotizing Fascitis Left Leg Left Hip Disarticulation Discharge Condition: Stable Discharge Instructions: *Follow up in Trauma & Plastic Surgery Clinic in 2 weeks. *Follow up with your Primary Doctor after your discharge from rehab. Followup Instructions: 1.Call [**Telephone/Fax (1) 6439**] for an appointment in Trauma Clinic; located in [**Hospital Ward Name **] Bldg, [**Location (un) 470**], [**Hospital Ward Name 517**] and [**Telephone/Fax (1) 26839**] for an appointment in [**Hospital 3595**] clinic 2.Call Dr. [**Last Name (STitle) **] for an apppointment after you are discharged from rehab. 3. You have an appointmnent with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2133-2-2**] 9:30. [**Hospital Ward Name 23**] Bldg, [**Hospital Ward Name 516**] Completed by:[**2133-1-23**]

[ "584.9", "493.90", "553.21", "995.92", "038.9", "997.69", "728.86", "V10.06" ]

icd9cm

[ [ [] ] ]

[ "38.7", "96.6", "53.51", "77.65", "84.18", "43.19", "83.39", "83.45", "93.59", "46.11", "38.93", "77.85", "86.74", "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

17800, 17870

13865, 16378

352, 681

17969, 17978

1395, 2110

18153, 18778

1104, 1121

16460, 17777

11450, 11567

17891, 17948

16404, 16437

18002, 18130

1136, 1141

262, 314

11596, 13842

709, 866

1155, 1376

888, 1010

1026, 1088

29,541

194,040

46052

Discharge summary

report

Admission Date: [**2173-8-14**] Discharge Date: [**2173-8-24**] Date of Birth: [**2112-6-24**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Morphine / Iodine-Iodine Containing / Keflex / Wellbutrin SR / Simvastatin / Demerol / Xalatan / Atropine / Epinephrine Attending:[**First Name3 (LF) 1390**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [**2173-8-14**] Exploratory laparotomy, removal of foreign body, closure of small bowel perforation, and washout of soft tissue History of Present Illness: Ms. [**Known lastname 98005**] is a 61 yo female with a history of Crohn's disease on steroids who was in her usual state of health up until [**2173-8-12**] at around 2130 when she had burning pain in her LLQ which she describes as the "worst burn ever." She also noticed that her abdomen was distended, and her lower abdomen was red. This morning she was not able to get out of bed and says she was very sick. She felt feverish (though her temperature was 97-98) and had chills. She denies nausea and vomiting. After calling her doctor, she went by ambulance to [**Hospital3 8834**]. On CT scan at the OSH, there was a ventral hernia containing a bowel loop with contrast extravasation from the bowel into the soft tissue of the anterior abd wall as well as air and inflammation in the abdominal wall. She was transferred to the [**Hospital1 18**] for further workup. Past Medical History: PMH: Crohn's dz dx age 16 (chronic prednisone 15 mg daily since [**2130**]), Glaucoma and macular degeneration, Osteoporosis: L3 fracture after fall [**2134**], right fifth metatarsal fracture in the [**2151**], hip fracture in [**2163**], toe fracture in [**12/2170**], Peripheral neuropathy, Depression (recently stopped taking prozac), Chronic pain, GERD, DM, HTN, recurrent UTIs, Hx of Fe def anemia, Obesity PSH: Ileocecal transverse colectomy in [**2129**], "minor bowel surgery" at [**Hospital1 **] ([**2143**]), sigmoid colostomy ([**2150**]), prolapse colectomy ([**2151**]), colostomy reversal ([**2152**]), vertebroplasty for T12 compression fracture ([**2171**]), B/L hip fx's and rod placement Social History: Occupation: Former nurse Drugs: denies Tobacco: denies Alcohol: denies Other: Lives alone but many friends and family nearby. Family History: Brother and father with [**Name (NI) 4522**] disease as well as neuropathy and diabetes. Her father also had coronary artery disease and diabetes, he died of CHF. Her mother also has CHF. Physical Exam: Temp 99.1 HR 118 BP 106/64 RR 18 O2 sat 98% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Obese, soft, nondistended. Very tender to light palpation in LLQ and lower abdomen. Large macular, erythematous rash extending throughout left lower quadrant. Multiple well healed surgical scars. No appreciable abd wall hernia in this obese patient. Ext: No LE edema, LE warm and well perfused. Bilateral rashes. Pertinent Results: IMAGING: TTE [**8-14**]: The left atrium and right atrium are normal in cavity size. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated Tricuspid annular plane systolic excursion is normal (1.7 cm) consistent with normal right ventricular systolic function. There are simple atheroma in the ascending aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. There are three aortic valve leaflets. The mitral valve appears structurally normal with trivial mitral regurgitation. Moderate to severe [3+] tricuspid regurgitation is seen. TTE [**8-14**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. Right ventricular chamber size is normal with borderline normal free wall function. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [**2173-8-17**] B/L LE US: No DVT [**2173-8-18**] Abd US : Small fluid collection underneath an old scar in the left lower quadrant as described above. The area is too small for catheter drainage but aspiration could be performed if clinically warranted. MICROBIOLOGY: [**2173-8-18**] 10:00 pm SWAB Source: abdomen. **FINAL REPORT [**2173-8-23**]** GRAM STAIN (Final [**2173-8-19**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2173-8-23**]): ENTEROCOCCUS SP.. SPARSE GROWTH. STAPH AUREUS COAG +. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | STAPH AUREUS COAG + | | AMPICILLIN------------ <=2 S CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- <=0.25 S PENICILLIN G---------- 8 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 2 S ANAEROBIC CULTURE (Final [**2173-8-23**]): NO ANAEROBES ISOLATED. PATHOLOGY: [**2173-8-14**]: Small bowel, foreign body removal: Predominantly bone fragments with admixed fecal material; single fragment of small intestinal mucosa, within normal limits. [**2173-8-13**] 10:15PM WBC-12.0*# RBC-4.35 HGB-11.4* HCT-33.4* MCV-77* MCH-26.2* MCHC-34.1 RDW-17.2* [**2173-8-13**] 10:15PM NEUTS-79* BANDS-12* LYMPHS-4* MONOS-2 EOS-3 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2173-8-13**] 10:15PM PT-15.6* PTT-24.8 INR(PT)-1.4* [**2173-8-13**] 10:15PM ALT(SGPT)-10 AST(SGOT)-14 ALK PHOS-52 TOT BILI-0.5 [**2173-8-13**] 10:15PM GLUCOSE-109* UREA N-12 CREAT-0.8 SODIUM-133 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-25 ANION GAP-13 Brief Hospital Course: The patient was transferred from an OSH w CT scan showing ventral hernia containing a bowel loop w contrast extrav from bowel into soft tissue of anterior abd wall. The patient was taken to the OR emergently for procedure as above. Intra-operatively, patient was noted to have PEA arrest following closure of abdomen while dressing was being placed. CPR was immediately initiated, atropine was given and she recovered pulse and pressure nicely. Echo showed no evidence of any cardiac dysfunction, except for mild tricuspid regurgitation. She was taken intubated to the SICU at the completion of the case. Neuro: [**Name (NI) **], pt was sedated/given pain control while intubated. She was extubated on post op day #1 and a chronic pain consult was obtained as she was on numerous medications pre op. Pain control was implemented per their recommendations. Long acting opioids and non-narcotic pain medication was used in combination to attain adequate analgesia. When tolerating oral intake, the patient was transitioned to oral Oxycodone along with Gabapentin, fentanyl patch and Lidocaine patch which in combination were effective. CV: As above pt had PEA arrest intra-operatively. Cardiology c/s was obtained and despite extensive workup including repeat TTE, EKGs, telemetry, no etiology of arrest was identified. Electrolytes were optimized as appropriate and no further cardiac abnormalities were appreciated until [**2173-8-20**] when she had PAF as high as 200bpm. She was asymptomatic but did have a low normal potassium and magnesium. These were repleted and she was started on a beta blocker. She remained on telemetry and remained in normal sinus rhythm. Cardiology recommendation was to follow up as an outpatient with Dr. [**Last Name (STitle) 22971**] for discussion of AICD placement. Home cardiac medications were resumed POD1. She also developed some edema and redness of her left lower leg and a duplex scan was done on [**2173-8-17**] which ruled out DVT. Her edema decreased with elevation and antibiotics which prmarily were for her abdominal cellulitis. Pulmonary: Patient was taken intubated to ICU postop given cardiac instability at end of case. Patient weaned ventilator appropriately and was successfully extubated POD1. Following this, pulmonary toilet including incentive spirometry and early ambulation were encouraged. The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Patient was admitted with small bowel perforation within ventral hernia. Repair was performed as stated above. Midline laparotomy wound was left open with packing to heal by secondary intention. Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced to clears POD2, which was tolerated well. She passed flatus on POD3 and had a bowel movement. She was then able to tolerate a diabetic diet without difficulty. She was started on a bowel regimen to encourage bowel movement. Foley was removed on POD#3 and she had no difficulty urinating. Intake and output were closely monitored. Endo: Patient is chronically steroid dependent related to Crohn's disease and was given stress dose steroids [**Date Range **]-operatively. POD2 patient was returned to home dose steroids and this was continued throughout admission. Her blood sugars were monitored routinely and she was placed on her pre op Actos once she tolerated a regular diet. Her sugars required coverage for > 200 at least daily. She was reluctant to start insulin and was instructed to record her blood sugars and follow up in 1 week with her PCP for review and possible medication adjustment. ID: Pre-operatively, the patient was started vancomycin, cipro and flagyl for free bowel perforation. On POD3, patient was noted to have area of fluctuance in abdominal wall. Ultrasound was obtained POD3 showing fluid collection that was I&D'd at bedside. Cultures were sent which revealed enterococcus. She was placed on a 7 day course of Ampicillin IV and later switched to oral Amoxicillin. She remained afebrile and her cellulitis was receding. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs, tolerating a regular, diabetic diet, ambulating, voiding without assistance, and pain was well controlled. She will be discharged with VNA services for abdominal dressing changes [**Hospital1 **]. Medications on Admission: alendronate 70 qWeek, baclofen 20 qid prn, celebrex 200-400', ciprofloxacin 500', citalopram 40', vit b-12 1000 Qmonth, vit D2 [**Numeric Identifier 1871**] 2x/week, estradiol 25 2x/month, fentanyl patch 72hr 100mcg/hr 2 Q2days, folic acid 1', furosemide 20', gabapentin 600 5x/day, gemfibrozil 600 mg'', hydromorphone [**7-13**]''' prn, lantanoprost, lidocaine patch 5% (700 mg/patch), lisinopril 20', loperamide [**1-1**] q4H prn, lorazepam 1''', methylphenidate ER 36-72', metronidazole 1% gel, omeprazole delayed release 20'', oxycodone 30-60''' prn, oxycontin 80'', pioglitazone 15', pravastatin 20', prednisone 20', quetiapine 25-50''', sucralafate 1'''', trazodone 25-100 mg qhs prn, vitamin C calcium carbonate, vitamin D3, flaxseed oil, vitamin E Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO 5 TIMES PER DAY (). 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Hold for SBP < 100, HR < 65. Disp:*90 Tablet(s)* Refills:*2* 10. insulin lispro 100 unit/mL Solution Sig: 0-8 units Subcutaneous ASDIR (AS DIRECTED) as needed for per sliding scale. 11. quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for PRN anxiety. 12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. fentanyl 100 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr Transdermal Q72H (every 72 hours). 15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 16. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO HS (at bedtime) as needed for insomnia. 18. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): thru [**2173-8-29**]. Disp:*20 Tablet(s)* Refills:*0* 19. oxycodone 15 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:*200 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: all care vna Discharge Diagnosis: 1. Small bowel perforation secondary to a foreign body. 2. Cardiac arrest 3. Wound infection 4. Rapid atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were admitted to the hospital with abdominal pain secondary to a bowel perforation from a chicken bone. * You had some problems at the end of the operation with your heart and actually required chest compressions and medication to stimulate activity. Your heart rhythme returned and you were transferred to the ICU for further monitoring. You had one episode of of a rapid, irregular heart beat which is called atrial fibrillation but that resolved with correction of your electrolytes and starting lopressor to slow your rate. Since then you have been in a regular rhythme but you will need to follow up with your doctor for further testing after you recover from the operation. * Your abdominal wound was opened in a few areas to drain fluid collections and you will need to continue dressing changes at home as it closes from inside out. The VNA will help you with that. * Continue to eat a regular diet and stay well hydrated. * Your pain medication can be constipating so make sure that you take stool softeners or a gentle laxative if needed. * The cellulitis on your abdomen is improving but check it daily to assure that the area is getting smaller. If it increases in size or you develop any chills or fevers > 101 please call your doctor or return to the Emergency Room. * Your blood sugars have been elevated at times. Now that your Actos is resumed please check them before each meal and at bedtime, record the results and review them with your PCP in case any modifications are needed. Followup Instructions: Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in 1 week for a wound check. Call Dr. [**Last Name (STitle) **] for a follow up appointment in 1 week to persue further cardiac evaluation and blood sugar assessment. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2173-8-25**] 12:45 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 8084**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2173-9-2**] 10:45 Provider: [**Name10 (NameIs) **] [**Doctor Last Name **] [**Doctor Last Name 22344**], OD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2173-9-3**] 1:00 Completed by:[**2173-8-24**]

[ "682.2", "357.2", "401.9", "936", "E879.8", "V45.72", "V58.69", "733.00", "530.81", "552.21", "997.1", "807.01", "250.60", "278.00", "041.11", "E915", "569.83", "397.0", "427.5", "733.13", "311", "338.29", "V58.65", "041.04", "569.81", "555.9", "787.91" ]

icd9cm

[ [ [] ] ]

[ "86.28", "54.59", "46.73", "54.0", "45.02", "96.71", "99.60", "88.72", "53.51" ]

icd9pcs

[ [ [] ] ]

13988, 14031

6815, 11371

428, 558

14197, 14197

3081, 6792

15882, 16617

2356, 2546

12178, 13965

14052, 14176

11397, 12155

14348, 15859

2561, 3062

374, 390

586, 1464

14212, 14324

1486, 2196

2212, 2340

1,485

132,425

54379

Discharge summary

report

Admission Date: [**2107-6-3**] Discharge Date: [**2107-6-7**] Service: MED Allergies: Macrodantin / Penicillins / Sulfonamides Attending:[**First Name3 (LF) 2641**] Chief Complaint: black stools x 2 weeks Major Surgical or Invasive Procedure: Colonoscopy Esopho-Gastro-Duodenoscopy History of Present Illness: 82 yo female with hx of HTN, chronic afib, s/p repair of ASD and h/o mitral and tricuspid value annuloplasty [**4-21**] presents with 2 weeks black tarry stools. No BRBPR/hemetemesis. Pt reports previous GI bleed one year ago with unknown etiology ( nl EGD and nl colonoscopy). Pt has had sx over the past 2 weeks - increased DOE, dizziness. Denies chest pain and abdominal pain. Pt denies NSAID use. Pt is on Coumadin for A.fib. In ER, Hct on arrival was 21.2 and dropped to 17.7 without transfusion and with minimal IVF. Pt underwent EGD in ER which did not show any source of bleed. She was sent for tagged rbc scan which showed bleeding in mid-ascending colon. Pt was transfused 1 u PRBC while waiting. Pt also recieved Vancomycin and Gentamycin - post EGD Abx, vit K to reverse Coumadin, and IV Protonix. Pt was admitted to MICU for further workup and care. Pt was transfused a total of 4 units in the MICU and had serial Hcts the final being 29.5 today. Pt has colonoscopy [**6-5**] which was negative for bleed. Pt has had BM without signs of bleeding. Pt feels fine today. No N/V/SOB/chest pain/dizziness. Past Medical History: 1) HTN 2) Hypothyroidism 3) Afib 4) ASD repair 5) Gallstones 6) h/o GIB Social History: no tobacco, no EtOH, no IVDU. Lives in [**Hospital3 **]. Has three children. Freelance photographer. Married twice. HCP: [**Name (NI) **] [**Name (NI) 111323**] ( nephew) [**Telephone/Fax (1) 111324**] ( H) Physical Exam: O: vs 98 164/58 65 18 99 % RA gen - lying in bed, NAD, pleasant heent - PERRLA, EOMI, moist mucus membranes cv - irreg, irreg, no murmurs lungs - cta B abd - soft, NDNT, + BS ext - no C/C/E Pertinent Results: [**2107-6-3**] 09:30AM WBC-5.5 RBC-2.18*# HGB-6.3*# HCT-20.7*# MCV-95 MCH-28.9# MCHC-30.5* RDW-14.3 [**2107-6-3**] 09:30AM PLT COUNT-231 [**2107-6-3**] 09:30AM %HbA1c-4.7 [**2107-6-3**] 09:30AM POTASSIUM-4.0 [**2107-6-3**] 09:30AM GLUCOSE-129* [**2107-6-3**] 11:15AM PT-19.9* PTT-32.4 INR(PT)-2.6 [**2107-6-3**] 11:15AM PLT COUNT-229 [**2107-6-3**] 11:15AM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL SPHEROCYT-OCCASIONAL [**2107-6-3**] 11:15AM NEUTS-84* BANDS-0 LYMPHS-10* MONOS-5 EOS-0 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [**2107-6-3**] 11:15AM WBC-4.5 RBC-2.20* HGB-6.5* HCT-21.2* MCV-96 MCH-29.6 MCHC-30.8* RDW-14.5 [**2107-6-3**] 11:15AM CALCIUM-8.9 PHOSPHATE-3.2 MAGNESIUM-2.1 [**2107-6-3**] 11:15AM CK-MB-NotDone [**2107-6-3**] 11:15AM cTropnT-<0.01 [**2107-6-3**] 11:15AM CK(CPK)-74 [**2107-6-3**] 11:15AM GLUCOSE-109* UREA N-27* CREAT-0.9 SODIUM-140 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13 [**2107-6-3**] 05:20PM HCT-17.7* Brief Hospital Course: A/P: 82 yo female with PMH of HTN, Hypothroid, A-fib, GIB, here with GI bleed Hct drop to 17.7. source was unclear ??AVMs. 1) GI - Pt with no bleeds since MICU. Hct [**6-7**] - 31.6 and so was discahrged home. 2) A. fib - Did well. with no acute issues. We Restarted Coumadin [**6-6**]. 3) Hypothyroid - continued on Synthroid 125 mcg QD. 4) Proph - Pantaprozole 40 mg po q24. Medications on Admission: 1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 3. Warfarin Sodium 1 mg Tablet Sig: 0.5 Tablet PO QD (once a day Discharge Medications: 1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 3. Warfarin Sodium 1 mg Tablet Sig: 0.5 Tablet PO QD (once a day). Discharge Disposition: Home Discharge Diagnosis: Gastrointestinal Bleed Discharge Condition: Good Discharge Instructions: Contact physician if you experience further blood in stools, dark stools, fever > 100.5, shortness of breath/chest pain or dizziness. Followup Instructions: Follow up with your primary care provider [**Last Name (NamePattern4) **] 2 weeks - Call for appt.

[ "285.1", "455.0", "427.31", "535.51", "V58.83", "272.0", "V45.01", "562.12", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "92.04", "99.04", "45.23", "45.16" ]

icd9pcs

[ [ [] ] ]

3951, 3957

3056, 3437

264, 305

4024, 4030

1999, 3033

4212, 4314

3706, 3928

3978, 4003

3463, 3683

4054, 4189

1787, 1980

202, 226

333, 1448

1470, 1543

1559, 1772

13,913

124,300

54046

Discharge summary

report

Admission Date: [**2152-10-1**] Discharge Date: [**2152-10-4**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor Last Name 10493**] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 87 yo lady with complex PMH most notable for CAD with known 3VD (not a PCI/CABG candidate), diastolic HF, severe AS (VA 0.8), colon CA s/p colectomy and a questionable history of COPD who presents to ED with SOB. Pt initially treated as COPD exacerbation with the administration of steroids. However Pt with a ECG showing possible STD in anterior leads and TropT 2.09, as well as a CXR consistent with CHF. Pt decompensated and required non-invasive positive pressure ventilation as well as started on Nito gtt and given a dose of Lasix IV. Given NSTEMI, hep gtt started and Pt given an ASA. Initiation of these modalities resulted in improvement of symptoms. Pt transferred to CCU for further monitoring and management. ROS: One to two days of "indigestion" and belching that seemed to resolve after SL NTG. Additionally, Pt described worsening SOB over the past 12-24 hours with no clear precipitant. Denies any CP, DOE, syncope. Past Medical History: 1. Coronary artery disease (3VD no prior intervention) 2. Colonic adenocarcinoma; status post right colectomy. 3. History of myocardial infarction. 4. Severe Aortic stenosis (0.8) 5. Congestive heart failure (LVEF 60%). 6. Type 2 diabetes mellitus. 7. Rheumatoid arthritis. 8. Gastroesophageal reflux disease. 9. History supraventricular tachycardia. 10. Status post appendectomy. 11. Status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. Social History: Pt is widowed and lives alone in a senior housing unit, with recent visits by her 4 adult children. Quit Tob 50 years ago, no EtOH. Family History: NC Physical Exam: VS: 95.3, 129/71, 64, 18 100% CPAP 10/5 50% PE: elderly lady, appearing mildly comfortable on CPAP PERRL (surgical R), MMM, OP wnl, no dentures supple, JVP difficult to appreciate, radiating murmur, delayed upstroke RRR, S1/S2, [**1-22**] musical peaking SM at best at USB decreasd BS R>L, bilateral basilar rales [**Date range (1) 5082**] with occ wheeze soft, NT, ND, NABS ext without edema, warm/well perfused, 1+PT, DP dop, RA degenerative changes A&O, CNs roughly intact Pertinent Results: FINDINGS: The heart and mediastinal contours are stable. The aorta is unfolded. There is increased hilar and perivascular haziness, consistent with interstitial edema. There are bilateral pleural effusions. There are again demonstrated pleural plaques. There is left retrocardiac atelectasis versus consolidation. Osseous structures are unchanged, again with evidence of old left proximal humerus fracture. IMPRESSION: 1) Congestive heart failure 2) Bilateral pleural effusions 3) Left retrocardiac atelectasis versus consolidation pneumonia Brief Hospital Course: Ms. [**Known lastname 110790**] is an 87 year old female with known 3VD non-surgical and PCI candidate in the past, diastolic heart failure, severe aortic stenosis who was admitted to CCU with NSTEMI and CHF. She was called out to the floor as soon as her cardiac issues stabilized. 1) CAD: Pt with cardiac catherization in [**2146**] which showed 3VD unable to be intervened upon and a non-surgical candidate who has been medically managed. The patient's home regimen includes BB, ASA, statin. On presentation to the ED, Ms.[**Known lastname 110790**] had a NSTEMI given positive cardiac enzymes. The patient did well with nitroglycerin, however given her severe AS it was minimized and stopped upon arrival to the CCU. The patient also started on heparin gtt and continued overnight until it was stopped in light of being pain free and CE trending down. Overnight BB was held given severe CHF and restarted in AM as Pt improved steadily. Once stable, Ms. [**Known lastname 110790**] [**Last Name (Titles) 8337**] her beta blockade which was titrated down for bradycardia. She was also restarted on an ACE I once her renal function improved. 2) Pump: Pt with diastolic dysfunction with LVEF 60% on recent echo, however limited forward flow given AS/MR. The patient was clearly volume overloaded in heart failure, some of which may have been secondary to dietary indiscretion. Ms. [**Known lastname 110790**] did well with CPAP temporarily and was gentled diuresised with Lasix. Afterload reduction was kept to a minimum given severe AS. The patient also not on an ACEi as outpt given preserved systolic function and not started on one initially on admission given [**Doctor First Name 48**]. She [**Doctor First Name 8337**] gentle diuresis well without hypotension. A new echo was obtained which showed an EF > 55% and she was started on an ACE I to prevent remodeling. 3) Valves: Pt with severe AS (area 0.8 cm2) and moderate MR on recent echo. Pt was minimally afterload reduced and gently diuresised. 4) Rhythm: NSR without active issue during hospitalization. 5) Resp: Pt in respiratory distress on presentation. Initially treated as COPD exacerbation in ED with little improvement. CXR consistent with CHF. Pt decompensated requiring initiation of CPAP, nitro gtt and lasix. Pt respnded well and had good resolvement of symptoms. Pt clearly vol overloaded with CHF. Upon arrival to CCU, Pt taken of CPAP and did very well on just a ferw liters via NC. Resp status improved as diuresis continued. At discharge, she had no oxygen requirement. 6) Renal: Pt with normal renal function at baseline (Cr 1.1), however on presentation Cr was 2.0. Pt was making good urine and electrolytes all normal. Pt most likely suffering from [**Doctor First Name 48**] secondary to decreased perfusion in the acute setting. Her renal function improved with a creatnine of 1.5 at discharge. Her creatinine continued to trend down despite adding an ACE I at the end of her hospitalization. 7) Anemia: Pt with Hct 30 on admission below baseline that trended down to 26 the following morning for which she recieved a unit of PRBCs. She also received another unit before discharge and [**Doctor First Name 8337**] both transfusions well. 8) Rheumatoid arthritis: Ms. [**Known lastname 110790**] was continued on her prednisone. Her methotrexate is Q week and so was not administered. The patient received both the flu vaccine and pneumovax before discharge. Ms. [**Known lastname 110790**] was discharged in good condition to her home with VNA services. Medications on Admission: Lasix 40 PO qd Lopressor 25 [**Hospital1 **] ASA 81 qd Potassium 40meq qd Lipito 10 mg qd MTX once a week Prednisone 5mg qd Protonix 40mg qd Actonel 35mg weekly Colace Vicodin PRN Albuterol PRN Ambien PRN Discharge Medications: 1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Potassium Chloride 20 mEq Packet Sig: Two (2) PO once a day. 8. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week. 9. Methotrexate 2.5 mg Tablet Sig: One (1) Tablet PO once a week. 10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 12. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 13. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home With Service Facility: [**Company **] Discharge Diagnosis: NSTEMI CHF GERD Rheumatoid arthritis colon cancer s/p colectomy aortic stenosis CHF with EF >55% Arrhythmia osteoporosis MI _3 vessel disease tuberculosis s/p bilateral knee replacement history of SVT GIB s/p appendectomy s/p TAH/BSO COPD R catarct surgery Discharge Condition: good 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 Call your physician if you experience chest pain, shortness of breath, swollen ankles, or fainting. Continue your home medications plus you will be adding lisinopril once per day. You've gotten both the flu vaccine and the pneumovax during this hospitalization. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern4) 7176**], MD Where: LM [**Hospital Unit Name 4275**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2153-1-29**] 1:00 Provider: [**Name10 (NameIs) 2052**],[**First Name3 (LF) **] [**Location (un) 2788**] CARDIOLOGY - PPS BILLING Where: [**Location (un) 2788**] CARDIOLOGY - PPS BILLING Date/Time:[**2153-3-27**] 1:20 Please call your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 10492**] for a follow up appointment. He may want to check your chemistry panel since you've started an ACE inhibitor. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]

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icd9cm

[ [ [] ] ]

[ "99.04", "93.90" ]

icd9pcs

[ [ [] ] ]

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3008, 6576

267, 273

8218, 8224

2440, 2985

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1923, 1927

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6602, 6808

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224, 229

301, 1251

1273, 1757

1773, 1907

46,263

102,405

39434

Discharge summary

report

Admission Date: [**2183-9-15**] Discharge Date: [**2183-10-7**] Date of Birth: [**2114-7-8**] Sex: M Service: NEUROLOGY Allergies: Phenergan Attending:[**First Name3 (LF) 2569**] Chief Complaint: Mental status changes and headache Major Surgical or Invasive Procedure: -Right craniotomy to biopsy brain tissue underlying large right IPH. -Wound vac changes and debridement (bedside) by Gen Surgery --> now changed by nursing (q3d) History of Present Illness: Initial presentation to neurosurgery: Pt is a 69m who was found to be a little confused today at his rehab facility. He was at rehab recovering from abdominal wall reconstruction 10 days ago. He currently has a VAC over his abdominal wound. He has been on Coumadin and heparin at this facility for treatment of DVT and PE. His INR today is 1.6. CT head at OSH showed right posterior parietal hemorrhage measuring 5mm with no report of midline shift. He did not receive FFP, Vit K or any other agents for reversal of his INR and was noted to be hypertensive on arrival with SBP in the 250's. He currently complains of headache and denies weakness/numbness of extremities, word finding difficulty or facial weakness. Initial Neurology Fellow's HPI: Mr. [**Known lastname 24735**] is a 69-year-old, L-handed man with a history of hypertension, DVT/PE on warfarin and heparin, and multiple abdominal surgeries who was transferred to [**Hospital1 18**] from a rehab facility yesterday ([**2183-9-15**]) with headache and confusion. CT revealed a right fronto-parietal hemorrhage. The patient reports that the headache started shortly after his operation on [**2183-8-20**], which took place at [**Hospital **] Hospital; he was transferred to a rehab facility from [**Hospital **] Hospital. He describes the headache as encompassing his entire head, it was associated with nausea, but no vomiting. The patient also describes confusion, specifically having difficulty remembering what happened on a day-to-day basis. He reports having seen "little furry things," brown and [**Location (un) 2452**] in color, which sometimes looked like sunflowers. He knew they weren't real and thought they must be "blood clots" in his eyes. A CT was performed at [**Hospital **] Hospital, which revealed a 5mm R posterior parietal hemorrhage with no midline shift. He received no FFP or vitamin K at the OSH and was found to be hypertensive on arrival to [**Hospital1 18**] with SBP in the 250s, INR of 1.8, and PTT of 27.7. The patient currently denies numbness of the face or extremities, but reports that he's felt somewhat weak and clumsy over the past few days, with trouble, for example, in opening his mobile phone. He also reports that his speech is slower than usual, with difficulty putting his thoughts into words. He denies headache currently and reports that his memory has improved, but that he still can't clearly remember the events of the past month. He denies abnormal perceptions. Past Medical History: - s/p hiatal hernia repair [**2182-11-17**] c/b post-op infections, s/p >7 surgeries for debridement - DVT/PE following hiatal hernia repair, treated with warfarin (and with heparin at recent stay at OSH) - "coma" following one of above surgeries; patient denies stroke - hypothyroidism - HTN - Afib - GERD - prostate CA s/p protatectomy 2 years ago; no hx radiation or chemotherapy treatment - s/p L nephrectomy and adrenalectomy ~40 years ago for renal problem caused by congenital malformation of kidney - chronic kidney disease Social History: Was at rehab prior to admission. Patient is married and lives with his wife. [**Name (NI) **] is a non-smoker (quit when he was a teenager). He had one alcoholic drink per month. Family History: No known history of strokes or heart disease. No known history of dementia or other neurologic disease. Physical Exam: On Admission T-98.2, HR-86, BP-137/72, RR-22, O2Sat-95% on 2L by NC Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally anteriorly and laterally Abd: Wound dressing in place Ext: no edema Neurologic examination: Mental status: General: alert, awake, normal affect, occasional loss of attention in interview with difficulty remembering topic Orientation: oriented to person, place, date, situation Attention: able to go backwards with DOW Executive function: follows simple axial and appendicular commands: closes and opens his eyes, shows me the tongue, points to ceiling, lifts R arm and L arm Memory: recalls current president and President [**First Name9 (NamePattern2) **] [**Last Name (un) 2450**], but forgot that [**Hospital1 1806**] was president before [**First Name9 (NamePattern2) **] [**Last Name (un) 2450**] and after [**Last Name (un) 2450**] senior; remembered [**3-19**] words after 5 minutes Speech/Language: fluent w/o paraphasic (phonemic or semantic) errors or blocking, but with occasional slowness; comprehension, repetition, naming normal; able to read, but not able to write with dominant L hand Praxis/Agnosia: able to demonstrate how to brush teeth and to use a hammer Patient has mild left side neglect Cranial Nerves: II: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Left hemianopia III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V1-3: Sensation intact V1-V3. VII: Facial movement symmetric. VIII: Hearing intact to finger rub bilaterally. IX & X: Palate elevation symmetric. Uvula is midline. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius full strength bilaterally. XII: Good bulk. No fasciculations. Tongue midline, movements intact. Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor Pronator drift present on L. Delt; C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7 Left 4- 4+ 4- 4 4- Right 5 5 5 5 5 . IP: Quad: Hamst: Dorsiflex: [**Last Name (un) 938**]:Pl.flex Left 5 5 5 5 5 5 Right 5 5 5 5 5 5 . Deep tendon Reflexes: . Biceps: Tric: Brachial: Patellar: Achilles Toes: Right 2 2 2 2 2 DOWNGOING Left 2 2 2 2 2 DOWNGOING . Sensation: Intact to light touch and pinprick on R; diminished light touch and pinprick on L, upper and lower extremities. . Coordination: finger-nose-finger normal on R, slow with overshoot on L Gait: deferred Romberg: deferred Pertinent Results: ADMISSION LABS: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2183-9-18**] 03:41 16.0* 3.23* 10.1* 29.9* 93 31.3 33.8 16.3* 648 [**2183-9-15**] 06:00PM GLUCOSE-87 UREA N-18 CREAT-1.6* SODIUM-139 POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-23 ANION GAP-14 DISCHARGE LABS: CT HEAD [**9-15**] Large right frontoparietal intraparenchymal hemorrhage with surrounding edema and mass effect. No significant shift of midline structures. An underlying mass lesion cannot be excluded. MRI is pending for further evaluation. MRI/A Brain [**9-16**] There is a right parietal intraparenchymal lesion suggestive of recent acute hemorrhagic episode on a background of chronic bleed or bleeding episodes. An occult vascular malformation would be the likely etiology. Further areas of small hemorrhages in the right cerbral hemisphere and right cerebellum may represent amyloid angiopathy or multiple arteriovenous malformations or a combination of both. It would be useful to compare any previous studies and followup imaging is advised for assessment of evolution Cerebral carotid arteriogram [**9-23**]: pt underwent cerebral arteriography for evaluation of right parietal hemorrhage. This study failed to demonstrate any evidence of AV vascular malformations, AV fistulas, aneurysms,vasculitis or significant vascular stenosis.The patient withstood the procedure well and had no immediate complications. MRI [**9-24**]: IMPRESSION: Right temporoparietal hemorrhagic lesion with perilesional edema, unchanged over the short interval. NCHCT [**9-24**] Expected post-operative changes status post resection of right parietal mass with a small amount of fluid, air, and post-operative blood within the resection cavity. Stable vasogenic edema surrounding the resection cavity causes minimal mass effect on the atrium of the right lateral ventricle. Small to moderate amount of right frontal pneumocephaly. MRI [**9-26**]: Since the previous MRI of [**2183-9-24**], patient has undergone resection of right parietal hemorrhagic lesion with expected post-surgical changes and blood products and pneumocephalus. No evidence of enhancement seen in this region. Enhancement in the left occipital lobe along the surface of the brain is unchanged. No acute infarcts or hydrocephalus. Other findings as described above are unchanged. Expected post-surgical appearance after right parietal mass resection with edema and a decreased amount of blood surrounding the surgical site. Interval decrease in the amount of pneumocephalus. No new hemorrhage. *** CT Chest/Abdomen/Pelvis [**9-16**]: No primary lesion CT Chest/Abdomen/Pelvis [**9-27**]: 1. Decreased size of horse-shoe shaped subcutaneous fluid collection adjacent to the anterior abdominal wall wound, which is otherwise little changed in appearance. 2. Status post IVC filter placement, with new evidence of thrombus in the IVC, right external iliac vein, and probably also in the left external iliac vein. IVC filter placement [**2183-9-23**]: IMPRESSION: 1.IVC venogram demonstrating single IVC with no evidence of thrombus. 2.Successful placement of an OptEase IVC filter below the level of the renal veins via the right common femoral venous approach. The OptEase filter can be retrieved after two weeks or can stay as a permanent filter. LEDs [**2183-9-29**]: 1. Incompletely occlusive thrombosis of right popliteal vein. 2. Dampening of normal respiratory variation within the right common femoral vein compared to the left is consistent with the right external iliac venous thrombosis previously seen on CT TTE [**9-26**]: The left atrium is mildly 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 65-70%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic 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. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Impression: no obvious intracardiac shunt seen on suboptimal imaging Brief Hospital Course: Initial hospital course on neurosurgery service: Patient presented to the ER at [**Hospital1 18**] as a transfer from an OSH. He had previously been at rehab and had been complaining of a headache since thursday as well as difficulty using his left hand. He presented to an OSH last evening [**9-15**] with complaints of mental status changes as well as continued headache. Imaging was done which showed a 5cm Right posterior parietal hemorrhage. He was then transferred to [**Hospital1 18**] for neurosurgical evaluation. Upon arrival a repeat CT scan of the head was done which showed stable appearance of the Right parietal blood, he had a left pronator drift but was otherwise neurologically intact, and was admitted to the ICU. MRI of the head with and without as well as an MRA of the brain was done overnight which showed a right parietal intraparenchymal lesion. His INR was 1.6 upon admission secondary to his coumadin use and as a result he received 1 unit fo platelets as well as 1 unit of FFP. On the morning of [**9-16**] on rounds he was noted to be neurologically intact except for a left pronator drift. His wound vac dressing from his recent abdominal surgery was in place but not connected to a vac unit. The wound care nurse evaluated him and removed the vac and found necrotic tissue. As a result, general surgery was consulted who removed the vac, and debrided necrotic tissue at the bedside. They also decided to aspirate the abdmoinal fluid collections. This was thought to be the source of the elevated WBC. Given the nature of his bleed and symptoms Stroke neurology was consulted. They were highly suspicious that this was likely a hemorrhagic stroke, and not a mass. The decision was made to obtain an MRI which revealed a mass under the hemorrhage. He will go to angiogram on Tuesday to have the lesion embolized and then resected on the following day. An IVCF will also be placed in IR by general surgery. On [**9-19**], patient was intact and no further debridements of his abdomen were done. He will remain in the ICU for monitoring until his angiogram. His dilantin level was 5.0 in the morning, a 300mg bolus was given. Pt underwent diagnostic cerebral angiogram on [**9-23**] to evaluate for vascular malformation or other lesions. This proved to be negative and pt was transfered to the floor in stable condition. He was seen post angio and was doing well. His groin site was clean and dry with no hematoma and he had good distal pulses and no change in his neurological status. Pt was made NPO on this night in preparation for craniotomy on [**9-24**] to evaluate for underlying lesion as his MRI was suspicious for hemorrhagic mass. On [**9-24**] pt underwent R sided craniotomy for exploration of his occiptal bleed. Tissue sent was consistent with hemorrhagic tissue and showed no malignancy. Pt was intubated post operatively but required re-intubation as his oxygenation was poor. He was transfered to the ICU for post operative care including strict blood pressure control and q1 neuro checks. On post op exam pt was following commands and moving all extremities. His incision was clean and dry with no active drainage. Pt was transfered to the neurology service on [**9-25**] for further care and medical managment of his stroke. He was transferred to the care of Neurology on [**9-25**], finding a bed on the floor on [**9-26**]. Surgery had signed off and signed back on for continued care of vacuum dressings. Floor (step-down unit) [**Hospital 878**] hospital course: Re. Neuro issues, There were no complications after the craniotomy; post-operative imgaing (MRI and HCT) looked good, neurologic exam remained stable to improved, and his staples and sutures were removed on [**2092-10-2**]. Post-op dexamethasone was tapered by [**9-27**] and Dilantin was tapered to off prior to discharge. Re. ID issues, Intraabdominal wound infection continued to improve, both radiographically and systemically, with the patient remaining afebrile both on, and then off IV abx (vanc + meropenem). These were stopped on [**9-30**] under the advice of the following inpatient ID consult service. His wound dressing was changed q3d initially by surgery, and then by wound-care nursing after ACS signed off the case on [**10-2**]. Re. heme issues, an IVC filter was placed while the patient was on Nsgy service. This became clotted (pt off a/c after IPH/crani), first evidenced on CT with contrast (obtained to trend abdominal wound), and later by RLE DVT evident on exam and LED. Thus, he was restarted on heparin bridge to warfarin on [**10-3**], with low-therapeutic PTT goal (40-60). INR was up to 1.5 at the time of discharge, dosing warfarin 10mg/d at that point ([**10-6**]). Per Hematology c/s, a hypercoagulability workup should be re-initiated (prot C/S, antithromb, FactV Leiden) after discharge; slightly abnormal levels drawn in the acute setting are of unknown significance. Pt was started on ASA 81. Also note that H&H trended down (Hb from 11s to [**8-25**]) gradually over the course of this hospitalization. Guiac negative. Thought [**2-18**] phlebotomy plus blood loss with craniotomy plus oozing with debridment/wound vac changes. Not transfused. Re. cardiologic issues, he was continued on 200mg [**Hospital1 **] amiodarone for afib. Re. endo issues, he was continued on Synthroid previous dose. Re. psychiatric issues, the patient's Wellbutrin was held during this admission, and should be restarted under the guidance of a psychiatrist/Neurologist if desired (this medication has been associated with seizures / reduced seizure threshold). He will follow up in [**Hospital1 18**] clinics with Dr. [**Last Name (STitle) **] (Neurosurgery) and with Dr. [**Last Name (STitle) **] (stroke/vascular Neurology). He will transfer his ID and wound care follow up to [**Hospital **] hospital, per his convenience. Our ID service will supply contact information for these services. Medications on Admission: Coumadin 4mg daily Ativan 1mg q6 PRN Zinc 220mg daily MVI 1 tab daily Synthroid 50mcg daily Lansoprazole 30mg daily Imipenem 250mg q8 Vit C, amiodarone 200mg daily Discharge Medications: . 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. Levothyroxine 50 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 3. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 4. Ascorbic Acid 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 5. Zinc Sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY (Daily). 6. Glucagon (Human Recombinant) 1 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 7. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 8. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 9. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas-discomfort/ileus. 12. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q12H (every 12 hours). 13. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 14. Psyllium 1.7 g Wafer [**Hospital1 **]: One (1) Wafer PO DAILY (Daily) as needed for constipation. 15. Warfarin 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4 PM. 16. Phenytoin 125 mg/5 mL Suspension [**Hospital1 **]: One (1) PO Q24H (every 24 hours). 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breathe. 18. Collagenase Clostridium hist. 250 unit/g Ointment [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 19. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 20. Heparin (Porcine) in D5W 12,500 unit/250 mL Parenteral Solution [**Hospital1 **]: One (1) Intravenous ongoing: Currently at 1200 units/ hr: check ptt next time at 6:00 pm, please Stop when INR is [**2-19**]. Discharge Disposition: Extended Care Facility: [**Hospital3 1122**] Center - [**Hospital1 3597**] Discharge Diagnosis: Right Parietal Hemorrhage Discharge Condition: HDS/VSS. AAOx3. Afebrile without leukocytosis x greater than one week prior to discharge, off IV abx x 6d. Neuro exam is notable for stable mildly impaired graphesthesia in Right hand, extiction to DSS on left (visual and somatosensory). And left-hand clumsiness/ataxia. Somewhat flat/depressed affect (at-home buproprion has been held [**2-18**] c/f seizure threshold), but improving. Wound vac packing to be changed q3d and followed up by surgery at [**Hospital **] Hospital. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance. Discharge Instructions: You have had a large right frontoparietal intraparenchymal hemorrhage with surrounding edema and mass effect that required surgery ?????? 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. Followup Instructions: (1) Please call [**Telephone/Fax (1) 2574**] to schedule an appointment with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Stroke Neurology, [**Hospital1 18**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]). (2) Neurosurgery: ??????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 without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ****** (3)ID AND GEN SURGERY will F/U at [**Hospital 420**] HOSPITAL [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

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icd9cm

[ [ [] ] ]

[ "38.91", "88.41", "38.93", "86.28", "01.14", "86.01", "01.59", "38.7" ]

icd9pcs

[ [ [] ] ]

19899, 19976

11314, 14824

305, 470

20046, 20526

6708, 6708

21167, 21951

3761, 3867

17475, 19876

19997, 20025

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231, 267

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5308, 6689

6724, 6992

20541, 20661

4271, 4271

3013, 3546

3562, 3745

23,788

141,071

16471

Discharge summary

report

Admission Date: [**2121-7-24**] Discharge Date: [**2121-7-29**] Date of Birth: [**2041-3-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2159**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: EGD History of Present Illness: 80yoM with h/o CAD s/p 3v CABG [**2116**] who presented with hematemesis, syncope, and guiaic positive stool. Patient was in his usual state of health, until developing some mid-epigastric pain. He said he began to feel dizzy and as his wife was calling the ambulance he past out in the bathroom (did not hit his head). In the ambulance on the way to [**Hospital3 46817**], the patient said he vomited bright red blood. Per chart review, on arrival to OSH ED T 97.6 HR 88 BP 138/76 RR 18 99%RA. He again vomited bright red blood and passed a formed guiaic positive stool. Hct was 32. TWI were noted on ECG in the inferolateral leads. Cardiac enzymes were negative. He was transfused one unit PRBC and stated on an octreotide gtt, and transferred to [**Hospital1 18**] for further evaluation. In the [**Hospital1 18**] ED T 98.1 HR 85 BP 128/76 R 18 94%RA. NG lavage was positive for bright red blood, and the NG tube left in place. He was evaluated by GI who planned to perform EGD once second set of cardiac enzymes were negative. . Briefly, the patient was admitted to the [**Hospital1 18**] ICU and had an EGD that revealed a large ulcer just above GE junction in the esophagus, he had a vessel cauterized. He was aggressively hydrated, given PPI, transfused a total of 3 units (to maintain his hct > 28), had some of his medications held (ASA, plavix, labetalol and felodipine). His syncope was thought to be due to his GIB, but he was ruled out for MI. . On transfer to floor, pt. denies cp, sob, dizziness, weakness, palpitations, nausea, vomiting, abdominal pain. The patient says he is feeling well and has no current complaint. Past Medical History: CAD s/p 3v CABG [**2116**] (LIMA to LAD, SVG to PDA, SVG to OM) HTN Hypercholesterolemia Anemia Carotid artery stenoses (U/S [**11/2120**] R ICA possible occlusion, moderate stenosis R ECA, L ICA) Social History: lives on [**Hospital3 4298**] with his wife; originally from Poland, immigrated in [**2063**], retired painter Tob: quit 4yrs ago, previously smoked 3ppd x 60yrs EtOH: 3beers/week Illicits: none Family History: father d. of pneumonia mother d. [**Age over 90 **]yrs sister d. [**Age over 90 **]yrs Physical Exam: BP: 139/61, HR: 87, RR 17, 97% RA Gen: comfortable, NAD, in bed HEENT: anicteric, MMM, OP clear, EOMI Neck: supple, no LAD, no JVD, right carotid bruit CV: RRR, no mrg Resp: CTAB Abd: +BS, soft, NT, ND, no masses, no HSM Ext: no edema, 2+ DPs, pneumoboots in place Neuro: A&Ox3, CN II-XII intact, strength 5/5 throughout, sensation intact Pertinent Results: Labs on admission [**2121-7-24**] 10:43PM HCT-28.7* [**2121-7-24**] 12:51PM CK(CPK)-107 [**2121-7-24**] 12:51PM CK-MB-6 cTropnT-<0.01 [**2121-7-24**] 09:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2121-7-24**] 08:41AM GLUCOSE-133* UREA N-55* CREAT-1.3* SODIUM-143 POTASSIUM-5.5* CHLORIDE-113* TOTAL CO2-25 ANION GAP-11 [**2121-7-24**] 08:41AM WBC-9.5 RBC-3.63* HGB-11.5* HCT-32.6* MCV-90 MCH-31.6 MCHC-35.1* RDW-15.1 . Pertinent results: CXR: IMPRESSION: No acute cardiopulmonary process . Head CT: IMPRESSION: 1. No acute intracranial hemorrhage. 2. Arachnoid cyst of the right middle cranial fossa measuring 4.5 cm in its greatest diameter. . Abd xray: IMPRESSION: 1. No free intraabdominal air. 2. Left pleural calcification. 3. Promient appearance of the bladder with surrounding lucency may be technical. However, CT of the pelvis is suggested for further evaluation . CT pelvis: IMPRESSION: 1. No evidence for bladder pathology. 2. Enlarged prostate and sigmoid diverticulosis. . EGD: EGD-large ulcer just above GE junction in the esophagus . EChO: Conclusions: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 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.] There is no pericardial effusion. Brief Hospital Course: This is an 80 yoM with h/o CAD presenting with hematemesis and syncope, found to have a bleeding esophageal ulcer which required cauterization. . 1) Upper GI Bleed: Patient was admitted on aspirin and plavix, and per EGD found to have an ulcer that had a vessel which was cauterized. He was followed by medicine and GI, and for protection continued on a [**Hospital1 **] PPI (pantoprazole). His hematocrit was followed, and he was transfused red cells to maintain his a hematocrit above 28. At discharge his hematocrit was stable, and his hemodynamics were stable as well. Per GI, he should have his ASA and plavix held for life, but with his history of CAD restarting ASA 81mg can be considered at 1 week post discharge, and restarting plavix not only for status post CABG but for carotid stenosis, can be decided by his PCP, [**Last Name (NamePattern4) **]. [**Name (NI) 46818**] in [**Hospital3 4298**]. Hematocrit should be rechecked soon after discharge. . 2) Syncope: The patient's syncope on admission was attributed to hypovolemia, secondary to his upper GI bleed. Other work-up was pursued, and he did not exhibit signs of arrythmia on telemetry, was ruled out for an MI, and his ECHO lacked significant valvular pathology. The patient has known carotid stenosis, that should be further addressed as an outpatient. On discharge, the patient was stable and without symptoms of pre-syncope. . 3) Coronary artery disease: The patient has a known history of CAD, and was ruled out for an MI. He had no symptoms during his course and was continued on atorvastatin, and labetolol. As above, because of his risk for bleed, his aspirin and Plavix, were held. Risk/benefit needs to be considered with restarting anti-platelet therapy. . 4) Hypertension: As the patient presented with a GI bleed, his anti-hypertensives were initially held. Once he was hemodynamically stable, his labetolol was titrated up to pre-admission doses. His felodipine and lasix were held, as he was normotensive, and restarting these should be done as an outpatient. . 5) Hypercholesterolemia: Stable with atorvastatin. Medications on Admission: Labetalol 200mg [**Hospital1 **] Felodipine 5mg [**Hospital1 **] Zantac 150mg daily Lasix 40mg daily Lipitor 60mg daily Aspirin 81mg daily Iron daily Plavix 75mg daily Advair 250/50 daily [**Last Name (LF) 46819**], [**First Name11 (Name Pattern1) 504**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary 1. Upper GI bleed, secondary to an esophageal ulcer. . Secondary 2. Anemia 3. Hypertension Discharge Condition: stable, tolerating medications, ambulating Discharge Instructions: 1. Please take all medications as prescribed. Please note that we have stopped two of your medications, Aspirin 81mg and Plavix 75mg. We also have stopped your Lasix and Felodipine. These may be restarted at the discretion of your Primary Care Physician. 2. Please see your doctor, Dr.[**Name (NI) 46820**] in [**Location (un) **], Wednesday, [**2121-7-30**] at 10:30 AM for a follow-up after discharge from the hospital. 3. Please return to the hospital for vomiting, unable to take medications, uncontrolled fevers, black tarry stools or bright red blood per rectum or breathing difficulties. Followup Instructions: 1. You have an appointment with Dr.[**Name (NI) 46820**], your primary care physician, [**Name10 (NameIs) **] Wednesday, [**2121-7-30**], at 10:30am. ([**Telephone/Fax (1) 36558**]. 2. You had stool that was guaiac positive, while this may be secondary to your upper GI bleed, you should discuss with your doctor the need for a colonoscopy. 3. We held your aspirin and plavix, discuss with your doctor or cardiologist the need to restart this given your significant risk of bleeding. 4. We held your felodipine and your lasix as your blood pressure was low, discuss restarting these with Dr.[**Name (NI) 46820**]. 5. You have carotid bruits, discuss with Dr.[**Name (NI) 46820**] the need for another study to confirm the degree of stenosis. 6. You are on pantoprazole (a proton pump inhibitor) for your bleed, discuss with Dr.[**Name (NI) 46820**] the need for once versus twice a day dosing, for longterm management of your ulcer. 7. You have been scheduled for a follow-up upper endoscopy on Wednesday, [**2121-8-13**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**] and Dr. [**First Name (STitle) **] [**Name (STitle) **] on the [**Hospital Ward Name 517**] at 1pm arrival time. Please call ([**Telephone/Fax (1) 2233**] with questions about this appointment. 8. You have been scheduled for a [**Hospital 702**] [**Hospital **] Clinic Appointment to discuss the results of the upper endoscopy on Wednesday, [**2121-8-20**] at 2pm with Dr. [**First Name (STitle) **] [**Name (STitle) **] in the [**Hospital Ward Name 23**] Building, [**Location (un) **], [**Hospital Ward Name 516**].

[ "V45.81", "433.30", "V42.2", "530.21", "396.3", "401.9", "493.90", "285.1", "276.52", "272.0", "398.91" ]

icd9cm

[ [ [] ] ]

[ "99.04", "42.33" ]

icd9pcs

[ [ [] ] ]

7953, 7959

4771, 6880

327, 333

8102, 8147

3436, 3488

8790, 10411

2452, 2541

7248, 7930

7980, 8081

6906, 7225

8171, 8767

2556, 2898

276, 289

362, 2002

3497, 4748

2024, 2223

2239, 2436

5,128

128,370

48620

Discharge summary

report

Admission Date: [**2132-6-4**] Discharge Date: [**2132-6-10**] Date of Birth: [**2076-6-10**] Sex: M Service: CARDIOTHORACIC Allergies: Vicodin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Coronary Artery Disease Major Surgical or Invasive Procedure: [**2132-6-4**] Cardiac Catheterization [**2132-6-5**] CABGx3 History of Present Illness: 55 year-old man, patient of Dr. [**Last Name (STitle) **] and Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**], with recent dyspnea and chest discomfort on exertion referred for cardiac catheterization. HPI: '[**25**] cath; nl ef, prox. RCA PTCA & brachytherapy. [**2-/2126**] cath; 80% m RCA (prox site open) treated with [**Doctor First Name 10788**] stent, jailed Am branch, 60 m LAD & 70% Diag at time [**4-/2126**] relook cath; RCA open, LAD/diag unchanged [**2132-3-13**] cath for exertional chest pain and inferior ischemia on ETT: RCA with a 30% ISR with a 70% stenosis before the bifurcation and a long 90% stenosis in the proximal PDA, successfully treated with a 2.5 mm Cypher and a 3.0 Cypher. The proximal LAD had diffuse disease up to 70%, 90% in the mid vessel. Cx with minimal disease. The mid LAD was treated with a 2.25 x 18 mm Pixel stent. EF 55%. The patient states that immediately after his PCI he felt well and was able to return back to the gym to exercise. Last week the patient began to notice recurrent exertional symptoms, described as chest burning, dyspnea and frequent burping. This is only occurring with activity, i.e.. Walking a mile up a slight [**Doctor Last Name **] to his house. These symptoms resolve with rest. He has not had any nocturnal symptoms or rest pain. He also reports that his blood pressure is significantly higher than his normal. He woke last night around 1am and noted his pressure to be 185/105. He took his atenolol and vasotec at that time. His pressure continues to be high, around 150/90. He is now referred back to the cath lab for relook angiography. Past Medical History: Hypercholesterolemia Hypertension Diabetes Mellitus Type II Fatty liver Left Carpal Tunnel Release Recent right ankle ligament tear Left eye Hemorrhage Benign Prostate Hypertrophy Social History: Patient is married and lives in [**Location 2251**]. Has 15 year old daughter. Retired. Quit smoking 28 years ago after a 22 pack year history. Denies alcohol use. Family History: Mother with CAD in her 40's Physical Exam: Ht: 5'[**37**]" Wt: 196 lbs General: weight stable. No acute distress Lungs: Clear Neuro: No focal deficits Heart: RRR, normal S1-S2. GI: Soft, round, nonteneder, nondistended, normoactive bowel sounds. EXT: no edema. 2+ Pulses throughout. Pertinent Results: [**2132-6-4**] 01:00PM WBC-6.0 RBC-4.66 HGB-13.4* HCT-37.9* MCV-82 MCH-28.8 MCHC-35.4* RDW-12.4 [**2132-6-4**] 01:00PM ALT(SGPT)-25 AST(SGOT)-32 ALK PHOS-63 AMYLASE-121* DIR BILI-0.2 [**2132-6-4**] 01:00PM GLUCOSE-236* UREA N-17 CREAT-0.8 SODIUM-139 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-21* ANION GAP-18 [**2132-6-4**] 10:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2132-6-10**] 06:15AM BLOOD WBC-4.3 RBC-3.21* Hgb-9.2* Hct-27.4* MCV-86 MCH-28.7 MCHC-33.5 RDW-13.1 Plt Ct-215 [**2132-6-10**] 06:15AM BLOOD Plt Ct-215 [**2132-6-9**] 05:50AM BLOOD Glucose-177* UreaN-21* Creat-0.9 Na-135 K-4.1 Cl-98 HCO3-28 AnGap-13 [**2132-6-4**] Femoral Ultrasound No evidence of pseudoaneurysm [**2132-6-4**] CXR Normal [**2132-6-8**] CXR No change from yesterday. Note that a vague oval density projecting over the left lung apex, which has raised the question of pneumothorax, may instead be due to loculated pleural fluid here. A lateral view is recommended when possible. [**2132-6-4**] Cardiac Catheterization 1. Initial angiography of this right dominant system revealed two vessel disease. The LMCA had no angiographically significant stenoses. The LAD was a small-caliber vessel with diffuse disease in the mid-velles up to 70% and in stent restenosis up to 90% in the distal vessel. The LAD gave off a large diagonal branch which itself had a focal 80% proximal stenosis. The LCX was a non-dominant vessel with mild luminal irregularities, but no angiographically significant stenoses. The RCA was a dominant vessel with a diffuse proximal disease up to 50% and distal disease, including in-stent restenosis up to 70% tinto the PDA. 2. Limited resting hemodynamics revealed mildly elevated systemic arterial pressures (MAP 114 mmHg). [**2132-6-7**] ECHO 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 low normal (LVEF 50%). Right ventricular chamber size is normal with free wall hyokinesis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. [**2132-6-7**] EKG Sinus rhythm Extensive ST elevation, consider pericarditis Since previous tracing of [**2132-6-5**], ST segment elevation more marked Brief Hospital Course: Mr. [**Known lastname 4027**] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical Center on [**2132-6-4**] for a cardiac catheterization. This revealed a 70% stenosed left anterior descending artery, a 90% stenosed diagonal artery, a 70% stenosed right coronary artery and a normal ejection fraction. Due to the severity of his disease, the cardiac surgical service was consulted for surgical revascularization. Mr. [**Known lastname 4027**] was worked-up in the usual preoperative manner. On [**2132-6-5**], Mr. [**Known lastname 4027**] was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname 4027**] awoke neurologically intact and was extubated. Plavix was resumed for his multiple coronary stents. He was transfused with packed red blood cells for postoperative anemia. His EKG revealed ST changes consistent with pericarditis. Cardiac enzymes were sent which were negative and ibuprofen was started. Mr. [**Known lastname 4027**] developed atrial fibrillation which was treated with beta blockade. He subsequently converted back into a normal sinus rhythm. On postoperative day three, Mr. [**Known lastname 4027**] was transferred to the cardiac surgical step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. As his oral intake improved, his oral diabetic [**Doctor Last Name 360**] was resumed. His drains and pacing wires were removed per protocol. Mr. [**Known lastname 4027**] continued to make steady progress and was discharged to his home on postoperative day five. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Atenolol 50mg daily Vasotec 5mg daily Aspirin 325mg daily Metformin 500mg twice a day Folic acid twice a day Plavix 75mg daily Lipitor 10mg qhs Norvasc 5mg qhs Ranitidine 150mg qhs Recently prescribed flomax 0.4mg qhs Vitamins Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4* 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 7. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days: Take with lasix and stop when lasix stopped. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Metoprolol Tartrate 50 mg Tablet Sig: 1 and [**1-20**] tablet Tablet PO BID (2 times a day): To total 75mg twice daily. Disp:*90 Tablet(s)* Refills:*2* 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks. Disp:*28 Capsule(s)* Refills:*0* 13. Will continue Motrin 400mg every 4 hours for 5 days (Pericarditis) 14. Riopan Suspension 20cc's every 6 hours with motrin. Take for 5 days, then stop. Discharge Disposition: Home With Service Facility: Caregroup Discharge Diagnosis: Coronary Artery Disease Discharge Condition: Good Discharge Instructions: Monitor wounds for signs of infection. These include redness, drainage or increased pain. Report any fever greater then 102. Report any weight gain of greater then 2 pounds in 24 hours. No driving for 1 month. No lifting more then 10 pounds for 1 month. No swimming or bathing for 1 month. Do not apply ointments, creams or lotions to your incision. Your cardiologist will start and Ace Inhibitor when your blood pressure can tolerate. Take lasix 20 mg and potassium (K-dur) twice daily for one week then stop. Take Motrin 400mg every 6 hours with 20cc's (20 ml) of riopan for five days, then stop. (Riopan 20cc's every 6 hours for 5 days.) Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks Follow-up with Dr. [**First Name (STitle) 2031**] in 2 weeks. Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Please call to arrange your appointments. Completed by:[**2132-6-10**]

[ "423.9", "427.31", "250.00", "413.9", "401.9", "414.01", "285.9", "996.72", "997.1" ]

icd9cm

[ [ [] ] ]

[ "39.61", "88.56", "36.12", "37.22", "99.04", "36.15" ]

icd9pcs

[ [ [] ] ]

9267, 9307

5215, 7220

297, 360

9375, 9381

2745, 5192

10070, 10318

2439, 2469

7497, 9244

9328, 9354

7246, 7474

9405, 10047

2484, 2726

234, 259

388, 2039

2061, 2242

2258, 2423

66,559

114,204

38448

Discharge summary

report

Admission Date: [**2175-7-12**] Discharge Date: [**2175-7-15**] Date of Birth: [**2096-3-29**] Sex: M Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 4095**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: 79M with history of afib on coumadin and recent diagnosis of CML on gleevec, history of diverticulosis, and hemmorhoids was transfered to [**Hospital1 18**] from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2175-7-12**] with 10 days of bright red blood srurrounding his stool associated with presyncopy and exertional SOB. He had a recent bone marrow biopsy around one month ago to investigate sources of the anemia and was found to have CML. He has been on iron and always has black stool. He reported having blood only with bowel movements and did not have any increase in bowel movements. However he felt the blood in the stool had worsened 2-3 days prior to admission. He reports that he has been worked up for a new anemia for some time now with a capsule that was negative in may as well as an EGD in [**Month (only) 116**] showed [**Last Name (un) 865**], some ?healed erosions, nothing active; ; [**Last Name (un) **] 5 years ago with ?polyps and was due for repeat in the next two weeks. He presented to OSH ED where labs showed BUN 77, creat 2.8 (up from 31/0.99 on [**7-3**]),and Hct 19.7 (24.2 on [**7-10**]), WBC 11.3, INR 3.3. He was transfed two units of pRBC and one unit of ffp and transfered to [**Hospital1 18**] for further management. He was admittied directly to MICU. . In the MICU, patient was started on golytely prep last night. He had been transfused two units of pRBC and 1 FFp yesterday without an appropriate bump in HCT. He recived another another unit PRBCs today and 1 of FFP and 40IV lasix prophylactically. He is continueing his bowel prep for tonight and has had 4 bottle of golytely yet he is still not clear. . Currently on the floor patient reports that he has noticed more blood in his during bowel movment without stool. He is feeling fatigued however he [**Doctor First Name 1638**] any fevers, chill, abdominal pain, vomiting, hemoptysis, diarrhea, SOB, chest pain or coughing. Past Medical History: DM - TYPE 2 DIABETES MELLITUS CML (chronic myelocytic leukemia) ATRIAL FIBRILLATIONS CAD s/p stenting [**6-18**] Lung nodule Morbid Obesity PULMONARY HYPERTENSION DIVERTICULOSIS COLONIC POLYPS CANCER - SKIN, SQUAMOUS CELL, lft forearm, r flank HYPERLIPIDEMIA BASAL CELL CARCINOMA CATARACT - NUCLEAR SCLEROTIC SENILE OPTIC NERVE CUPPING, SUSPICIOUS HEART FAILURE - DIASTOLIC, CHRONIC GLAUCOMA SUSPECT W OPEN ANGLE HYPERTENSION, ESSENTIAL DISC DISORDER OF LUMBAR REGION ASTHMA Social History: Retired literature teacher, just celebrated 55th wedding anniversery. - Tobacco: Quit 30+ years ago, 10 pack year history - Alcohol: social - Illicits: None Family History: Non-contributory Physical Exam: Vitals: T:afebrile BP:110/54 P:67 R:19 O2:98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, 1+ clubbing, no cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred . Discharged Physical Exam: VS: 98.1 124/72 HR 72 18 99%RA. Not orthostatic -- BP 130/70 and HR 80 lying, sitting, standing. GENERAL: Pleasant, well developed older man sitting up in chair [**Location (un) 1131**], no acute distress, AOX3. Pertinent Results: Admission Labs: [**2175-7-12**] 12:40PM BLOOD WBC-10.5 RBC-2.43* Hgb-7.2* Hct-21.6*# MCV-89 MCH-29.6 MCHC-33.3 RDW-15.6* Plt Ct-296# [**2175-7-12**] 12:40PM BLOOD Neuts-83.6* Lymphs-10.3* Monos-3.6 Eos-0.6 Baso-1.9 [**2175-7-12**] 12:40PM BLOOD PT-26.2* PTT-37.1* INR(PT)-2.5* [**2175-7-12**] 12:40PM BLOOD Glucose-152* UreaN-73* Creat-2.5*# Na-135 K-5.9* Cl-102 HCO3-21* AnGap-18 [**2175-7-13**] 05:30AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.9* . Discharge Labs: [**2175-7-15**] 08:00AM BLOOD WBC-7.7 RBC-2.87* Hgb-8.2* Hct-25.6* MCV-89 MCH-28.6 MCHC-32.0 RDW-16.0* Plt Ct-267 [**2175-7-14**] 10:30AM BLOOD PT-18.4* PTT-34.2 INR(PT)-1.7* [**2175-7-14**] 10:30AM BLOOD Glucose-118* UreaN-23* Creat-1.3* Na-144 K-4.5 Cl-109* HCO3-26 AnGap-14 [**2175-7-14**] 10:30AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.5 . Colonoscopy: [**2175-7-14**] Findings: Flat Lesions A localized AVM that was actively bleeding was seen in the cecum. APC was applied to this lesion with subsequent hemostasis. Protruding Lesions Small non-bleeding grade 2 internal hemorrhoids were noted in the sigmoid [**Last Name (un) **]. Excavated Lesions A few non-bleeding diverticula were seen in the sigmoid. Diverticulosis appeared to be of mild severity. Impression: Grade 2 internal hemorrhoids Diverticulosis of the sigmoid Angioectasia in the cecal Otherwise normal colonoscopy to cecum Brief Hospital Course: 79M with history of afib (on coumadin) and recent diagnosis of CML on gleevec, history of diverticulosis, and hemorrhoids transferred from OSH to [**Hospital1 18**] on [**2175-7-12**] with 10 days of bright red blood per rectum associated with presyncope and SOB on exertion, found to have AVM cauterized on colonoscopy. . # AVM: Patient was admitted because of large bloody bowel movements for 10 days. On admission his hematocrit was found to be 21.6% down from 29.2 a month ago. He was admitted directly to the MICU where he received 2 units of blood transfusion and 1 unit of FFP to reverse his INR. After prep, he had a colonoscopy which showed bleeding AVMs which were then cauterized. Patient's hematocrit remained stable after the colonoscopy, he tolerated full diet and did not have any further episodes of bloody bowel movements. Per gastroenterology, his coumadin will be held for five days after colonoscopy. (See Below) He was discharged to follow p with PCP. . # Anemia and CML: Anemia most likely from GI bleeding with possible contribution from his CML. Hematocrit on discharge was stable. His Gleevec was stopped on admission. He will follow with his Oncologist on [**7-18**] to resume his Gleevec. . # Afib: CHADS2 of 4 for CHF, htn, age, diabetes. No prior history of stroke. Patient's coumadin was held on admission and his INR reversed for colonoscopy. Per GI, his Coumadin should be held for five days after colonoscopy. Patient will restart his Coumadin on [**2175-7-19**] and follow up with his PCP titrate his Coumadin dose. Patient's home atenolol was also stopped on admission because of [**Last Name (un) **] (see below). PCP will resume atenolol. . # [**Last Name (un) **]: On admission patient's Cr was 2.5 up from baseline of 0.7 most likely prerenal. After blood transfusions and volume resuscitation his Cr continued to trend down with discharge Cr of 1.3. On admission home, lasix, lisinopril and atenolol were held. Patient will follow up with PCP to resume these medications. . # CAD and CHF: PTCA and stenting of the distal LAD on [**6-18**]. Patient did not have any chest pain during this admission. No evidence of congestive heart failure. He was discharged on aspirin and simvastatin. Atenolol, Lisinopril and lasix to be restarted by PCP. . # Type II DM: A1c 6.0 from [**6-20**]. Blood sugar well controlled during this admission. Patient discharged on home metformin. . # Asthma: Not active. Continued on Albuterol Inhaler and advair. . # GERD: Not active. Continued on Omeprazole. . # BPH: Not active. Continued on Doxazosin and finasteride. . #Code: Full Code . Transitions of care: - No pending studies. - Patient will resume his Coumadin on [**2175-7-19**] and follow up with PCP for INR monitoring and dose adjustment. - PCP will resume Lisinopril, lasix, and atenolol when appropriate given his [**Last Name (un) **] in the hospital. - Patient will see his Oncologist on [**7-18**] to resume his gleevac. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientAtrius. 1. Omeprazole 20 mg PO DAILY 2. Imatinib Mesylate 400 mg PO DAILY 3. Doxazosin 2 mg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. Warfarin 5 mg PO DAILY16 Per INR nurses 6. Furosemide 60 mg PO DAILY 7. Finasteride 5 mg PO DAILY 8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **] 9. Simvastatin 20 mg PO DAILY 10. Lisinopril 40 mg PO DAILY 11. Atenolol 12.5 mg PO DAILY 12. Vitamin D 1000 UNIT PO DAILY 13. Aspirin 81 mg PO DAILY 14. MetFORMIN (Glucophage) 500 mg PO BID 15. Psyllium 1 PKT PO TID:PRN constpipation 16. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -600 unit Oral daily 17. Magnesium Oxide 800 mg PO DAILY 18. Fish Oil (Omega 3) 1000 mg PO DAILY 19. Albuterol Inhaler 1 PUFF IH Q6H:PRN dyspnea Discharge Medications: 1. Albuterol Inhaler 1 PUFF IH Q6H:PRN dyspnea 2. Aspirin 81 mg PO DAILY 3. Doxazosin 2 mg PO DAILY 4. Finasteride 5 mg PO DAILY 5. Fish Oil (Omega 3) 1000 mg PO DAILY 6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **] 7. Omeprazole 20 mg PO DAILY 8. Simvastatin 20 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -600 unit Oral daily 11. Ferrous Sulfate 325 mg PO DAILY 12. MetFORMIN (Glucophage) 500 mg PO BID 13. Psyllium 1 PKT PO TID:PRN constpipation Discharge Disposition: Home Discharge Diagnosis: Primary Dignosis: Angioectasia (AVM) in the cecal . Secondary Diagnosis: Atrial Fibrillations Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 13964**], it was a pleasure taking care of you during your hospitalization at [**Hospital1 18**]. You were admitted because you were having bloody bowel movements at home. On admission your blood count was low and you recived blood transfusions. You then had a colonoscopy which showed bleeding vessel (AVM) in your colon which was couterized to stop the bleeding. Your blood count remained stable after the colonoscopy and you did not have any further bloody bowel movements. You were disharged to follow up with your PCP and your oncologist. . During this admission your Coumadin has been stopped temporarily. Since you are at increased risk of bleeding after the colonoscopy, our gastroentestinal specialists recommend that you not take your Coumadin until [**2175-7-19**]. You can start taking your usual dose of Coumadin On [**2175-7-19**] and follow up for your routine INR checks. Followup Instructions: Please see your Oncologist Dr. [**First Name (STitle) **] on Tuesday, [**7-18**] for followup. Please call his office on Monday to clarify the time of Tuesday's appointment. . Please call your PCP ([**Telephone/Fax (1) 17476**]) Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to make a follow up appointment in the next 3-7 days. Department: DIGESTIVE DISEASE CENTER When: WEDNESDAY [**2175-7-19**] at 11:30 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 85582**], MD [**Telephone/Fax (1) 85583**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage Department: ENDO SUITES When: WEDNESDAY [**2175-7-19**] at 11:30 AM Completed by:[**2175-7-16**]

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icd9cm

[ [ [] ] ]

[ "45.43" ]

icd9pcs

[ [ [] ] ]

9713, 9719

5300, 7928

313, 327

9857, 9857

3928, 3928

10953, 11804

3000, 3020

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9740, 9792

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9872, 9984

7949, 8278

2328, 2805

2821, 2983

1,875

122,192

11807

Discharge summary

report

Admission Date: [**2120-4-15**] Discharge Date: [**2120-4-22**] Date of Birth: [**2064-6-30**] Sex: M Service: UROLOGY CONDITION AT DISCHARGE: Stable. DISPOSITION: Discharged to home with visiting nurse services. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 37307**] is a 55 year old male who was diagnosed with Grade III T2 bladder cancer. He was deemed a surgical candidate and preoperatively received neo-adjuvant chemotherapy (MVAC), which was completed on [**2120-3-6**]. He now presents for his scheduled radical cystoprostatectomy, bilateral pelvic lymph node dissection, and orthotopic diversion. PAST MEDICAL HISTORY: 1. Hypertension. 2. Neo-adjuvant chemotherapy. 3. Mitral valve prolapse. PAST SURGICAL HISTORY: 1. Transurethral resection of a bladder tumor in [**2119-1-5**]. 2. Umbilical herniography in [**2104**]. 3. Arthroscopic surgery of the left knee. 4. Trauma to the left leg. ALLERGIES: He has no known drug allergies. MEDICATIONS: 1. Diovan 80 mg p.o. q. day. PHYSICAL EXAMINATION: On physical examination, he is a well appearing middle aged male in no acute distress. His Head and Neck examinations are benign. His lungs are clear to auscultation. His heart is regular rate and rhythm. There is a midline upper abdominal scar consistent with his previous umbilical hernia repair. He has no inguinal hernias. His rectal examination reveals normal tone with a 15 to 20 gram prostate with the right lobe slightly larger than the left. His lower extremities showed no edema. HOSPITAL COURSE: The patient was admitted on [**2120-4-15**], status post a radical cystoprostatectomy, bilateral pelvic lymph node dissection, and orthotopic diversion (neo-bladder), performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Interoperatively, there were no complications. The patient received two units of packed red blood cells. He was transferred to the Intensive Care Unit for initial postoperative monitoring. He received 24 hours of SBE prophylaxis with Ampicillin and Gentamicin. On postoperative day two, the patient was stable and was transferred to the Surgical Floor. He remained with a nasogastric tube for bowel rest. His activity was slowly advanced as tolerated. Of note, initially postoperatively he sustained a right anterior thigh numbness as well as right hip flexion weakness and right knee extension weakness, consistent with a femoral nerve stretch injury. This improved dramatically over time. Physical Therapy was called to assist with his ambulation. The patient increased his ambulation, progressing from a walker to just a cane. His [**Location (un) 1661**]-[**Location (un) 1662**] drain output remained low and was removed. On postoperative day five, the patient's nasogastric tube continued to have a low output. It was removed. The patient tolerated this well and on postoperative day six, was started on a regular diet due to the passage of flatus. Postoperatively, his electrolytes and hematocrit remained stable. On discharge, postoperative day seven, the patient was discharged with his Foley catheter, bilateral ureteral stents, hooked up to one drainage bag as well as a second drainage bag hooked up to the suprapubic tube. He was tolerating flushes through the suprapubic tube and out the Foley catheter without difficulty. There was no significant excess of mucus on irrigation. His midline incision was healing well with a small area of erythema and minimum drainage in the infraumbilical portion of the incision. This was being treated with Keflex on discharge. On discharge day, postoperative day seven, the patient remained afebrile with stable vital signs. He continued to tolerate a regular diet. He was ambulating independently. He was comfortable with his tube teaching. He will follow-up on [**2120-5-1**], for removal of his bilateral ureteral stents as well as for removal of his surgical clips. He will be discharged home with the Visiting Nurse Service to continue with the flushings of the suprapubic tube and out his Foley catheter. DISCHARGE MEDICATIONS: 1. Percocet one to two tablets p.o. q. four hours p.r.n. pain. 2. Keflex 500 mg p.o. four times a day times five days. 3. Colace 100 mg p.o. twice a day. 4. Diovan 80 mg p.o. q. day. DISCHARGE INSTRUCTIONS: 1. His suprapubic tube will be flushed with 60 cc of normal saline and this fluid will be withdrawn from the Foley catheter twice a day. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**] Dictated By:[**Last Name (NamePattern1) 22142**] MEDQUIST36 D: [**2120-4-22**] 06:47 T: [**2120-4-22**] 12:11 JOB#: [**Job Number 37308**]

[ "998.59", "188.8", "424.0", "E878.8", "401.9", "956.1" ]

icd9cm

[ [ [] ] ]

[ "56.51", "40.3", "57.71" ]

icd9pcs

[ [ [] ] ]

4127, 4315

1568, 4104

4339, 4759

759, 1029

1052, 1550

162, 236

265, 637

659, 736

81,543

172,553

44749+44750

Discharge summary

report+report

Admission Date: [**2140-10-1**] Discharge Date: [**2140-10-5**] Date of Birth: [**2092-4-6**] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 2167**] Chief Complaint: Chest pain and shortness of breath Major Surgical or Invasive Procedure: Hemodialysis on [**10-3**] History of Present Illness: 48 yo M with PMHx sig. for DM on HD, hyperlipedemia, obstructive sleep apnea, CAD s/p 2 stents ([**5-4**], RCA and [**9-2**] OMI stent) and chronic cough with hemoptysis presents with chest pain and worsening shortness of breath. Pt reports sudden onset of substernal chest pain and dyspnea yesterday afternoon while lying in bed. He describes the chest pain as a pressure (like 2 hands are pressing on his chest), [**7-7**], no radiation, associated with shortness of breath, lightheadedness. This felt worse than prior angina, and is the first time occured at rest, typically CP occurs when climbing stairs. He has felt malaise, fatigued, and had intermittent low grade fevers to 101.4 for the past week. He denied diaphoresis, nausea, vomiting, palpitations. Pain partly improved with NTG SL, recurred, then improved on 2nd NTG at home. No PND, orthopnea, or pedal edema. He has had a long-standing cough for the past few years, which is unchanged though for the past month notes that it is tinted with blood. He recently was evaluated in pulmonary clinic at [**Hospital1 18**], where it was thought that post-nasal drip contributed to cough. Thursday he had a bronchoscopy and felt fine afterwards. Microbiology showed 10,000-100,000 oropharyngeal flora, [**Hospital1 **] AFB, [**Hospital1 **] PCP, [**Name10 (NameIs) **] viral, and pathology pending. He has no exposure to coal, asbestos, berrylosis, pigeons, chemotherapy, travel outside the country or central, SE, or SW U.S. No pets or small children at home. No prison, or homeless shelter exposure. No reported PPD. He has dialysis on MWF, and typically notes that his weight increases by 3kg on the weekend, and develops mild SOB on weekends. Past Medical History: 1. CAD s/p DES to OM1 in [**9-2**] 2. End-stage renal disease, on HD since [**6-3**] (MWF) 3. Diabetes mellitus, type 2: Diagnosed at age 20, on insulin, c/b nephropathy, neuropathy, and retinopathy status post multiple laser surgeries. Right upper extremity fistula. Chronic ulcerson left foot. 4. Hypertension 5. Hyperlipidemia 6. Obstructive sleep apnea 7. G6PD deficiency 8. Right fifth toe amputation, [**2137-3-29**]. 9. History of hepatitis B infection 10. Sexual dysfunction s/p penile prosthesis implantation Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. The patient lives with his wife and 2 sons in [**Name (NI) 669**]. Previously worked at NSTAR as a janitor, and is currently on diability. Family History: There is no family history of premature coronary artery disease or sudden death. Mother has diabetes mellitus. Father is healthy and multiple half brothers and sisters. Two children, both boys, are healthy. Multiple aunts and uncles decreased from complications of diabetes. Physical Exam: Vitals: T: 101, BP: 144/74, P: 82, R: 20, O2: 95% on 2L. Blood sugars 211 228. General: Alert, oriented, no acute distress, no cough, breathing comfortably and speaking in full sentences. No accessory respiratory muscle use. HEENT: Sclera anicteric, EOMI, MMM, oropharynx clear Neck: supple, no LAD, mildly elevated JVD Lungs: Crackles at lung bases bilaterally . CV: Regular rate and rhythm, nl S1 S2, II/VI systolic murmur at upper sternal borders. Abdomen: soft, non-tender, non-distended, normoactive bowel sounds, no rebound tenderness or guarding, no organomegaly Ext: dry, warm, faint pulses, no LE edema, superficial ulcer at base of R foot and great toe. RUE fistula thrill. Pertinent Results: Labs: WBC RBC Hgb Hct MCV MCH MCHC Plt [**2140-10-2**] 07:30AM 6.0 2.74* 8.3* 25.7* 94 30.2 32.2 171 Glucose UreaN Creat Na K Cl HCO3 AnGap [**2140-10-2**] 07:30AM 198* 44* 9.6*# 138 4.3 95* 29 18 ALT AST CK AlkPhos TotBili [**2140-10-1**] 06:28PM 11 18 52 58 0.5 [**2140-10-2**] 07:30AM cTropnT 0.26 Calcium Phos Mg [**2140-10-2**] 07:30AM 9.0 5.3*# 1.9 calTIBC VitB12 Folate Ferritn TRF [**2140-10-1**] 06:28PM 153* 627 GREATER TH1 792* 118* Lactate K [**2140-10-1**] 06:37PM 1.5 4.4 [**2140-9-29**] 9:11 am BRONCHOALVEOLAR LAVAGE Site: LT. LINGULA. RESPIRATORY CULTURE (Final [**2140-10-1**]): 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. POTASSIUM HYDROXIDE PREPARATION (Final [**2140-9-29**]): TEST CANCELLED, PATIENT CREDITED. This is a low yield procedure based on our in-house studies if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): YEAST. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. Sputum [**10-2**] 2:20am Contaminated [**10-22**] PMNs and >10 epithelial cells/100X field. [**2140-10-1**] 6:20 pm Blood culture pending x2 . Images: CHEST (PORTABLE AP) Study Date of [**2140-10-1**] IMPRESSION: Cardiomegaly and moderate pulmonary edema. . CT CHEST W/O CONTRAST Study Date of [**2140-9-8**] IMPRESSION: 1. Widespread alveolitis, or less likely hypersensitivity pneumonitis, possibly drug- related. Chronic hemorrhage is also less likely due to absence of interstitial thickening. Chronic CMV infection is possible, in this patient on chronic dialysis. 2. Possible pulmonary hypertension. 3. Extensive coronary artery and peripheral arterial calcification. 4. Calcified gallstones. Liver granulomas. 5. Sub-3 mm lung nodules. If this patient has no risk factor, no further follow up is recommended. If risk factors are present for neoplasia, follow up in 12 months is recommended. . CT CHEST WITHOUT CONTRAST [**2140-10-3**] IMPRESSION: 1. New small bilateral pleural effusion, small pericardial effusion, and diffuse soft tissue edema associated with minimal septal thickening suggests volume overload, more prominent than on [**2140-9-8**]. 2. Increased widespread ground-glass opacity, now severe with more confluent regions in the right upper lobe suggests progression of widespread alveolitis, less likely hypersensitivity pneumonitis, could be drug related. Chronic hemorrhage is less likely due to diffuse distribution, although it cannot be completely excluded. Infection in an immunocompromised patient such as PCP or CMV could also give this radiological appearance. . TTE (Complete) Done [**2140-5-3**] The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality (E:A > 2:1, short E wave deceleration time), with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Moderate left ventricular hypertrophy with preserved global/regional biventricular systolic function. Mild mitral regurgitation. Elevated filling pressures. . EKG x2: NSR at 75-80 bpm, nl axis, nl intervals. LAE. No Q waves. J point elevation in V2-V3. TWI in I, II, aVL and V6. ST depression in V6. No change from [**7-5**]. . Chest AP and Lateral xray [**2140-10-3**] FINDINGS: In comparison with the study of [**10-1**], there is continued enlargement of the cardiac silhouette without vascular congestion or pleural effusion. No definite pneumonia is appreciated on this plain radiographic image. Brief Hospital Course: In the ED, initial vs were: T100.6, P81, BP187/67, R24, O2 sat 91% on 2L. EKG was unchanged. CXR showed no obvious consolidation. Patient was given ASA, 2mg IV morphine and NTG SL x3, which resolved the pain after 2 hours. Pt was also given levaquin. He was admitted to medicine for further evaluation. . 1) Fever: Low grade fever and chronic cough. No leukocytosis. CXR showed pulmonary edema w/o inflitrate. Sputum culture contaminated. Treated with levofloxacin empirically for atypical community-acquired pneumonia and fever resolved. 2) Shortness of breath: Likely due to pulmonary edema from Stage 5 renal failure (on hemodialysis) vs underlying interstitial lung disease. Given CAD, DM, high risk of ACS, and myocardial infarction was ruled out with serial troponins at baseline and no EKG changes. He underwent hemodialysis, which improved his shortness of breath, O2 sat was stable at 95% on room air s/p hemodialysis, and pulmonary edema resolved on repeat chest xray. Regarding interstitial lung disease, no risk factors for hypersensitivity pneumonitis, drugs that cause pulmonary injury, pneumoconioses though noted brief asbestos exposure ~10 yrs ago. No known collagen vascular disorders. Could be related to pulmonary edema. High resolution CT chest w/o contrast indicated worsening alveolitis. Interstitial lung disease will be followed by Dr. [**Last Name (STitle) **] in pulmonary clinic on [**10-20**]. 2) Stage 5 kidney failure. He was hemodialyzed on Mon and Wed, and continued on his home regiment of sevelamer to control serum phosphate concentration; Vitamin D and calcium to prevent renal osteodystrophy; Cinacalet for hyperparathyroidsim in end-stage kidney disease; and nephrocaps 3) Anemia. The pt was anemic with a HCT of 28.6, down from baseline of 32. This was felt to be likely due to chronic renal failure. 4) DM II. The patient was continued on his home insulin regimen. Was noted to be hypoglycemic at the time of discharge to 45 with complaint of headache. Improved to 87 after juice, crackers, and dinner. In the morning [**10-5**] he no longer had had any symptoms of hypoglycemia and his blood sugar was stable at 85. 5) Hypertension. The patient was continued on his home regimen of Isosorbide Mononitrate, Lisinopril, Losartan, and Nifedipine. Was noted to be hypertensive at the time of discharge on [**10-5**] to 206/96. He had no confusion, chest pain, or visual changes. He was administered an additional dose of nifedipine, which lowered his blood pressure to 170/60. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 20239**] [**First Name9 (NamePattern2) 95745**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] PGY-III Medications on Admission: Nephrocaps Cinacalcet 60 mg PO DAILY Isosorbide Mononitrate 30 mg PO DAILY Lisinopril 20 mg daily Atorvastatin 80 mg PO DAILY Losartan 100 mg PO DAILY Metoprolol Succinate 100 mg PO TID Nifedipine 60 mg PO TID Clopidogrel 75 mg PO DAILY Ranitidine HCl 300 mg PO HS Trazodone 100 mg 0.5-1 Tablet PO DAILY Ezetimibe 10 mg PO DAILY Aspirin 325 mg PO DAILY NPH- 50Units qAM, 50Units qPM Humalog- 10Units qAM, 12Units qPM Sevelamer 800 mg PO TID W/MEALS Fluticasone 220 mcg 2 pulls [**Hospital1 **] Loperamide 2 mg daily Omeprazole 20 mg daily NTG SL Discharge Medications: B Complex-Vitamin C-Folic Acid 1 mg Capsule One (1) Cap PO DAILY(Daily). Cinacalcet 30 mg Tablet Two (2) PO DAILY (Daily). Isosorbide Mononitrate 30 mg Tablet One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Lisinopril 20 mg One (1) Tablet PO DAILY (Daily). Atorvastatin 40 mg Tablet Two (2) Tablet PO DAILY (Daily). Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO TID (3 times a day). Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Loperamide 2 mg Capsule Sig: One (1) Capsule PO once a day as needed for diarrhea. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Humalog 100 unit/mL Solution Sig: Ten (10) units Subcutaneous daily before breakfast. Humalog 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous daily before dinner. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifty (50) units Subcutaneous qam. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty (30) units Subcutaneous at bedtime. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO every six (6) hours as needed for gassy abdominal pain. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 5 days. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Pulmonary edema [**1-30**] stage 5 renal failure Chest pain, ruled out myocardial infarction Secondary diagnosis: 1. CAD s/p drug-eluting stent to OM1 in [**9-2**] and drug-eluting stent to distal RCA in [**5-5**] 2. End-stage renal disease, on HD since [**6-3**] (MWF) 3. Diabetes mellitus, type I: Diagnosed at age 25, on insulin, c/b nephropathy, neuropathy, and retinopathy status post multiple laser surgeries. Right upper extremity fistula. Chronic ulcers on left foot. 4. Hypertension 5. Hyperlipidemia 6. Obstructive sleep apnea on CPAP 7. G6PD deficiency 8. Right fifth toe amputation, [**2137-3-29**]. 9. History of hepatitis B infection 10. Sexual dysfunction s/p penile prosthesis implantation 11. Chronic cough, started 4 years ago, followed by Dr. [**First Name4 (NamePattern1) 1370**] [**Last Name (NamePattern1) 95746**]. Discharge Condition: Stable, ambulatory, and O2 saturation stable on room air. Afebrile. Discharge Instructions: You were admitted with shortness of breath and chest pain. Your work-up was negative for a heart attack or heart arrythmmia. This was likely due to a combination of fluid overload from kidney and pulmonary disorders. You were also found to have a fever, likely due to an infection in the lungs and will need to complete your course of the antibiotic called Levaquin to treat this. You underwent hemodialysis on Monday for your kidney disorder. You also had a PPD placed, which showed you did not have tuberculosis. . You were kept overnight for observation as your blood sugars were low yesterday. This was likely from an interaction with the antibiotic. Please continue to monitor your blood sugar levels carefully at home. . Beyond Levaquin, there were no other changes made to your prior medication regimen other than a medication called simethicone for gassy abdominal pain. . Please call your doctor or return to the emergency room if you experience any of the following: worsening shortness of breath, fever > 101, or worsening chest pain. Followup Instructions: Please follow-up with your PCP [**Last Name (NamePattern4) **] 1 week. You will also need to follow-up with the pulmonologists. You have an appointment with Dr. [**Last Name (STitle) 95747**] and Dr. [**Last Name (STitle) **] on [**10-20**] at 2 pm. You will need to show up at 1:40 pm for pulmonary function testing. The appointment is in the [**Hospital Ward Name 23**] clinical buildling on the [**Location (un) **]. Please call [**Telephone/Fax (1) 609**] if you need to make any changes. You also have the following appts: 1) Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2140-10-18**] 3:20 Completed by:[**2140-10-5**] Admission Date: [**2140-10-6**] Discharge Date: [**2140-11-1**] Date of Birth: [**2092-4-6**] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 5119**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: Flexiable bronchoscopy Rigid bronchoscopy Food debridement History of Present Illness: Patient is a 48 year old male with past medical history of DMI, ESRD on HD, CAD with DESx2 most recent [**5-5**] who presented to the hospital with about [**12-30**] cup of hemoptysis 3 hours after a recent discharge for chest pain and shortness of breath believed to be related to bronchitis. In brief, the patient has a history of 4 years of chronic dry cough. He has undergone an extensive workup that had not yet revealed a cause. Over the summer he was started on inhaled steroids with some relief. In [**2140-8-29**] he started to have mild hemoptysis. His PCP ordered [**Name9 (PRE) 11149**] and a CT. The PFTs showed a mild restrictive picture and his CT showed diffuse mild ground glass opacities. He was next bronchoscopied in the beginning of [**2140-9-28**]. The bronchoscopy was positive for hemosiderin laden macrophages but otherwise no infectious agents. It was unclear at that time if these were due to hemoptysis or a vasculitis. The day after the bronchoscopy he presented to the ED with chest pain, SOB on [**2140-10-1**]. During that hospitalization a repeat CT showed worsening of the ground glass opacities consistent with alveolitis. Ultimately he was believed to have fluid overload which was treated with HD and pneumonia, and was discharged on levofloxacin on [**2140-10-5**]. A few hours later on [**2140-10-6**] he returned to the ED with frank hemoptysis. He was bronchoscopied for further evaluation of the ground glass opacities and during the bronch developed submassive hemoptysis. He was taken emergently to the OR for intubation and a rigid bronch and had laser coagulation of the overlying area of bleeding. The likely source of bleeding had been identified during the earlier flexible bronchoscopy. IP believed it could be a a Dulefoys ulcer, although these are usually seen in GI tract. Of note patient had a [**Date Range **] placed 5 months prior and is on ASA and Plavix. During this and his previous bronchoscopy he was found to have hemosiderin laden macrophages, again raising the possibility of some form of pulmonary hemosiderosis versus chronic bleed from hemoptysis or vasculitis. Multiple serologies were sent. RF , CRP, ESR, were positive. ANCA, GBM, and [**Doctor First Name **] were negative. . On further history, the pt reported long term chronic diarrhea which he controls with loperamide. An antiTTG was sent and came back positive. Based on this constellation of findings, pulmonary consult raised the [**First Name8 (NamePattern2) 95748**] [**Last Name (NamePattern1) **] syndrome - which is defined essentially as celiac disease and ideopathic pulmonary hemosiderosis. . His MICU course was complicated by difficult to control hypoglycemia on his home regimen of insulin and ultimately ended up on an insulin drip as well as persistent hypertension. He also had the complication of lobar colapse from the hemmorrhage and bronchoscopies which is resolving. Otherwise, his extubation was uneventful and he did well. He was transfered to the floor after being cleared for POs by speech and swallow and an HD session. . On the floor he verified the details of his history and had no additional complaints. His speech was slowed and he is a somewhat poor historian. Much of his history was taken from MICU and pulmonary house staff. Past Medical History: 1. CAD s/p [**Last Name (NamePattern1) **] to OM1 in [**9-2**] and [**Month/Day (1) **] to RCA in [**5-5**] 2. End-stage renal disease, on HD since [**6-3**] (MWF) 3. Diabetes mellitus, type I: Diagnosed at age 20, on insulin, c/b nephropathy, neuropathy, and retinopathy status post multiple laser surgeries. Right upper extremity fistula. Chronic ulcers on left foot. 4. Hypertension 5. Hyperlipidemia 6. Obstructive sleep apnea 7. G6PD deficiency 8. Right fifth toe amputation, [**2137-3-29**]. 9. History of hepatitis B infection 10. Sexual dysfunction s/p penile prosthesis implantation Social History: The patient lives with his wife and 2 sons in [**Name (NI) 669**]. Previously worked at NSTAR as a janitor, and is currently on diability. No tobacco or EtOH use. Family History: There is no family history of premature coronary artery disease or sudden death. Mother has diabetes mellitus. Father is healthy and multiple half brothers and sisters. Two children, both boys, are healthy. Multiple aunts and uncles decreased from complications of diabetes. No family hx of Wegener's or [**Last Name (un) 95749**]-[**Doctor Last Name 3532**] disease. Physical Exam: GEN: NAD, alert and oriented, conversant but with slowed speech VS: HEENT: Dry MM, no JVD or LAD CV: RRR, III/VI SEM ?radiating to the carotids. PULM: Mild bibasilar crackles R>L ABD: BS+, NTND, no masses or HSM LIMBS: Wasted limbs, 1+ LE edema, ?able clubbing SKIN: Acanthosis nigricans of the elbows and neck Pertinent Results: ADMISSION LABS [**2140-10-5**] 08:20AM BLOOD WBC-4.7 RBC-2.92* Hgb-8.7* Hct-26.4* MCV-90 MCH-29.9 MCHC-33.1 RDW-17.2* Plt Ct-217 [**2140-10-5**] 11:00PM BLOOD PT-14.5* PTT-30.3 INR(PT)-1.3* [**2140-10-5**] 08:20AM BLOOD Glucose-81 UreaN-58* Creat-9.8*# Na-135 K-5.3* Cl-96 HCO3-25 AnGap-19 [**2140-10-5**] 08:20AM BLOOD Calcium-9.3 Phos-5.3* Mg-2.4 DISCHARGE LABS [**2140-10-31**] 08:20AM BLOOD WBC-6.4 RBC-3.64* Hgb-11.0* Hct-33.9* MCV-93 MCH-30.3 MCHC-32.5 RDW-17.2* Plt Ct-305 [**2140-10-31**] 08:20AM BLOOD PT-12.9 PTT-32.2 INR(PT)-1.1 [**2140-11-1**] 06:45AM BLOOD Glucose-101 UreaN-29* Creat-8.0*# Na-137 K-4.2 Cl-98 HCO3-29 AnGap-14 [**2140-11-1**] 06:45AM BLOOD Calcium-8.9 Phos-5.8*# Mg-2.2 . ABS: CPK ISOENZYMES proBNP [**2140-10-6**] 05:14PM [**Numeric Identifier **] . AUTOANTIBODIES ANCA [**2140-10-14**] 10:40AM PND [**2140-10-6**] 05:14PM NEGATIVE . [**First Name9 (NamePattern2) 32906**] [**Doctor First Name **] CRP dsDNA [**2140-10-7**] 07:30AM 31*1 [**2140-10-6**] 05:14PM NEGATIVE NEGATIVE [**2140-10-6**] 05:14PM 38.1*2 . COMPLEMENT C3 C4 [**2140-10-7**] 07:30AM 102 35 . tTG-IgA [**2140-10-7**] 07:30AM 105 . DISCHARGE LABS: [**2140-10-28**] 08:10AM BLOOD WBC-2.4* RBC-3.49* Hgb-10.6* Hct-32.6* MCV-93 MCH-30.5 MCHC-32.7 RDW-17.0* Plt Ct-266 [**2140-10-28**] 09:30AM BLOOD PT-12.3 PTT-27.7 INR(PT)-1.0 [**2140-10-28**] 08:10AM BLOOD Glucose-113* UreaN-34* Creat-8.2* Na-134 K-4.4 Cl-98 HCO3-24 AnGap-16 [**2140-10-28**] 08:10AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.2 . Portable TTE (Complete) Done [**2140-10-8**] at 10:30:44 AM The left trial volume is markedly increased (>32ml/m2). The left atrium is dilated. There is moderate symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Moderate symmetric LVH with normal regional and global biventricular function. Diastolic dysfunction with elevated filling pressures. Moderate thickening of aortic valve leaflets without stenosis. . CT CHEST W/O CONTRAST Study Date of [**2140-10-2**] 12:44 PM FINDINGS: Since [**2140-9-8**], widespread ground-glass opacity increased, now severe with more confluent areas in the right upper lobe. Minimal septal thickening is new with new small bilateral pleural effusion, small pericardial effusion, and increased diffuse soft tissue edema. New mucoid impaction is also in the left lower lobe. Diffuse air trapping is present in expiration. Signs of anemia are present. Mild cardiomegaly and severe vascular calcifications are unchanged. Main pulmonary artery is still enlarged. 3-mm lucency in the right upper lobe is unchanged, probably a bulla. Lung nodules are unchanged as follows: 2 mm left lower lobe (104:120), 2 mm right lower lobe (104:128), and 1 mm right lower lobe probably calcified nodule(104:153). Right middle lobe calcified granuloma is present. The upper esophagus is dilated. Mediastinal lymph nodes are still not enlarged using CT criteria but are enlarged since the prior study, probably reactive. Left eleventh rib fracture is not healed, and tenth rib fracture is healed. This study was not tailored for subdiaphragmatic evaluation except to note calcified liver granulomas and extensive vascular calcifications. IMPRESSION: 1. New small bilateral pleural effusion, small pericardial effusion, and diffuse soft tissue edema associated with minimal septal thickening suggests volume overload, more prominent than on [**2140-9-8**]. 2. Increased widespread ground-glass opacity, now severe with more confluent regions in the right upper lobe suggests progression of widespread alveolitis, less likely hypersensitivity pneumonitis, could be drug related. Chronic hemorrhage is less likely due to diffuse distribution, although it cannot be completely excluded. Infection in an immunocompromised patient such as PCP or CMV could also give this radiological appearance. . CT CHEST W/O CONTRAST Study Date of [**2140-10-15**] 10:29 AM FINDINGS: Since prior study, the widespread ground-glass opacity has now essentially resolved. Regions of ground glass opacity which persist when the patient is prone are along the anterior lung, and persisting opacity when the supine are along the posterior lung--each resolving when the patient repositions, consistent with dependent change. Minimal air trapping is noted on expiration. No focal consolidation or evidence of acute pulmonary edema is present. Trace pericardial effusion is again present. The degree of subcutaneous edema is not appreciably changed. There are no pleural effusions. Mediastinal and hilar lymph nodes are not prominant and appear smaller than before. Significant three-vessel coronary artery calcifications as well as diffuse calcified atherosclerotic plaque within the ascending, arch, and descending thoracic aorta. Splenic artery calcifications are again noted without appreciable change. Punctate hepatic calcifications are probably from intrahepatic vasculature, though granulomas also possible. Gynecomastia is present. IMPRESSION: 1. Resolution of ground glass opacities since prior study of [**2140-10-2**]. Trace pericardial effusion remains. No pleural effusions are present. 2. Diffuse coronary and aortic artery calcifications. . MR HEAD W/O CONTRAST Study Date of [**2140-10-17**] 7:24 PM FINDINGS: There are no focal areas of altered signal intensity on the FLAIR sequence in the brain parenchyma including the brainstem and the cerebellar hemispheres. There are a few prominent perivascular spaces, noted in the centrum semiovale with CSF signal intensity, on both sides (series 5, image 20). There are no areas of intracranial hemorrhage or restricted diffusion to suggest acute infarction. The ventricles and extra-axial CSF spaces are normal. There is increased signal intensity in the mastoid air cells on both sides, representing fluid and/or mucosal thickening. The major intracranial arterial flow voids are noted on the axial T2-weighted images. IMPRESSION: 1. No focal abnormality on the non-contrast brain images, to explain the patient's symptoms. Dedicated MRA can be considered if there is concern for VBI. D/w consult team. 2. Moderate amount of fluid and/or mucosal thickening in the mastoid air cells on both sides. . PATHOLOGY: BRONCHIAL WASHINGS Procedure Date of [**2140-10-7**] NEGATIVE FOR MALIGNANT CELLS. Abundant hemosiderin-laden macrophages and few bronchial epithelial cells . Bronchial lavage, cell block (C08-[**Numeric Identifier 95750**]): [**2140-9-30**]: Abundant pulmonary macrophages. No viral cytopathic effect present; CMV immunostain is negative . Brief Hospital Course: Pt is a 48M with DMI, ESRD on HD, CAD with DESx2 and a complicated history of chronic cough and chronic diarrhea admitted for hemoptysis. He was initially admitted to the MICU for airway protection after a bleed after bronchoscopy. He has stabilized well and is admitted to the floor with a suspected [**First Name8 (NamePattern2) 95748**] [**Last Name (NamePattern1) **] syndrome, characterized by celiac disease and ideopathic pulmonary hemosiderosis. He will need further work up to prove this diagnosis. The DD could be multiple primary diagnoses, BOOP and COPP as well. He also has new cerebellar deficits which are being worked up and ultimately seemed more to be due to deconditioning and non=compliance with exams + profound diabetic neuropathy. Ultimately the most difficult problems have been diet and control of BP. . # HTN: Continues to be difficult to control on home regimen. Currently on Isosorbide Mononitrate, Lisinopril, Losartan Potassium, Metoprolol, and NIFEdipine. Various meds were increased although pt would often refuse 1 or many of these. At times he also refused vital signs. Ultimately a regimen was found with which he would comply and BP control was much improved with increased ultrafiltration at HD. . # Chronic food ulcer: [**2140-10-28**] Podiatry excised ulcer and underlying bone. Will be off this foot for the time being. Tylenol PRN for pain. No morphine as the Pt is in renal failure. On percoset for breakthrough pain. On Agumentin per podiatry. . #. Bleeding Vessel during bronch: likely source of bleeding was identified during flex bronch, the patient coughed and had resultant bleeding. Of note patient had [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 5 months prior and is on ASA/Plavix. On PRN cough suppressants to avoid irritation of the airway and stabilization of the clot. Restarted on Plavix and ASA without trouble. . #. Ground Glass Opacities: at first worsened on interval CTs, but improved on latest CT. Differential inculdes vasculitis, infectious, and rheumatologic disease. Infection has been largely ruled out by bronchs. Vasculitis remains a possibility, but ANCA is negative. Rheumatologic differential is narrowed by serologies. Notably, TTG is positive consistent with celiac disease or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] syndrom (celiac disease with pulmonary involvement). Drug toxicity is a possibility, but difficult to assess. He has no known exposures to drugs known to cause pulm issues. Also worth considering cough leaving to chronic hemoptysis. As said, TTG positive. GI deferring duodema biopsy for now. Ultimately believed to be [**First Name8 (NamePattern2) 95751**] [**Last Name (NamePattern1) **] syndrome. . # Chronic diarrhea: Long term problem. Pt take loperamide for control. TTG positive this admission. Could be related to the [**First Name8 (NamePattern2) 95752**] [**Last Name (NamePattern1) **] syndrome. On gluten free diet with improvement in diarrhea. Nutrition consulted and is helping to educate the pt. . # Cerebellar signs: Pt with what appears to be truncal ataxia. Limb deficits seem at least partially [**1-30**] poor participation with exam. CT negative. MR negative. Worth noting that there is literature on celiac disease causing cerebellar ataxia. Could also be from vascular event (PVD with thrombosis v embolic) or low flow state during bleed. Per wife, his wide based and stiff walk are not his baseline. Hand coordination seems intact and more limited by participation. Will need rehab per PT if patient will comply. Progressively improved and was ultimately believed to be due to a combination of profound diabetic neuropathy and deconditioning. Medications on Admission: Levofloxacin 250 mg PO Q48H x 5 days ASA 325mg PO daily Isosorbide Mononitrate SR 30 mg PO daily Lisinopril 20 mg PO daily Atorvastatin 80 mg PO daily Losartan 50 mg PO daily Toprol XL 300mg PO daily Nifedipine SR 60 mg PO TID Clopidogrel 75 mg PO daily Humalog 10 u before breakfast, 12 u before dinner NPH 50u qAM, 30u qPM Ranitidine 300 mg Tablet PO HS Trazodone 50 mg PO HS prn Ezetimibe 10 mg PO daily Sevelamer 800 PO TID with meals Fluticasone 110 mcg/Actuation 2 puffs [**Hospital1 **] B Complex-Vitamin C-Folic Acid 1 mg PO daily Cinacalcet 60 mg PO daily Omeprazole 20 mg PO daily Simethicone 80 mg q6 prn Loperamide 2 mg PO once a day as needed for diarrhea. Discharge Medications: 1. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Isosorbide Mononitrate 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 16. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 3.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). 17. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 18. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 19. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 20. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 21. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. 22. Insulin Lispro 100 unit/mL Solution Sig: [**1-3**] unis Subcutaneous as directed: Please see SS in diet order. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] syndrome . Secondary Diagnosis: Diabetes Mellitus ESRD on HD CAD s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] 2 HTN Hyperlipidemia OSA Discharge Condition: Stable vital signs, feeling well Discharge Instructions: You were admitted for coughing up blood, also called hemoptysis. While you were in the hospital you have two different types of bronchoscopy. A bleeding blood vessel was found on the second bronchoscopy which was coagulated. During your hospitalization it was found that you have celiac disease, a severe allergy to gluten, a protein in wheat that causes diarrhea. We think it is possible that some of the problems with your lungs is related to your allergy to gluten. This [**First Name8 (NamePattern2) 95753**] [**Last Name (NamePattern1) **] syndrome. It is very rare, but as far as we can tell the best way to treat this is to avoid gluten. In addition, your blood pressure was very high during your admission. We increased some of your medications and added a new one called hydralazine. Finally, you have been having more trouble walking. You will need rehabilitation for this problem. . Please attend your follow up appointments. . Please take your medications as prescribed. . Please stick to a gluten free, wheat free diet. . Please continue to take your blood pressure at home. Call your doctor if it is higher than 190/100. . Please come to the emergency room or call your doctor if you have chest pain, shortness of breath, unexplained swelling, coughing, coughing up blood, uncontrolled diarrhea or vomiting, or other concerning symptoms. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2140-11-3**] 11:00 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2140-11-8**] 3:00 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2140-11-21**] 4:00 [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2140-11-26**]

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Discharge summary

report

Admission Date: [**2128-5-7**] Discharge Date: [**2128-5-14**] Date of Birth: [**2061-3-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 10682**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 67M CAD, DM2, COPD on 4L of home O2, HTN, asbestos exposure (asbestosis?), OSA on nocturnal Bipap, admitted to [**Hospital 1474**] Hospital on [**2128-5-3**] with subacute respiratory distress, started on broad spectrum antibiotics, transfered to MICU this AM because of worsening respiratory distress, found to have multifocal pneumonia, transfered to [**Hospital1 18**] for further management. Patient has been admitted to [**Hospital1 1474**] multiple times in the last few weeks. He was admitted most recently to [**Hospital1 1474**] on [**2128-5-3**] at which time he was not able to provide much clinical history but had been having worsening shortness of breath as well as significant diarrhea and fever to 103F, stating that he had been feeling sick for a long time. He was noted to be somewhat somnolent, easily falling asleep, increased oxygen requirement. He had also reported increasing weight and leg edema over the last several days to weeks. He was started on Vancomycin, Zosyn, and Cipro in the ED for hospital-acquired pneumonia coverage after right-sided infiltrate was seen on CXR. On morning of transfer, patient's O2sat was noted to desat to 50% on Cpap while on the floor, so he was palced on high flow non-rebreather with improvement in O2sat to 96%. He was given a dose of IV lasix 80mg x1. ABG showed hypoxemia and hyercapnea, though hypercapnea was presumed to be at his baseline. CXR done also in setting of spiking fevers showed new developing infiltrate. He was transfered to CCU for worsening multifocal pneumonia and heart failure. ABG was 7.38/60/107 on 10L O2 by facemask. Family requested transfer to [**Hospital1 18**]. On arrival, the patient was in no acute distress but having some difficulty breathing. He was transitioned from non-rebreather during transport to CPAP on 6L NC. He did have a large loose bowel movement on arrival. States that cough is worsening but can not cough out sputum. He denies nausea currently, but states that he did have an episode of emesis earlier today. Patient states that abdomen has been increasingly distended over the last several weeks, as well as increased lower extremity edema. He believes he has gained 40 lbs in the last couple of months. Over the phone, his wife believes the patient had an aspiration episode at some point in the last few weeks, though unclear when, perhaps at home; wife has been in the hospital for a few weeks, so she does not know details of recent history well. Of note, patient was admitted to [**Hospital1 1474**] [**Date range (1) 89899**] for presumed COPD exacerbation triggered by viral illness, including self-limited nausea/vomiting, diarrhea. He had a fever to 100.8, no pneumonia seen on CXR, negative blood cultures. He was given a dose of IV solumedrol and started on a prednisone taper. He was admitted from [**Date range (1) 17717**] for ankle edema and atypical chest pain, diuresed effectively, thought to have poor compliance with low sodium diet. Review of sytems: (+) Per HPI. Gained 30-40 lbs in last 1-2 months. Has had recent fevers at OSH. (-) Denied chest pain or tightness, palpitations. Denies current nausea or abdominal pain. No dysuria. Past Medical History: 1. CAD - s/p anteroseptal MI in [**2122-6-3**] s/p Cypher stenting x 3 of the LAD, Cypher stent to LCx. LVEF 40% post procedure but improved with medical management. - [**3-8**]: Cx and LAD stenting for ISR; [**4-8**] repeat cath: patent LAD and Cx - [**2124-9-19**] cath: successful Cypher stenting of the RCA - [**10-10**] cardiac cath: 80% LAD ISR s/p Promus DES, s/p PTCA of the ostial and mid D1 with a 2.5 mm Voyager balloon. 30-40% residual stenosis noted. Post procedure patient had left facial droop and left hemiparesis, treated with IV TPA- no residual deficits. 2. Hypertension 3. hyperlipidemia 4. Diastolic CHF, s/p admission to [**Hospital3 417**] Hospital [**2127-5-26**] for exacerbation 5. O2 dependent COPD (4 Liters) 6. Diabetes 7. Sleep apnea 8. ?Asbestosis 9. s/p epigastric hernia repair 10. s/p laparoscopic Cholecystectomy (patient reports difficulty "waking up" after surgery) 11. pancreatitis 12. s/p tracheostomy many years ago in setting of severe sleep apnea Social History: Retired truck driver. Married 45 years with 3 children, 7 grandchildren. Enjoys fishing. Tobacco: 40 year pack history of smoking, quit 2 years ago. Does not drink alcohol or use recreational drugs. Family History: - Strong family history of DM2, obesity - Mother died of CAD - Father died of lung cancer. - He has a 30yo daughter with CAD. Physical Exam: Admission exam: Vitals: T: 97.9 BP: 116/60 P: 68 R: 18 O2: 99% on non-rebreather General: well-nourished gentleman in no acute distress, Alert, oriented HEENT: Sclera anicteric, dry mucus membranes, oropharynx with soft palate floppy and with dark exudate on soft palate Neck: thick neck, supple, JVP difficult to appreciate Lungs: diffuse rhonchi with mild exp wheeze CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: + distended, no fluid wave, diffuse mild tenderness particularly in periumbilically and suprapubically, normoactive bowel sounds present; ?ventral hernia Ext: warm, well perfused but edematous 1+ lower extremities, palpable pulses Pertinent Results: Admission labs: [**2128-5-7**] 09:41PM BLOOD WBC-5.8 RBC-3.27* Hgb-9.7* Hct-30.6* MCV-94# MCH-29.8 MCHC-31.8 RDW-14.6 Plt Ct-208 [**2128-5-7**] 09:41PM BLOOD Glucose-54* UreaN-52* Creat-2.2* Na-143 K-3.7 Cl-97 HCO3-35* AnGap-15 [**2128-5-7**] 09:41PM BLOOD ALT-21 AST-24 LD(LDH)-240 AlkPhos-50 TotBili-0.4 [**2128-5-8**] 01:06PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-884* [**2128-5-7**] 09:41PM BLOOD Albumin-3.4* Calcium-8.1* Phos-5.3* Mg-2.4 [**2128-5-8**] 01:12AM BLOOD Lactate-0.7 [**2128-5-7**] 09:41PM BLOOD PT-12.5 PTT-27.5 INR(PT)-1.1 Discharge labs: Micro: [**2128-5-7**] 9:41 pm BLOOD CULTURE Source: Line-PICC. Blood Culture, Routine (Pending): NGTD [**2128-5-8**] 4:29 am URINE Source: CVS. Legionella Urinary Antigen (Final [**2128-5-9**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. [**2128-5-8**] 10:52 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2128-5-9**]): Feces negative for C.difficile toxin A & B by EIA. Imaging: [**2128-5-7**] CXR: There is a right-sided PICC line whose distal tip is low and has an unusual course with the distal tip to the left of midline. This may be within the azygos vein and should be readjusted for more optimal placement. The catheter will have to be pulled back at least 4-5 cm before readjustment. The cardiac silhouette is prominent but stable. There is prominence of the pulmonary interstitial markings as well as more focal areas of consolidation at the lung bases. This may be due to combination of fluid overload as well as developing infiltrates, particularly at the lung bases. No pneumothoraces are seen. There is calcification along the right hemidiaphragm which is stable since the [**2126**] study and may be due to pleural plaques. [**2128-5-8**] KUB: There is contrast seen throughout the colon extending into the rectum. There are mildly prominent loops of small bowel which are air filled in the left abdomen. Overall, these findings are nonspecific and there are no signs for small-bowel obstruction. No extraluminal contrast is seen. There is no free air in the abdomen or pelvis. [**2128-5-9**] CXR: Cardiac silhouette remains enlarged, and there is persistent vascular engorgement and perihilar haziness. Asymmetrically distributed more confluent opacities are present in the right mid and left lower lung regions, and are slightly worse compared to the recent study. This may reflect asymmetrical edema, but superimposed infection is also possible in the appropriate clinical setting. Small pleural effusions are again demonstrated as well as pleural plaques, the latter consistent with prior asbestos exposure. UNILAT LOWER EXT VEINS LEFT Study Date of [**2128-5-11**] Normal Doppler ultrasound left lower extremity. No evidence for DVT. TTE (Complete) Done [**2128-5-10**] The left atrium is dilated. The right atrium is markedly dilated. 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. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. [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 no pericardial effusion. IMPRESSION: Suboptimal image quality due to body habitus. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. The right ventricle is not well seen but is probably normal. No significant valvular abnormality. Unable to assess pulmonary artery systolic pressures. Brief Hospital Course: Patient is a 67 yo man with PMHx sig. for CAD, COPD on 4L O2, HTN, OSA who was transferred from [**Hospital1 1474**] with multifocal pneumonia, transferred to MICU on [**2128-5-7**] for respiratory distress, improved on vanco/levofloxacin, and transferred to Medical service on [**2128-5-9**]. NICU COURSE: The patient was admitted to the ICU on [**2128-5-7**] for respiratory distress which was thought to be multifactorial from a possible PNA, obstructive sleep apnea, and fluid overload. He was initially treated with Vanc/Zosyn/Cipro which was later changed to Vanc and Levo to cover for possible healthcare-associated PNA. He was given lasix 80mg IV x 1 and diuresed over 4L. His respiratory status improved after this and was given another dose of Lasix 80mg IV on the morning of [**2128-5-9**]. He was kept on bipap for his OSA. Urine legionella was negative and C. Diff was negative. Imdur, Metoprolol and Lisinopril were initially held in the setting of acute illness but Imdur and Metoprolol were restarted on [**2128-5-9**]. He was not placed on full dose of Lantus insulin due to decreased PO intake and fingersticks were in the normal range. # Multifocal pneumonia, bacterial: Patient completed an 8 day course of Vancomycin and 5 day course of levofloxacin. His respiratory status improved. # Acute on chronic diastolic CHF: Repeat ECHO showed stable EF. He was initially diuresed with IV furosemide. However, he developed hypovolemia with increasing Cr, BUN, and contraction alkalosis, and further diuresis was held for 48 hours prior to discharge with stabilization of Cr at 1.6. Discharge weight is 136 kg. For discharge, he was restarted on a lower dose of his prior home regimen of furosemide at 40 mg [**Hospital1 **]. This should to adjusted as needed. He was restarted on half of his home dose of lisinopril and can also be titrated up pending improvement of his creatinine. # Acute renal failure: Baseline Cr is ~1.3. On admission, Cr was 2.2 and improved with diuresis in the MICU. However, he developed hypovolemia with increasing Cr, BUN, and contraction alkalosis, and further diuresis was held for 48 hours prior to discharge with stabilization of Cr at 1.6. For discharge, he was restarted on a lower dose of his prior home regimen of furosemide at 40 mg [**Hospital1 **]. This should to adjusted as needed. While he was in the MICU, he developed penile bleeding, likely from traumatic Foley placement; however ANCA, [**Doctor First Name **], cryoglobulin, and anti-GBM were sent to eval for pulmonary-renal syndromes and were all unremarkable. # L leg pain/swelling: Patient developed L > R pedal edema. Ultrasound was negative for DVT. This improved with diuresis and TEDS. # Urinary retention: Patient was noted to have urinary retention. A Foley was placed, and he failed voiding trial. Flomax was started and he will need outpatient Urology follow up. # COPD: He did not have an acute exacerbation. He was on standing nebulizers and Advair. # DM2, uncontrolled, with complications: Initially, he had issues with hypoglycemia, requiring decreased insulin dosing compare to prior. This will need to be adjusted prn. # Coronary artery disease: He was continued on ASA, plavix, statin, and beta blocker. # Obstructive sleep apnea: Patient utilizes CPAP overnight. Medications on Admission: HOME MEDICATIONS: humalog 45u sq with meals lantus 70u sq QHS imdur 90mg daily metoprolol 25mg po BID albuterol nebs q4h prn symbicort 2 puffs [**Hospital1 **] senna 8.6mg po qhs prn colace 100mg po bid aspirin 81mg daily plavix 75mg daily furosemide 80mg [**Hospital1 **] lisinopril 20mg daily oxycontin 10mg po TID protonix 40mg daily simvastatin 40mg po with supper zetia 10mg po daily Discharge Disposition: Extended Care Facility: [**Hospital 27838**] Rehabilitation & [**Hospital **] Care Center - [**Hospital1 1474**] Discharge Diagnosis: Pneumonia, bacterial Acute on chronic diastolic heart failure Acute renal failure Urinary retention Chronic obstructive pulmonary disease Diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 10083**], It was a pleasure taking care of you. You were transferred to [**Hospital1 69**] with severe pneumonia and worsening of your heart failure. Your breathing has improved with antibiotics and Lasix to remove fluid. You are being discharged on Lasix 40 mg twice a day, this may need to be increased at rehab. Your lisinopril dose was also decreased to 10 mg once a day and may also need to be increased at rehab. Your insulin dosing was decreased and will be adjusted at rehab. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 17996**] within 2 weeks of being discharged from rehab. His clinic number is [**Telephone/Fax (1) 6699**]. Please obtain a referral from Dr.[**Name (NI) 106624**] office for a Urologist in [**Hospital1 1474**]. You will need to see a Urologist within 2 weeks to assess your urinary retention. Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Specialty: Cardiology Location: [**Hospital1 **] HEALTHCARE - [**Location (un) 8720**] Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY,[**Apartment Address(1) 8722**], [**Location 8723**],[**Numeric Identifier 18655**] Phone: [**Telephone/Fax (1) 8725**] Appointment: Thursday [**5-27**] at 5:20PM

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icd9cm

[ [ [] ] ]

[ "57.94", "93.90", "99.21", "38.93" ]

icd9pcs

[ [ [] ] ]

13445, 13560

9670, 13005

324, 346

13760, 13760

5680, 5680

14484, 15260

4835, 4963

13581, 13739

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374, 3368

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13775, 13919

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4617, 4819

13,783

145,266

45242

Discharge summary

report

Admission Date: [**2155-2-1**] Discharge Date: [**2155-2-8**] Date of Birth: [**2092-2-20**] Sex: F Service: CARDIAC INTENSIVE CARE UNIT CHIEF COMPLAINT: Status post cardiac arrest. HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname 17437**] is a 62-year-old female who was found unresponsive by her husband at approximately 7:00 p.m. the night of admission. For approximately one week prior, the patient had been having intermittent back pain, located between the shoulders and radiating down her arms. The pain would come on at rest and last several hours. The patient was seen at [**Hospital **] Hospital ED and told that the pain was not cardiac. They were having apparently normal EKGs and one negative set of cardiac enzymes and a negative CT of the chest. The patient was apparently then sent home but continued to have the pain intermittently through the next week. On the day of admission, the patient went to the movies with her husband. After coming home, the patient collapsed in the kitchen. She was not breathing and did not have a pulse. The patient's husband called [**Name (NI) 9168**] who came within five to ten minutes. An automated external fibrillator was placed and shocked to 200 joules, restoring normal [**Name (NI) **] rhythm. The patient was intubated in the field and started on lidocaine and a nitroglycerin drip. She was given Lopressor 5 mg IV times four and Esmolol 40 mg IV times one. The first set at the outside hospital showed a CK of 55.9, troponin 6.02. The patient was then transferred to the [**Hospital6 1760**] for cardiac catheterization and further evaluation and treatment. At baseline, the patient is very sedentary. She has had some dyspnea on exertion. She has never had chest pain before. She has had syncope three to four times throughout her life, no known etiology. She has a 75 pack year history. Occasionally, she takes Percocet for abdominal discomfort. PAST MEDICAL HISTORY: 1. Flare of MS many years ago. 2. History of GERD. 3. Depression. 4. Anxiety. OUTPATIENT MEDICATIONS: 1. Protonix 40 mg p.o. q.d. 2. Paxil 20 mg p.o. q.d. 3. Klonopin 0.5 mg p.o. b.i.d. 4. Percocet p.r.n. TRANSFER MEDICATIONS: 1. Lidocaine drip at 2.0 mg per minute. 2. Nitroglycerin drip at 80 micrograms per kilogram per minute. ALLERGIES: The patient has no known drug allergies. She does have some type of allergy to paper tape. SOCIAL HISTORY: She works at a surgical supply company. She is married and lives with her husband, but no children in the house. She has a 75 pack year history, quite ten years ago. She denied any alcohol or drug use, per the family. FAMILY HISTORY: The patient's mother had a MI in her 50s and died in her 50s after having a defibrillator placed or a pacemaker. The patient's family denied any history of diabetes, hypertension, or sudden cardiac death. PHYSICAL EXAMINATION ON ADMISSION: Upon presentation to the Cardiac Intensive Care Unit, the patient had the following physical examination. Vital signs: Temperature 100.3, blood pressure 118/70, heart rate 105, [**Hospital6 **] tachycardia. She was on assist control ventilator with tidal volume 600, respiratory rate 12, 75% oxygen. She had a PEEP of 5, saturating 99% on those settings. General: Intubated and sedated, unresponsive. HEENT: The pupils were equal, round and reactive to light. She had eyes roving bilaterally. She was anicteric. Cardiovascular: Tachycardiac but regular. She had no murmurs, rubs, or gallops. There was normal S1 and S2 appreciated. There was no S3 or S4. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, with normal bowel sounds. Extremities: No clubbing, cyanosis or edema. She had 2+ DP and PT pulses bilaterally. Neurologic: Arm responses, not withdrawing to pain at that time. Her feet were held in extension bilaterally, slightly increased tone and upper extremity tone was within normal limits. Her toes were downgoing bilaterally. Her deep tendon reflexes were 1+ and symmetric throughout. LABORATORY STUDIES FROM THE OUTSIDE HOSPITAL: White blood cell count 14.2, hemoglobin 14.2, hematocrit 43.0, platelets 340,000. PT 13.1, PTT 23.1, INR 1.1. Chemistry Seven: Sodium 143, potassium 3.8, chloride 108, bicarbonate 22, BUN 15, creatinine 0.9, glucose 146. Of note, she had a tox screen that was positive for opiates at the outside hospital. She had a U/A which showed 30 protein, [**3-5**] red blood cells. Her CK here at [**Hospital3 **] was 1,142 with MB of 56, troponin 6. She had a head CT at the outside hospital which was negative for bleed. An EKG at [**Hospital1 **] [**First Name (Titles) 654**] [**Last Name (Titles) **] tachycardia around 100, left axis deviation, normal intervals, possible [**Hospital1 **]-atrial enlargement, no ventricular hypertrophy. There were Q waves in I and aVL and V5 and V6. There was T wave flattening in I, aVL, V4 through V6. There were no rhythm strips available from the field where she was defibrillated. LABORATORY DATA FROM [**Hospital3 **]: The first set of laboratories revealed a white blood cell count of 18.5, hematocrit 39.8, platelets 327,000. PT 20.1, PTT 127, INR 1.1. Sodium 141, potassium 3.7, chloride 108, bicarbonate 21, BUN 18, creatinine 0.7, glucose 157. Calcium 8.8, magnesium 1.6, phosphorus 2.6. Her first CK here rose from the outside hospital was 1,142 to 2,273. She had an echocardiogram at the bedside which showed global left ventricular hypokinesis with an EF of about 20%. She had a chest x-ray shot which showed possible cephalization and possible right upper lobe collapse. In addition, the patient subsequently had an U/A drawn which showed trace leukocyte esterase, [**4-2**] white cells. She also had cardiac catheterization performed which revealed the following: The patient had a cardiac output of 3.75, cardiac index 2.13. Her coronary angiography revealed a normal left main coronary artery, a moderate calcification of the LAD with a 50% mid, 60% ostial D1 lesion. Her left circumflex was with 100% thrombotic OM-1 with patent left collaterals. The RCA showed balance dominance fills a small portion of PDA territory. No significant disease. The other findings included mildly elevated filling pressures with a depressed cardiac index. Left ventriculography showed anterolateral and apical akinesis, no mitral regurgitation. Left ventricular ejection fraction of 25%. The patient had subsequent chest x-rays which revealed resolution of CHF and no opacities or infiltrates. Her CKs continued to rise to 4,044 and peaked there. Her pulmonary capillary wedge pressure was 20. The day prior to discharge, the patient had the following laboratory values. Her white blood cell count was 8.2, hematocrit 30.1, platelets 222,000. Sodium 139, K 3.9, chloride 102, bicarbonate 26, BUN 17, creatinine 0.6, calcium 8.7, magnesium 1.8, phosphorus 4.1. HOSPITAL COURSE: 1. CARDIOVASCULAR: Pump function as shown by echocardiography and cardiac catheterization: The patient has a severely depressed left ventricular ejection fraction with elevated filling pressures. The EF is approximately 20%. The patient was clinically volume overloaded with crackles bilaterally on examination. She was diuresed and started on 40 p.o. q.d. of Lasix with gradual resolution of the crackles. She was started on an ACE inhibitor and beta blocker and tolerated these well for her low ejection fraction. RHYTHM: The patient was transferred here for apparent V-fib arrest presumed due to ischemia given the ruling in by cardiac enzymes, findings on EKG consistent with a myocardial infarction. She had an implantable cardioverter defibrillator placed two days prior to discharge. She experienced no ectopy the last several days of her admission. She was rate controlled with beta blocker. CORONARY ARTERY DISEASE: The patient had a stent placed to a large OM-1 vessel following non ST elevation MI. She remained chest pain-free throughout the duration of her hospital stay. She was started on Plavix, statin, aspirin, beta blocker, and ACE inhibitor. Of note, the patient complained of back pain through the hospital stay. This was certainly not ischemic. She had no further EKG changes and had chronic complaints of back pain prior to admission. 2. NEUROLOGIC: The patient was unconscious for approximately five to ten minutes before being defibrillated and regaining consciousness. Through the hospital stay, she had a short-term memory deficit but really no other neurologic deficits. She was seen by the Neurologic Service and then subsequently by the Behavioral Neurology Consultation Service who said that the patient had an antegrade amnesia of mild degree and also stated that recovery from the neurological standpoint occurs over the first three to six weeks primarily and plateaus at three to six months and said that the patient had a good prognosis given her rapid recovery over the hospitalization and limited deficits. They also recommended that she not drive and she follow-up with Behavior Neurology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], at [**Telephone/Fax (1) **], and was given the number for that. No imaging was done subsequent to the CT at the outside hospital. MRI was considered but given the recent placement of the cardiac stent, it was deemed that the risk of dislodging the stent outweighed the benefit that may be obtained from the MRI as there would likely be no neurologic intervention, although the prognosis might be more clear by the MRI. 3. INFECTIOUS DISEASE: The patient was given a seven day course of levofloxacin for her positive leukocyte esterase and UTI, although likely an actual urinary tract infection seemed low. In the setting of the V-fib arrest and her tenuous status in the Intensive Care Unit, it was thought to be prudent to start her on levofloxacin. She did continue a seven day course. 4. PSYCHIATRIC: The patient has a history of anxiety. She was started back on her daily dose of Klonopin 0.5 mg b.i.d. the day after admission and continued on her Prozac. She was mildly anxious and agitated for the first several days of her hospitalization but thereafter had no further agitation following the administration of Klonopin and the Prozac. CONDITION AT DISCHARGE: Fair. DISCHARGE STATUS: To home with [**Name (NI) 269**], PT and OT. DISCHARGE DIAGNOSIS: 1. Status post ventricular fibrillation arrest. 2. Status post non ST elevation myocardial infarction. 3. Status post stent placement in obtuse marginal I branch of the left circumflex artery. 4. Anoxic brain injury with short-term memory loss. 5. Urinary tract infection. 6. Mild congestive heart failure. 7. Left ventricular ejection fraction roughly 20%. 8. Anxiety. 9. Gastroesophageal reflux disease. DISCHARGE MEDICATIONS: 1. Furosemide 40 mg p.o. q.d. 2. Toprol XL 50 mg p.o. q.d. 3. Klonopin 0.5 mg p.o. b.i.d. 4. Protonix 40 mg p.o. q.d. 5. Plavix 75 mg p.o. q.d. 6. Lisinopril 20 mg p.o. q.d. 7. Prozac 20 mg p.o. q.d. 8. Atorvostatin 10 mg p.o. q.d. 9. Aspirin 325 mg p.o. q.d. FOLLOW-UP PLANS: The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Cardiology. She is to call his office for an appointment. She will be given the phone number. She is also to follow-up with Dr. [**First Name (STitle) **], Behavioral Neurology, and has been given his phone number as well. Finally, she should call her internist and make an appointment for one week following discharge for follow-up as well. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**] Dictated By:[**Last Name (NamePattern1) 11801**] MEDQUIST36 D: [**2155-2-7**] 03:15 T: [**2155-2-8**] 17:16 JOB#: [**Job Number 32236**]

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icd9cm

[ [ [] ] ]

[ "36.06", "99.20", "37.26", "37.23", "36.01", "88.56", "88.53", "37.94", "96.71" ]

icd9pcs

[ [ [] ] ]

2679, 2907

10903, 11173

10464, 10880

6968, 10355

2082, 2190

10370, 10443

11191, 11935

172, 1953

2212, 2424

2922, 6951

1975, 2058

2441, 2662

4,696

123,934

45413

Discharge summary

report

Admission Date: [**2121-9-9**] Discharge Date: [**2121-9-16**] Date of Birth: [**2049-6-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: Transfer from [**Hospital3 1196**] for hypotension during dialysis and leukocytosis. Major Surgical or Invasive Procedure: None History of Present Illness: 71F with ESRD on HD, IDDM, PVD, AF s/p PPM, cirrhosis, [**Hospital 35745**] transferred from [**Hospital3 **] after becoming hypotensive(SBPs to 80) yesterday during hemodialysis. 1 liter removed. Aching in left neck and jaw. Also reported vague abdominal pain over one week in addition to foul smelling urine and dysuria. trop to 0.3. 1 liter fluid bolus given with little response. The patient was started on peripheral dopamine at that time as well as vancomycin and Zosyn after CXR with reported RLL opacity and concern for HD catheter infection. ? of medication allergy, therefore placed only on Cipro for UTI at this time. Ct abdomen given abdominal pain with bilateral pleural effusions, LLL air space opacities. Left adrenal mass, liver lesion, cholelithiasis, hyperdense mass in the right kidney midpole. ascites in the subcutaneous tissue and in the mesentery. Pt continued to necessitate pressors max dopa at 5mcg but is refusing central line or A-line. To [**Hospital Unit Name 153**] somnolent but arousable, afebrile, BP 110/48 on 4 mcg dopamine. . Of note, [**Date range (1) 83275**] admission for hypercarbic respiratory failure setting of OSA, narcotic use vs pneumonia. 7 day course of ceftriaxone, azithromycin. Vanc for suspicion of HD catheter infection. Trop leak to 0.27, no EKG changes. MRSA wound cx [**2121-4-10**], MRSA blood cx [**2121-1-28**]. Note from Dr. [**Last Name (STitle) 2434**] for non healing LE ulcer to have vanc course, pt denies taking at HD. ROS: Mild abdominal discomfort, Occasional nausea. Denies fever, chills, hematemesis, Reports baseline sob on 2L NC at home for presumed COPD. Past Medical History: -ESRD/CRI - Patient receives HD @ "[**Last Name (un) **]" center in [**University/College **] M/W/F. Attempted HD yesterday no filtrate -IDDM - Course has been complicated by polyneuropathy, nephropathy, retinopathy, and Charcot foot bilaterally. Patient does not check her FS at home. Followed by Dr. [**First Name (STitle) 1313**] ? in [**Last Name (un) **]. -Peripheral vascular disease -AF - Pt is s/p pacemaker placement. She is not anticoagulated due to multiple falls. -Anemia -Hyperlipidemia -Cirrhosis secondary to cholestasis -Hypertension -Coronary artery disease- Pt had three vessel disease on cardiac cath from [**2111**]. She is s/p NSTEMI in [**2110**]. Stress test '[**12**]. Moderate, fixed perfusion defect in the inferior wall. Mild global hypokinesis. -Dilated ischemic cardiomyopathy- Pt's most recent echo was [**2119-6-26**]. EF 40%; mod LA/RA dilation; mild LVH/mild global HK (most prominent in the septum); 1+ MR. Mod pulmonary HTN -Adrenal adenoma -S/P TAH for leiomyoma -Right facial droop in [**7-/2119**] for which she declined workup or treatment. -Depression -s/p mechanical fall, L elbow/olecranon Fx on [**2120-1-6**] - conservative management Social History: Pt lives in her own home in [**Location (un) 1110**]. She has 24 hour help at this time, although recently helper can't come in over the weekend, the son has been speding more time with her. The patient rare walks with a walker and mostly gets about in a wheelchair. She is very close with her daughter, [**Name (NI) 2808**], who visits often and her son, [**Name (NI) 96930**], who is her healthcare proxy. His phone number is [**Telephone/Fax (1) 96931**]. DNR/DNI. Pt used tobacco in the past - quit 24 years ago. Denies ETOH or drug use. Pt uses a wheelxhiar, not active. Family History: Fa - DM, CAD; Ma - Breast Ca; Physical Exam: Vitals- T 98.9 BP 110/42 HR 65 RR 10 O2sat: 93% on 3L NC Gen- sleepy appearing female responding to questions when asked HEENT- OP clear, MMM, Unable to assess JVP secondary to girth CV- bradycardic, RRR, no M/R/G Resp- sparse crackles. Dullness to percussion at bases bilaterally. Poor inspiratory effort. HD catheter with hypoerpigmentation, no purulence. Non tender to palpation. Abd- distended. Hyperactive bowel sounds. Mild tenderness to palpation all quadrants. No rebound or gaurding. No dullness to percussion. No echymoses. Ext- cool to touch. Trace radial pulses. Dopplerable pedal pulses. Large stage 2 pressure ulcer right heel with green area. Similar 2x2 inch ulceration over left lateral malleolus. Decreased sensation below ankle. Denuded skin intertriginous. Contracture left 3,4,5 finger. Skin- Cool extremities. [**Name (NI) 298**] Pt sleepy but alert oriented x 3. Pt non compliant with cranial nerve exam. Unable to assess strength or CN. Pertinent Results: ON ADMISSION: [**2121-9-9**] 11:29PM BLOOD WBC-13.8* RBC-3.29* Hgb-11.2* Hct-35.2* MCV-107* MCH-34.0* MCHC-31.8 RDW-19.9* Plt Ct-86* [**2121-9-9**] 11:29PM BLOOD Neuts-63 Bands-0 Lymphs-9* Monos-27* Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-1* [**2121-9-9**] 11:29PM BLOOD PT-15.1* PTT-31.6 INR(PT)-1.4* [**2121-9-9**] 11:29PM BLOOD Glucose-191* UreaN-28* Creat-4.3*# Na-137 K-5.7* Cl-97 HCO3-30 AnGap-16 [**2121-9-9**] 11:29PM BLOOD ALT-5 AST-7 LD(LDH)-198 CK(CPK)-22* AlkPhos-86 Amylase-14 TotBili-0.3 [**2121-9-10**] 04:59AM BLOOD CK(CPK)-24* [**2121-9-9**] 11:29PM BLOOD CK-MB-5 cTropnT-0.80* [**2121-9-10**] 04:59AM BLOOD CK-MB-6 cTropnT-0.73* [**2121-9-9**] 11:29PM BLOOD Albumin-3.5 Calcium-7.8* Phos-4.0# Mg-1.9 [**2121-9-10**] 01:16AM BLOOD Lactate-1.2 Brief Hospital Course: 72 yr old ESRD on [**Hospital **] transferred from [**Hospital3 1196**] after presenting with hypotension post HD, with leukocytosis. . #CAD/Troponin Leak: Concerned in setting of hypotension with hemodialysis that patient developed demand ischemia. No acute changes in ECG per NWH, and ECG here show no acute changes. Peak troponin 0.8, MB 6, CK 22. Baseline tropinin due to CKD is about 0.3. Patient's sensation of neck/jaw pain on the left side, her anginal requivalent, resolved over the night of [**9-9**]. Patient medically managed on ASA, statin. B-Blocker was held in the setting of hypotension requiring pressor support. - Spoke with patient's outpatient cardiologist about event, Dr. [**Last Name (STitle) 96932**] [**Name (STitle) **], who given patient recommended imaging only if patient would be willing to undergo a medical intervention. Patient has declined any further medical interventions such as a cardiac catheterization. -pt discharged on prior home dose of metoprolol 12.5 mg po bid . #Hypotension: Patient has history of episodes of hypotension with dialysis. Patient not febrile, but has had HD catheter infections before and due to the patient's poor access status the decision has been made to treat through possible infections ([**2-12**] last time access was changed). Patient was started on Vancomycin and Zosyn at NWH, but patient required dopamine drip for pressures. Given patient's troponins, ICU team suspected the patient's persistent hypotension was more likely due to troponin leak with component of myocardial stunning than sepsis. Patient had negative urine and blood cultures to date. Patient has multiple sources for sepsis inc. pulmonary: RLL opacification and bilateral consolidation/effusions, urine: scant urine, but + U/A, Extremities: chronic venous/pressure ulcerations which have grown MRSA and pseudomonas in the past, and the most likely is HD catheter infection given patient per notes was supposed to be on Vancomycin with HD for ? of line infection. Plan is to treat with vanco for total two weeks ([**9-24**]) for presumptive HD line infection due to pt's leukocytosis and prior hx, although no further evidence per cxs, exam and hx. U Cx. repeated [**9-14**] - negative. . # Abdominal pain: Most likely due to constipation. Pt required disimpaction during admission. On aggressive bowel regimen and passing stool on own. . Abdominal pain in the setting of hypotension with hemodialysis - resolved. Patient states she frequently gets abdominal pain with low pressures which resolve as soon as her pressures normalize. Suspect chronic mesenteric ischemia. Patient does not want aggressive interventions. Will defer to PCP if desires further work-up. . #Leukocytosis: Resolved [**9-10**] on antibiotics. To 14.6 at OSH. Treating for line infection emperically with vancomycin dosed at HD - last dose planned for [**9-19**]. . #ESRD: On HD (MWF) at [**Last Name (un) **] in [**University/College **]. No further episodes of hypotension during dialysis in hospital. #Somnolence: Resolved with antibiotics. Patient alert and oriented *[**2-9**]. Pt with hypercarbic respiratory failure in the past; likely component of OSA. Patient does not tolerate CPAP due to extreme anxiety. . #Foot ulcers: Concerning given Hx., but no acute change - daily wound care continued. . #Wrist fracture: Pt's L forearm imaged as she sustained fall prior to admission to hospital (reportedly fell OOB). Imaging showed multiple fractures of the distal radius, distal ulna, fifth metacarpal, and scaphoid. Degenerative changes at the first CMC joint. Plastic surgery consulted and they recommended conservative management with thumb spica cast. . #Thrombocytopenia: Baseline platelets 50-100K, of uncertain etiology. Documented negative HIT antibody x 2 in past. . #Cirrhosis: Documented as secondary to cholestasis. Continued ursodiol. #DMII-Continued home DM regimen. . #Code status: DNR/DNI. Medications on Admission: Meds on transfer from [**Hospital6 4620**]: renagel 1600 mg TID with food Folic acid 1 mg daily Protonix 40 mg daily Lipitor 20 mg daily Aspirin 81 mg daily Zoloft 50 mg daily Zosyn 2.25 mg IV Q8 (DC'd) Actigall 300 mg [**Hospital1 **] Cipro 500 mg daily Hep sub q Lispro sliding scale Discharge Medications: 1. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 9. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 10. Clonazepam 0.5 mg Tablet Sig: half Tablet PO QHS (once a day (at bedtime)) as needed for insomnia/anxiety. 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 12. Metoprolol Tartrate 25 mg Tablet Sig: half Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*2* 14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 capsules* Refills:*2* 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twenty-four(24) hours. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1) 35 units Subcutaneous qAM: Note: this dose per [**5-19**] discharge. Continue prior home dose. . 17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1) 15 units Subcutaneous qPM: Note: dose per [**5-19**] discharge. Continue prior home dose. 18. Insulin Lispro 100 unit/mL Solution Sig: One (1) sliding scale Subcutaneous three times a day: Use lispro sliding scale per prior home usage. Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Ms [**Known lastname 410**] you were admitted due to low blood pressure during dialysis. Discharge Condition: Vital Signs Stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2121-9-16**] 10:40

[ "250.60", "996.62", "458.21", "403.91", "272.4", "357.2", "459.81", "585.6", "571.5", "E879.1", "564.00", "250.40", "285.21", "427.31", "413.9", "707.15", "362.01", "443.9", "287.4", "414.01", "250.50" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

12032, 12091

5697, 9637

399, 405

12223, 12244

4908, 4908

12393, 12517

3877, 3908

9973, 12009

12112, 12202

9663, 9950

12268, 12370

3923, 4889

275, 361

433, 2065

4923, 5674

2087, 3267

3283, 3861

27,743

135,557

3100

Discharge summary

report

Admission Date: [**2164-4-2**] Discharge Date: [**2164-4-14**] Date of Birth: [**2118-11-10**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 922**] Chief Complaint: new onset back pain Major Surgical or Invasive Procedure: Repair of type A dissection/reexploration for hematoma [**2164-4-2**] History of Present Illness: 45 yo female s/p mechanical MVR in [**2153**] by Dr. [**Last Name (STitle) 14714**]. New onset back pain on [**4-2**] at OSH. echo showed type A aortic dissection. Transferred to [**Hospital1 18**] for further eval. and treatment. Past Medical History: mechanical MVR [**2153**] (29mm Carbomedics) HTN DJD with chronic LBP spontaneous PTX [**2138**] C section [**2151**] Social History: married, lives with husband non-[**Name2 (NI) 1818**], no ETOH Physical Exam: NAD neuro grossly intact CTAB, well-healed sternal incision RRR 3/6 SEM soft, flat abd, +BS warm extrems, no edema, + distal pulses BP equal in both arms Pertinent Results: [**2164-4-14**] 06:12AM BLOOD WBC-19.0* Plt Ct-828* [**2164-4-13**] 07:00AM BLOOD WBC-17.2* RBC-3.56* Hgb-10.6* Hct-30.8* MCV-87 MCH-29.9 MCHC-34.6 RDW-14.9 Plt Ct-700* [**2164-4-14**] 06:12AM BLOOD Plt Ct-828* [**2164-4-14**] 06:12AM BLOOD PT-39.8* INR(PT)-4.5* [**2164-4-10**] 01:50AM BLOOD Glucose-119* UreaN-16 Creat-0.7 Na-139 K-3.3 Cl-106 HCO3-25 AnGap-11 [**2164-4-9**] 10:40AM BLOOD ALT-24 AST-23 LD(LDH)-379* AlkPhos-76 Amylase-130* TotBili-1.5 [**2164-4-9**] 10:40AM BLOOD Lipase-127* [**2164-4-9**] 10:40AM BLOOD Albumin-3.5 Brief Hospital Course: Admitted on [**4-2**] and CTA done to evaluate aorta. Type A confirmed and taken to OR emergently with Dr. [**Last Name (STitle) 914**] for repair of ascending aorta via redo sternotomy. Transferred to the CSRU in stable condition on neosynephrine and propofol drips. Returned to the OR for mediastinal exploration for bleeding early the next morning. Clot was evacuated and chest dressed open with esmarck bandage. Kept sedated and paralyzed while chest open. Went back to OR for sternal washout and closure on POD #2. Coumadin started on POD #3 and pacing wires were removed. On amiodarone drip for A fib and extubated on [**4-5**]. On heparin drip initially while INR was increasing. Evaluated by swallowing consult. Chest tubes removed on POD #4. Dobhoff tube placed. Foley removed on POD #5 and transferred to the floor to begin increasing her activity level. Beta blocade titrated. Abdominal labs sent for poor appetite. Swallowing evaluation repeated on [**4-9**] and much improved. Heparin DCed on [**4-10**] and lovenox started. Baseline postop CTA done on [**4-11**] and had improving PO intake. Levofloxacin started for small amount serous sternal drainage on [**4-13**].WBC increased to 19 on [**4-14**], but cultures were negative. Cleared for discharge by Dr. [**Last Name (STitle) 914**] on POD #[**11-25**]. Target INR is 3.0-3.5. INR on day of discharge 4.5. Coumadin held for evening of discharge. Coumadin dosing and INR to be followed by Dr. [**Last Name (STitle) 14715**] in [**Location (un) 8117**] NH [**Telephone/Fax (1) 14716**]. Next blood draw scheduled for [**4-16**]. Medications on Admission: coumadin 5 mg daily cardizem 240 mg daily folic acid daily zantac vitamins calcium tylenol abx prophylaxis for dental procs. Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days: Then decrease dose to 200 mg PO daily. Disp:*35 Tablet(s)* Refills:*0* 8. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:*50 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 11. Coumadin 1 mg Tablet Sig: Zero (0) Tablet PO tonight: Take 1 mg on [**4-15**] PM, then take as directed by Dr. [**Last Name (STitle) 14715**] for INR goal of [**2-17**].5. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Home Health & Hospice Care of [**Location (un) 8117**], NH Discharge Diagnosis: Acute type A aortic dissection. s/p Mechanical MVR chronic LB pain HTN Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 3 months. Shower daily, let water flow over wounds, pat dry with a towel. Call our office for sternal drainage, temp>101.5. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 14717**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 914**] for 4 weeks. INR/coumadin dosing to be followed by Dr. [**Last Name (STitle) 14715**] in [**Location (un) 8117**] [**Numeric Identifier 14718**]- target INR 3.0-3.5 Completed by:[**2164-4-16**]

[ "V58.61", "423.0", "286.9", "420.90", "722.52", "441.01", "V43.3", "998.11", "424.1", "427.31", "401.9" ]

icd9cm

[ [ [] ] ]

[ "34.72", "35.39", "35.11", "39.61", "39.31", "38.45", "99.07", "99.05", "37.12", "99.04", "96.6" ]

icd9pcs

[ [ [] ] ]

4902, 4991

1601, 3200

297, 369

5106, 5114

1041, 1578

5392, 5720

3375, 4879

5012, 5085

3226, 3352

5138, 5369

865, 1022

238, 259

397, 629

651, 770

786, 850

22,973

153,156

42944

Discharge summary

report

Admission Date: [**2171-5-10**] Discharge Date: [**2171-6-5**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1**] Chief Complaint: Transferred from OSH for gastric outlet obstruction. Major Surgical or Invasive Procedure: s/p CVL placement and TPN support s/p Gastrojejunostomy [**5-20**] s/p j-tube placement (removed [**5-31**] secondary to partial small bowel obstruction at the level of the tube) s/p laryngoscopy for vocal cord edema History of Present Illness: She presented with 2 episodes of hematochezia and 1 episode of hematemesis 3 months ago in [**2171-1-29**]. She was admitted to [**Hospital 2586**] Medical centre when she was found to have erosive gastritis and gastric ulcers per EGD. 1 day post discharge she had another episode of melena and increased burping and was re-admitted via the ED to [**Hospital3 **]. EGD at that time revealed 2 nonbleeding gastric ulcers with new duodenal ulcer with visible vessel. Patient was discharged on omeprazole. She noticed increasing abdominal distention and burping several weeks ago. She represented with these symptoms and another episode of melena on [**5-10**] and an EGD done at that time demonstrated gastric outlet obstruction. She was transferred here for further care. Past Medical History: CAD s/p MI [**42**], 88 Angina HTN, arthritis hypercholesterolaemia L total hip replacement Gout Social History: married 2 children 4 grandchildren retired admistrative assistant ex-smoker. stopped 30 years ago non drinker no recreational drug use Family History: father:lung cancer died in this 70s from MI no other history of malignancy Physical Exam: P/E: tmp: 98 bp 110/50; p 101; rr 22; saO2 95% on 1L O2 HEENT: normal Neck: supple. supraclavicular LN negative CVS: RRR, HS normal, no murmurs RR: clear Neruo: grossly normal Abd: Soft, NT, ND Ext: no oedema Skin: normal Pertinent Results: [**2171-5-10**] 11:05AM WBC-12.1* RBC-3.80* HGB-10.4* HCT-31.4* MCV-83 MCH-27.3 MCHC-33.0 RDW-14.6 [**2171-5-10**] 11:05AM GLUCOSE-101 UREA N-48* CREAT-1.7* SODIUM-138 POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-26 ANION GAP-18 Brief Hospital Course: EGD was repeated on [**5-13**] and showed ulcer in the duodenal bulb as well as duodenal stricture, causing gastric outlet obstruction. A PICC line was placed and she was started on TPN for nutritional support. Exploratory laporatomy [**5-20**] revealed a gastric mass and obvious peritoneal and liver studding. Biopsy of a mesenteric mass was positive for adenocarcinoma. Gastrojejunostomy and feeding jejunostomy were performed. Her post operative course is summarized as follows: 1. Neuro: Her pain was well controlled initially with a PCA and prior to DC with oral dilaudid. 2. CVS: As recommended by Cardiology prior to surgery, she was started on beta-blockers that were continued postoperatively. with these, her BP and HR were well controlled. 3. Resp: On POD she developed significant dyspnea and wheezing. workup rued out any significant pulmonary process (CXR). PE (neg. CTA) or cardiac event. she did not respond to nebulizers or diuretics. Her saturations remained stable at all times. Because of her upper airway wheezes she was seen by the ENT service and on laryngoscopy was found to have reduced left vocal cord mobility and paradoxical cord movement. On a repeat exam she was found to have worsening laryngeal and vocal cord edema and was started on inhaled and systemic steroids with significant clinical improvement. Prior to DC she is stable with good respiratory rate/sats and breath sounds. During the period of her acute respiratory issues she was transferred temporarily to a unit for close observation. 4. GI: she presented with persistent delayed gastric emtying. tube feeds through her j-tube were gradually advanced and tolerated well. An UGI on [**5-26**] showed o emtying through the gastrojejunostomy. A CT done [**5-31**] showed contrast passing through with partial obstruction at the level of the J-tube. The tube was removed on [**5-31**] and she was restarted on TPN. Once the tube was removed we were able to gradually advance her diet to soft solids which she tolerated well prior to DC. 5. GU: she presented with a rising WBC and no fevers. Work up included a positive UA. Cx were contaminated with mixed bacterial flora. She was treated for 5 day with Levofloxacin with good response (WBC prior to DC 11, no GU complaints). 6. Heme: Prior to surgery she required a transfusion for a low HCT. Postop her Hct remained stable. She recieved appropriate DVT prophylaxis. 7. ID- UTI as above. wound has healed well with no signs of infection. 8. Other: Seen by Heme.Onc for her new diagnosis of unresectable metastatic tumor. Patient and family are aware of diagnosis and will follow up in the [**Hospital **] clinic. Medications on Admission: Acetaminophen Cetylpyridinium Chl (Cepacol) Dolasetron Mesylate Heparin Hydromorphone Insulin Lorazepam Metoprolol Pantoprazole Sucralfate Discharge Medications: 1. Hydromorphone HCl 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Pantoprazole Sodium 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* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:*25 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Gastric outlet obstruction secondary to adenocarcinoma. s/p TPN support s/p Gastrojejunostomy [**5-20**] s/p j-tube placement (removed [**5-31**] secondary to partial small bowel obstruction at the level of the tube) s/p postoperative laryngeal and vocal cord edema requiring laryngoscopies and inhaled and systemic steroid treatment (short term, resolved) UTI treated with Levofloxacin Discharge Condition: stable Discharge Instructions: No strenuous exercise and no heavy lifting (>10lbs) for 6 weeks. Continue eating multiple small meals of soft blended food as instructed by nutritionist. Pain medication should be taken only as needed. While on pain medication you can not drive and might become constipated (continue taking stool softeners) Please call your doctor or come to the emergency room if you develop fever, worsening abdominal pain, vomiting or any discharge from the wound. Followup Instructions: Please call Dr [**Last Name (STitle) **] at [**Telephone/Fax (1) 92685**] to schedule a follow up appointment in his oncology clinic. Please call Dr [**Last Name (STitle) **] at [**Telephone/Fax (1) 9011**] to schedule a follow up appointment in his clinic. Completed by:[**2171-6-5**]

[ "388.72", "537.3", "518.5", "401.9", "285.9", "197.6", "996.59", "537.0", "478.6", "V43.64", "274.9", "197.7", "412", "530.10", "786.1", "414.01", "151.9", "532.90", "272.0", "599.0", "715.90" ]

icd9cm

[ [ [] ] ]

[ "99.15", "44.39", "99.04", "45.16", "31.42", "38.93", "54.23", "96.07", "46.39" ]

icd9pcs

[ [ [] ] ]

5715, 5773

2203, 4858

311, 530

6204, 6212

1955, 2180

6712, 7000

1620, 1697

5048, 5692

5794, 6183

4884, 5025

6236, 6689

1712, 1936

218, 273

558, 1330

1352, 1451

1467, 1604

27,456

111,343

6710

Discharge summary

report

Admission Date: [**2156-6-24**] Discharge Date: [**2156-7-1**] Service: MEDICINE Allergies: Levofloxacin Attending:[**First Name3 (LF) 603**] Chief Complaint: GIB Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: [**Age over 90 **] y.o. female with multiple medical problems, most pertinent for a history of diverticulosis and diverticulitis, transferred from [**Hospital3 7571**]Hospital with for further management of a GIB. Patient was admitted to [**Hospital3 7571**]Hospital on [**6-22**] with BRBPR and a Hct of 23, for which she received 4 units of PRBCs. Her Hct increased to 30 with this intervention and she remained stable for the remainder of [**6-22**] and [**6-23**]. During this time, GI and surgery were consulted and plans from both perspectives were supportive care/conservative management, particularly as she was not felt to be a surgical candidate and the patient refused. On [**6-24**], patient's Hct was noted to drop to 23 and she began to have continuous BRBPR. She remained normotensive and was not tachycardic despite these intermittent GI bleeds. She received one unit of PRBCS and an RBC scan was performed, which reportedly showed bleeding at the splenic flexure. Patient received an additional unit of PRBCs while in route to [**Hospital1 18**] for further management. Past Medical History: CAD s/p PCI Hypertension Anemia History of urinary retention and recurrent UTIs Hypothyroidism Depression GERD Osteoporosis Glaucoma TAH and bladder lift Ataxia ([**1-31**] peripheral neuropathy) Nephrolithiasis History of C. diff colitis CCY Atrial fibrillation Social History: Denies history of tobacco, alcohol or illicit drug use Family History: NC Physical Exam: VS: T - 97.6, BP - 133/67, HR - 70, RR - 18, O2 - 96% RA GEN: Awake, alert, well-related, NAD HEENT: NC/AT; PERRLA, EOMI, conjuctival pallor; OP clear, dry mucous membranes CV: RRR, nl s1, s2, no m/r/g PULM: CTAB, inspiratory crackles at left base ABD: soft, NT, ND, + BS, no HSM Rectal: Maroon-colored, guaiac positive stool EXT: warm, dry, +2 distal pulses BL Pertinent Results: EKG: Sinus at rate of 60 with prolonged PR, borderline QRS, nl QT, LAD, poor R wave progression, TWF in V1, V2, V3, no STE, no STD; Unchanged from prior . Brief Hospital Course: [**Age over 90 **] y.o. female with multiple medical problems, transferred from OSH with persistent GIB. . # GIB: Pt was initially admitted to the ICU for serial hct monitoring and pending colonoscopy by GI. Colonoscopy was performed which revealed 2 polyps and diverticulosis with old blood, but no active bleeding was visualized. Patient remained hemodynamically stable (with respect to heart rate and blood pressure) despite several episodes of rebleed. Tagged RBC scan was performed twice in the setting of active rebleed, however they failed to reveal a clear source of bleed. Her hct was monitored serially and she was transfused supportively with a total of 5 units of pRBCs. Her last episode of BRBPR was on [**2156-6-28**]. She will need daily CBC and if hematocrit drops below 25 or she has BRBPR she should be evaluated immediately and transfused. She would need interventional radiology assessment for possible embolization procedure. . # Leukocytosis: She presented with a leukocytosis of 17K with only mild neutrophil predominance of 80%. It was thought to be most likely from GI bleed/stress response as she had no history of fever and no localizing signs/symptoms of infection. UA was negative, CXR did not reveal any infiltrate. Urine culture was negative. . # CAD: She had no chest pain and EKG was without ischemic changes even in setting of her anemia and acute blood loss. Cardiac enzymes were cycled on presentation, which were negative. TTE on [**6-25**] showed preserved EF, mild LVH, and mild pulm htn (27mmHg). Her aspirin was held in the setting of GI bleed, this was restarted at 81mg daily upon discharge. She was not on beta blocker, statin, nor ACEI on presentation. Fasting lipids were checked, which were within normal limits. . # Urinary Retention: Patient was transferred without foley and Urology was consulted for foley placement due to difficulty identifying the urethral meatus. . # Hypothyroidism: She was continued on her outpatient synthroid dose of 100mcg daily. . # Atrial fibrillation: She remained in NSR on amiodarone. Her CHADS2 score was 2, with <3% yearly risk of stroke due to emboli from A fib. She was not anticoagulated in the setting of bleeding diathesis during her hospital stay, however, anticoagulation should be considered as an outpatient, she was discharged on 81mg of aspirin daily. . # Depression: She was continued on outpatient antidepressants. . # GERD: Continued on PPI. . # Glaucoma: Continued outpatient timolol and brimonidine eye drops. . # Osteoporosis: Continue calcium carbonate and she received her weekly vitamin D on [**2156-6-26**]. . # CODE: DNR/DNI confirmed with patient on arrival. Medications on Admission: Timolol gtt QD Levothyroxine 100 mcg PO QD Amiodarone 100 mg PO QD Aspirin 81 mg PO QD Celexa 20 mg PO QD MVI PO QD Omeprazole 20 mg PO QD Preservision 2 capsules PO QD Vitamin D 50,000 TU PO Qmonth (on the 28th) Vitamin B12 injection Qmonth (on the 16th) Brimonidine 0.2% gtt [**Hospital1 **] Calcium Carbonate 500 mg PO BID Senna 2 tabs PO BID Natural Balance Tear Drops 1 drop R eye QID Sodium Chloride 5% solution 1 drop L eye QID Desipramine 10 mg PO QHS [**Doctor First Name **] 180 mg PO QHS Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. Desipramine 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-31**] Drops Ophthalmic PRN (as needed). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 12. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO once a day. 13. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO Monthly on the 28th. 14. Natural Balance 0.4 % Drops Sig: One (1) Ophthalmic four times a day: to Right eye. 15. Sodium Chloride 5 % 5 % Parenteral Solution Sig: One (1) Intravenous four times a day: to Left eye. 16. [**Doctor First Name **] 180 mg Tablet Sig: One (1) Tablet PO at bedtime. 17. Xalatan 0.005 % Drops Sig: One (1) Ophthalmic at bedtime: to BOTH eyes. 18. Milk of Magnesia 400 mg/5 mL Suspension Sig: 30 cc PO once a day as needed for constipation. 19. Maalox 200-200-20 mg/5 mL Suspension Sig: 30 cc PO every four (4) hours as needed for indigestion. 20. Acetaminophen 650 mg Suppository Sig: One (1) Rectal every 4-6 hours as needed for fever/ pain with nausea. 21. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**4-4**] hours as needed for fever or pain. 22. Vitamin B12-Vitamin B1 100-1 mg/mL Solution Sig: 1 cc Intramuscular monthly on 16th. 23. PreserVision 226-200-5 mg-unit-mg Capsule Sig: Two (2) Capsule PO once a day. 24. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 25. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 26. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 25576**] Discharge Diagnosis: Primary: GI bleeding Secondary: CAD s/p PCI Hypertension Anemia History of urinary retention and recurrent UTIs Hypothyroidism Depression GERD Osteoporosis Glaucoma TAH and bladder lift Ataxia ([**1-31**] peripheral neuropathy) Nephrolithiasis History of C. diff colitis CCY Atrial fibrillation Discharge Condition: fair, with stable Hct (~29-30), and stable vital signs. Discharge Instructions: You were transferred to [**Hospital1 69**] for further management of your gastrointestinal bleeding. Studies we performed failed to identify the source of bleeding. Because you deemed not to be a candidate for surgery, and because you did not want a surgery, you were treated supportively with fluids and blood transfusions. Your blood pressure and heart rate remained stable even with episodes of bleeding, and your last episode of bleeding was on [**2156-6-28**]. . If you experience bleeding again, have chest pain, shortness of breath, fatigue, or ANY other worrisome symptoms, please contact your primary care physician or go to the emergency room. Followup Instructions: Please call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 1159**], at [**Telephone/Fax (1) 20587**] to make a follow-up appointment for sometime in the next 1-2 weeks.

[ "276.1", "733.00", "285.1", "530.81", "244.9", "564.00", "578.9", "211.3", "V45.82", "427.31", "562.10", "401.9" ]

icd9cm

[ [ [] ] ]

[ "45.23", "99.04" ]

icd9pcs

[ [ [] ] ]

7831, 7883

2309, 4993

222, 235

8223, 8280

2129, 2286

8982, 9234

1727, 1731

5543, 7808

7904, 8202

5019, 5520

8304, 8959

1746, 2110

179, 184

263, 1352

1374, 1639

1655, 1711

2,156

157,872

14234

Discharge summary

report

Admission Date: [**2109-4-1**] Discharge Date: [**2109-4-12**] Date of Birth: [**2049-4-17**] Sex: M Service: MEDICINE Allergies: Penicillins / Bactrim / Tape Attending:[**First Name3 (LF) 2181**] Chief Complaint: transferred from OSH with hypotension, leukocytosis Major Surgical or Invasive Procedure: placement and removal of central venous access debridement of sacral ulcers History of Present Illness: 59yoM with h/o Afib, HTN, s/p right hip replacement c/b right hip osteomyelitis, colostomy, who presented to [**Hospital3 3583**] with complaints of "dehydration," and was found to by hypotensive and with a leukocytosis. He was also noted to have an ARF and anemia (Hct 20), and coagulopathic. He was given a dose of Vancomycin and Zosyn, and transferred to [**Hospital1 18**] ED. Baseline Hct [**First Name8 (NamePattern2) **] [**Hospital 46**] Hosp 2.0. Baseline Hct 27. . Per reports from the patient and his son, the patient has been bed bound x2-3yrs secondary to a failed right hip fracture c/b osteomyelitis. He developed two large sacral/peroneal decubitus ulcers which eventually requireda diverting colostomy to encourage healing. He continues to suffer from depression and non-healing ulcers despite multiple courses of antibiotics. . In the ED he was still hypotensive to 70s/30s, received 5L NS and had a negative head CT, and was admitted to the MICU. In the MICU he was treated with continued iv fluids. He was continued initially on Zosyn and Vanco. Blood culture results from [**Hospital3 3583**] returned showing gram negative rods. Antiobiotics were changed on [**2109-4-2**] to Zosyn and Levofloxacin for double gram negative coverage. Speciation showed it to be Proteus, sensitivities still pending. CT of the chest, abdomen, and pelvis showed bilateral opacities concerning for pneumonia or aspiration, and a sacral ulcer with concern for osteomyelitis. A cortisol stimulation test was done; the results were within normal range. The patient was sent for MRI of the right hip; results now pending. Blood cultures since [**2109-4-1**] at [**Hospital1 18**] have been no growth to date. Echo [**2109-4-2**] showed dilated RA, mild LVH, nml EF (>65%), mild AS, moderate AR. No vegetations were seen, but could not be excluded by this study. . On presentation tonight he denies current fevers, chills, sweats, headaches, chest pain, shortness of breath, abdominal pain, nausea, dysuria, or skin changes. He complains of continued back pain. He states that all of the above symptoms have bothered him at some point over the past few days, but he had no current complaints other than back pain. Past Medical History: 1. Afib- diagnosed [**2053**], on coumadin since [**2072**] 2. R hip arthritis s/p fracture, s/p replacement, s/p osteomyelitis with Staph infection 3. ?CHF per reports 4. Colstomy 5. Gout 6. Depression 7. Hypertension 8. h/o morbid obesity 9. Perineal abscess 10. melanoma on chest Social History: divorced, lives alone, son [**Name (NI) **] lives nearby previously worked as an embroidery designer, now on disability tob: quit 5yrs ago etoh: none ivdu: none Physical Exam: T 98.7 HR 72 RR 11 BP 118/46 100% 2Lnc Gen: lying on back, anxious, tremoring in arms bilaterally HEENT: PERRL, anicteric, MMM, OP clear Neck: right IJ in place, supple, no L LAD CV: RRR, II/VI SEM, nml s1s2, no s3s4 Resp: decreased breath sounds throughout, no crackles, rhonchi, wheezes Abd: ostomy bag, soft, +bs, ttp diffusely, greatest B lower quadrants, no rebounding, no guarding, no hsm Ext: no edema Back: large stage IV sacral ulcer Skin: no rashes, ulcer as above Neuro: A&Ox3, CN II-XII intact, strength 5/5 BUE, sensation intact grossly to fine touch, with resting tremor ?associated with pain Pertinent Results: [**2109-4-1**] Head CT: No acute hemorrhage or mass effect. [**2109-4-1**] CT Chest/Abd/Pelvis: IMPRESSION: 1) Patchy centrilobular opacities at both lung bases, consistent with an infectious process or aspiration. 2) Deep gluteal ulcer extending to the sacrum, which is concerning for osteomyelitis. Sacrum is suboptimally evaluated, and MRI or bone scan is recommended. Mild inflammatory changes posterior to the rectum without evidence of an abscess. 3) Enlargement of the left adrenal gland with possible adenoma. 4) Probable cyst in the left kidney. Further characterization by ultrasound is recommended. 5) Dysplastic right femoral head and acetabulum. Advanced degenerative changes in the left hip. Brief Hospital Course: 59yoM with history of atrial fibrillatin, osteomyelitis, and chronic sacral decubitus ulcer, transferred from outside hospital with sepsis secondary to GNR bacteremia. During his hospitalization, the following problems were addressed: 1. Sepsis: the patient presented in sepsis and was admitted to the MICU where he was given aggressive iv fluid and treated with Zosyn and vancomycin. Blood cultures at the OSH grew gram negative rods, and antibiotics were changed to Zosyn and levofloxacin. He stabilized hemodynamically and was transferred to the floor. Speciation of the blood cultures at the outside hospital showed Proteus that was sensitive to levofloxacin. The Zosyn was stopped, and he was continued on po levofloxacin. He had no positive blood cultures at [**Hospital1 18**]. Urinaralysis and urine cultures were negative. His decubitus ulcers were swabbed and cultures sent. These too grew pansensitve Proteus, and this was thought to be the source of his bactermia. CXR and chest CT also showed bilateral lower lobe infiltrates concerning for pneumonia. Initially he required supplemental O2 by nasal canula. He remained afebrile and was weaned off oxygen while continuing on the levofloxacin. Transthoracic echo showed no vegetations. MRI of the pelvis and right hip was concerning for osteomyelitis. Infectious disease service was consulted and recommended six week of antibiotics. Plastic surgery was consulted. They performed bedside debridement of the ulcersThey recommended continued [**Hospital1 **] dressing changes of his wounds with wet to dry dressings and supportive care. He received QID fingersticks. With the exception of two blood glucose measurements in the 170s at noontime, blood sugars remained within normal range, and fingersticks were discontinued. He did not require insulin to maintain good glucose control. He was given folate, zinc, and vitamins A, C, and E to provide nutritional support for wound healing. On the day prior to discharge, culture results from the sacral ulcers grew sparse pansensitive Proteus and VRE. ID service was consulted and recommended a two week course of Linezolid 600mg [**Hospital1 **]. He will require an additionally 5 weeks of Levofloxacin 500mg po daily. He should have twice weekly CBC and creatinine levels checked while on Linezolid. Results can be faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11382**] in Infectious Disease at [**Telephone/Fax (1) 1419**]. 2. Decubitus ulcers: the patient has chronic ulcers. Plastic surgery and wound care services were consulted. They initially did not feel he was a candidate for VAC. It was recommended he continue with supportive care. They later determined that he should have a VAC placed on the sacral and perineal ulcers. There is no evidence of osteomyelitis on the MRI. Despite this he will be treated for 6weeks as precaution treatment for osteo. He should have [**Hospital1 **] wet to dry dressing changes with narcotics pretreatment for pain control until the VAC is placed. VAC to be changed every 3 days. He will follow-up with Dr. [**Last Name (STitle) **] in Plastic surgery for further care of these wounds. 3. Atrial fibrillation: patient has a longstanding history of Afib. When he presented to the intensive care unit he had a coagulopathy. This was reversed with Vitamin K, and his INR normalized. He was not previously on any rate control medications, but has continued to be bradycardic to normocardic with heart rate 38-80. He was monitored on telemetry. Metoprolol was not started given that he was hypotensive and did not require rate control medication. After transfer to the floor, coumadin was restarted. This was subsequently held for further debridement procedures of his wound. Goal INR once stable and facing no further procedures is [**1-31**]. 4. Anemia: patient presented with Hct 20 and was transfused. He stabilized at around 27-30, and [**First Name8 (NamePattern2) **] [**Hospital 46**] Hosp records, his baseline is around 27. Anemia was thought to be due to chronic inflammation. Stool was guiaic negative. Iron studies were not consistent with iron deficiency or chronic inflammation. His hematocrit remained stable for the rest of his hospitalization, and he required no further transfusions. 5. Coagulopathy: patient initially presented to MICU with elevated PTT and INR. Value corrected with vitamin K and FFP. His liver function tests were normal. This was thought to be due to coumadin use and nutritional deficiency. 6. Acute renal failure. Initial creatinine on admission was 3.8. It corrected with iv fluid rehydration and was likely do to prerenal azotemia. Per records from [**Hospital3 3583**], his baseline creatinine is 2.0. However, it correct to 1.2-1.3 by the time of discharge. 7. Conjestive heart failure: patient has a history of diastolic dysfunction. He had a normal EF on echo. After iv fluids he did become hypoxic, and CXR showed pulmonary edema. He was diuresed with one dose of 20mg iv lasix. Hypoxia improved and he was breathing comfortably on room air for the five days prior to discharge. His home medications had included lasix and zaroxylin. This were held, and the patient did not develop any further evidence of CHF or fluid overload. 8. Metabolic alkalosis: patient presented with a metabolic alkalosis. This was thought to be contraction alkalosis secondary to dehydration and corrected with rehydration. 9. Depression: patient was continued on his outpatient regimen. It was initially held when he was hypotensive and then resumed prior to discharge. The dose of Fluoxetine was halved as there is risk of developing a serotonin syndrome while on concurrent Linezolid. The Prozac should be titrated down while on Linezolid. After he completes the two week course of Linezolid, he should resume his usual 40mg dose. Signs of serotonin syndrome to watch for include fever, nausea, muscle rigidity, diarrhea, and restlessness. Please note that the patient has a resting and action tremor at baseline. 10. Disposition: he was evaluated by both physical and occupational therapy who recommended rehab. He was discharged to rehab for continued PT/OT and wound care. He is a full code. Communication is with the patient and his son [**Telephone/Fax (1) 42308**](h) [**Telephone/Fax (1) 42309**](c). He will follow-up with Dr. [**Last Name (STitle) **] and Plastic surgery and Dr. [**Last Name (STitle) 11382**] in ID. Medications on Admission: Meds on Admission: Allopurinol 450mg daily Celebrex 200mg daily Folate Klonipin 1mg [**Hospital1 **] Protonix 40mg daily Selenium 100mg daily thiamine 100mg daily VitC/A/E Lasix 40mg T,Th,[**Last Name (LF) **],[**First Name3 (LF) **] KCl 20mg daily Duragesic 125mg q72hrs Percocet 2tabs q4hrs Prozac 40mg daily Zaroxylen 2.5mg daily Remeron 7.5mg daily Zinc 220mg daily Coumadin 3mg daily . Meds on Transfer: Oxycodone 10mg q4hrs prn pain Zosyn 2.25mg iv Q6hrs Levofloxacin 250mg daily Fluoxetine 40mg daily Protonix 40mg daily Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Oxycodone HCl 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 4. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Zinc Sulfate 220 mg 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. Vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 12. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 weeks. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 15. Morphine Sulfate 2-4 mg IV BID with dressing change please give as pretreatment for dressing change 16. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Discharge Disposition: Extended Care Facility: [**Hospital3 20639**] Rehab - [**Location (un) 38**] Discharge Diagnosis: Primary: Proteus bactermia Sepsis Osteomyelitis Chronic decubitus ulcers Atrial fibillation Bradycardia Secondary: Depression s/p colostomy Discharge Condition: stable Discharge Instructions: If you develop fevers, chills, night sweats, chest pain, palpitations, shortness of breath, abdominal pain, or any other concerning symptoms, please call your primary care physician [**Name Initial (PRE) **]/or return to the emergency department. Please have the rehab facility draw a CBC and creatinine twice a week and fax the results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11382**] in Infectious Disease (FAX # [**Telephone/Fax (1) 1419**]) Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13076**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2109-4-23**] 10:00 You will also follow up with Dr. [**Last Name (STitle) 42310**], your primary care physician, [**Name Initial (NameIs) 20212**] [**2109-4-17**] at 10:45AM. You can call [**Telephone/Fax (1) 42311**] for details. Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2647**], MD Where: [**Hospital6 29**] SURGICAL SPECIALTIES Phone:[**Telephone/Fax (1) 20278**] Date/Time:[**2109-4-18**] 10:00

[ "041.6", "599.0", "311", "584.9", "427.31", "782.0", "730.18", "286.7", "038.49", "276.5", "401.9", "486", "269.9", "V09.80", "707.03", "995.92", "428.31", "V44.3", "525.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "99.07", "86.28", "38.91", "86.22" ]

icd9pcs

[ [ [] ] ]

13035, 13114

4568, 11080

340, 418

13299, 13307

3828, 3843

13830, 14481

11659, 13012

13135, 13278

11106, 11111

13331, 13807

3186, 3809

249, 302

446, 2675

3853, 4545

11125, 11497

2697, 2991

3007, 3171

11515, 11636

22,958

126,908

47079+58976

Discharge summary

report+addendum

Admission Date: [**2118-5-30**] Discharge Date: [**2118-6-8**] Service: MEDICINE Allergies: Penicillins / Tegretol / Quinidine/Quinine / Erythromycin Base / Vancomycin / Protonix / Neurontin / Nortriptyline Attending:[**First Name3 (LF) 898**] Chief Complaint: back pain Major Surgical or Invasive Procedure: none History of Present Illness: 81F with h/o recurrent falls, MVR on coumadin, afib, CHF, CAD, pulm htn, neuropathy p/w a recurrent fall while walking up stairs and turning suddenly, tripping, and falling down 2 stairs on to her buttocks. She developed pain in her lower back and buttocks after, her neighbor saw her later the next day and told her she needed to go to the hospital. In the ED she was found to have a new T12 compression fx and a gluteal hematoma, with an INR of 4.5. Past Medical History: 1. Rheumatic heart disease, S/P MVR with Bjork-Shiley valve. Echocardiogram [**4-/2117**]: higher gradient across valve than expected; increased (moderate) pulmonary hypertension, MR, TR, normal EF. 2. Chronic atrial fibrillation, on anticoagulation. 3. CAD. S/P remote SEMI x 2. Cardiac cath in [**2112**]: 40% L main and 40% RCA lesions, diastolic dysfunction, pulmonary hypertension. No angina or dyspnea with exertion, climbs 1 long flight stairs many times per day without sx. 4. Hypertension. 5. Colon adenomas. Last colonoscopy [**3-/2113**], next due in [**2117**]. Chronic constipation, no bleeding. 6. Peripheral neuropathy R leg since [**2087**], now bilat, unresponsive to rx. 7. Watermelon stomach with gastric varices, without bleed in more than 2 years. 8. Anxiety, depression, insomnia. maintained on celexa + ambien, much improved although recently took an extra ambien. rarely uses lorazepam, "doesn't really help". 9. Hypothyroidism s/p resection of thyroid nodule. 10. Hypercholesterolemia. 11. COPD, only symptomatic with infections. 12. Hx of actinic keratosis removed [**2108**]. 13. s/p C2 fx, R humerus and R clavicle fx, healed. 14. hx of vertigo / inner [**Last Name **] problem. 15. hx of diverticulitis. 16. CRF: baseline cr 1.3 Social History: Divorced, then remarried, now widowed. Lives alone, independent in all ADLs. Retired telephone operator trainer. Has 2 children. Nonsmoking since [**2109**], does not drink alcohol. Family History: nc Physical Exam: Tm 99.5 Tc 98.7 HR 66-88 BP 80-130/36-61 R 18 sat 100% 4LNC gen: NAD A+OX3 HEENT: mmm, no LAD, no JVD CV: RRR no m/r/g pulm: CTAb abd: s/nt/nd +BS extr: no edema, trace PT Pertinent Results: [**2118-5-30**] 02:00PM PT-27.2* PTT-24.2 INR(PT)-4.9 [**2118-5-30**] 02:00PM WBC-12.2* RBC-3.03* HGB-9.2* HCT-28.7* MCV-95 MCH-30.4 MCHC-32.1 RDW-16.5* [**2118-5-30**] 02:00PM NEUTS-85.3* BANDS-0 LYMPHS-9.4* MONOS-4.3 EOS-1.0 BASOS-0 [**2118-5-30**] 02:00PM PLT SMR-NORMAL PLT COUNT-164 [**2118-5-30**] 02:00PM UREA N-63* CREAT-4.3*# SODIUM-137 POTASSIUM-5.3* CHLORIDE-101 TOTAL CO2-23 ANION GAP-18 [**2118-5-30**] 02:32PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2118-5-30**] 02:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2118-5-30**] 07:45PM HCT-26.1* [**2118-5-30**] 07:45PM GLUCOSE-133* UREA N-60* CREAT-3.8* SODIUM-140 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-24 ANION GAP-16 [**2118-5-30**] 07:45PM CALCIUM-7.6* PHOSPHATE-3.9 MAGNESIUM-2.4 Brief Hospital Course: She was taken to the trauma SICU [**5-30**], was transiently hypotensive with falling hct and was given a total of 8U PRBCs in the ICU. Anemia was attribute to expansion of hematomas, as CT was negative for retroperitoneal and abdominal bleeds and guaiac negative throughout. Her coumadin was reversed, and she was restarted on heparin [**6-2**], but became hypotensive transiently with a hct drop to 24, so heparin was stopped, accepting risk of thromboembolism. Once Hct and hemodynamically stable, heparin was restarted with goal PTT 60-80. Coumadin restarted 24 hours later with goal INR 2.5-3.5. She was observed 36 hours and then discharged to rehab with Hct 32.5, INR 1.3, PTT 78. 1. Falls: Unclear etiology, though likely multifactorial, partially mechanical as she was turning quickly on the stairs at the time. In addition, suspect contribution from deconditioning and multiple sensory defects. It is unclear if she was orthostatic prior to her hematoma. No evidence of seizure, arrhythmia, or MI by history, and head CT wnl. Discharged to rehab for physical therapy and home safety evaluation. 2. T12 compression fracture: Compression fracture s/p fall in this osteoporotic elderly woman. Pain was well-controlled with MS Contin [**Hospital1 **], calcitonin intra-nasal, and tylenol. Discharged with TLSO brace, CaCO3, and vitamin D. Continue to hold fosamax, given GI effects, recent blood loss and ho gastric varices. 3. MVR/afib: Stable irregularly irregular heartbeat throughout admission. ECG Rate controlled with diltiazem SL. Heparin restarted [**6-5**] and coumadin [**6-6**] with INR goal 2.5-3.5 and PTT goal 60-80. 4. CAD/CHF: Held ASA and ACE-I in the setting of bleed and acute renal failure. Plan to restart as outpatient. Clinically, hypervolemic following multiple pRBC transfusions, but tolerated diuresis well with resolution of mild CHF flare by discharge. 5. Acute renal failure: Creatinine 4.3 on DOA, likely due to blood loss. Normalized following transfusions and returned to baseline by discharge. Good urine output throughout. Medications on Admission: Meds at home: dilt SR 240', zestril 20', lasix 40', coumadin 7.5', atrovent, synthroid 150', ambien, tums, psyllium, colace, senna, lactulose, vit D Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 5. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. 7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 12. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please have your INR checked 2-3 times weekly to adjust your coumadin dose to an INR of 2.5-3.5, once your INR is >2.5 your heparin can be stopped. 13. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 14. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) spray Nasal DAILY (Daily) for 1 months. 15. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: As dir As dir Intravenous ASDIR (AS DIRECTED): Heparin weight based protocol, current gtt at 1400 U/hour, goal PTT 60-80 seconds, when INR is >2.5 can d/c heparin gtt. 18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: T12 compression fracture Soft tissue hematomas Anemia Atrial fibrillation Congestive heart failure Acute renal failure Discharge Condition: Stable Discharge Instructions: 1. Please call your doctor if you are light-headed, dizzy, short of breath, or develop chest pain. Please call your doctor if your bruises increase in size. Please call your doctor if you have weakness or numbness in your arms or legs, severe headache, or new visual changes. 2. For CHF: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet 3. Please continue coumadin and have your INR checked weekly. 4. Continue to wear brace out of bed for 2 weeks. Followup Instructions: 1. Please have your PCP arrange to have a CT T spine checked to evaluate T12 fracture in 2 weeks. 2. Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1683**], in [**11-21**] weeks after discharge from rehab. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 9119**] [**Name12 (NameIs) 9120**] MEDICINE (PRIVATE) Where: ADULT MEDICINE UNIT [**Hospital3 **] HEALTHCARE - 1000 [**Location (un) **] - [**Location (un) 2352**], [**Numeric Identifier 9121**] Phone:[**Pager number **] Date/Time:[**2118-6-10**] 11:30 3. You will need your PTT followed at rehab with goal PTT 60-80 for mechanical mitral valve, until your INR is 2.5-3.5, then heparin can be stopped. You will need your INR followed so your coumadin dose can be adjusted. Completed by:[**2118-6-8**] Name: [**Known lastname 15993**],[**Known firstname 12944**] A Unit No: [**Numeric Identifier 15994**] Admission Date: [**2118-5-30**] Discharge Date: [**2118-6-8**] Date of Birth: [**2037-4-21**] Sex: F Service: MEDICINE Allergies: Penicillins / Tegretol / Quinidine/Quinine / Erythromycin Base / Vancomycin / Protonix / Neurontin / Nortriptyline Attending:[**First Name3 (LF) 211**] Addendum: Please see changes to discharge medications. Please see instructions for follow up with orthopedic service. Chief Complaint: see discharge summary Major Surgical or Invasive Procedure: none History of Present Illness: see discharge [**Last Name (un) 275**] Past Medical History: see discharge summary Social History: see discharge summary Family History: see discharge [**Last Name (un) 275**] Physical Exam: see discharge summary Pertinent Results: see discharge [**Last Name (un) 275**] Brief Hospital Course: see discharge summary Medications on Admission: see discharge summary Discharge Medications: Addendum: a) Please increase warfarin to 7.5 mg QD,as INR 1.3 on [**6-8**] b) Please hold furosemide [**6-8**] through [**6-10**] Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 2314**] Discharge Diagnosis: see d/c summary Discharge Condition: see d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 275**] Discharge Instructions: see d/c summary Followup Instructions: 4. Please follow up with your [**Hospital1 8**] orthopedic surgeon, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on Thursday [**6-16**] at 1pm to have your spine re-imaged and for TLSO brace. [**Telephone/Fax (1) 15995**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**] MD [**MD Number(1) 225**] Completed by:[**2118-6-8**]

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icd9cm

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Discharge summary

report

Admission Date: [**2133-8-30**] Discharge Date: [**2133-9-8**] Service: [**Month/Day/Year 662**] Allergies: E-Mycin / Levofloxacin / Aspirin / Metronidazole / Nitrofurantoin / Tetracycline Attending:[**First Name3 (LF) 3565**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Name13 (STitle) 4027**] is a [**Age over 90 **] year old woman with atrial fibrillation on warfarin admitted for multifactorial hypoxia secondary to pneumonia, pulmonary edema, and question of COPD exacerbation, transfered to ICU in setting of acute intracranial bleed s/p fall. She was started initially on vancomycin and zosyn for pneumonia, transitioned to community acquired coverage with cefpodoxime and azithromycin. She was also given lasix for pulmonary edema which improved her respiratory symptoms. There was also some concern initially for a potentialy COPD exacerbation, so she was given a dose of methylprednisolone 125mg then switched to prednisone. She received one dose of prednisone, and it was discontinued. Patient fell out of chair around 3:30am morning of MICU admission. Head CT showed small right subdural bleed, and mental status was alert and oriented x3. In late morning, patient complained of headache and had new word finding difficulties. Neurosurgery was consulted and suggested repeat Head CT 12 hours after previous one and reversal of INR. She was given 1 unit of FFP and 10mg IV vitamin K along with an extra dose of 40mg IV lasix in the late morning. Because she sounded fluid overloaded on morning rounds, she had received an extra dose of 40mg IV lasix in addition to home dose 2mg bumex as well. After FFP, patient developed respiratory distress, presumed to be secondary to flash pulmonary edema. She was triggered on the floor for tachypnea. She received an extra dose of 40mg IV lasix in early afternoon, and a foley was placed. Nitro paste was also placed. CXR showed pleural effusions, right greater than left, and pulmonary edema. MICU consult was initiated, at which time, patient was verbally responsive to her name but not oriented and not able to hold conversation. She was weaned from face mask to 2L nasal canula, on which she was satting 93%. She underwent stat head CT which showed significantly expanded subdural hematoma bilaterally, left worse than right. She had an episode of nausea with dry-heaving on return to the floor. No mass effect was seen on CT. Neurosurgery evaluated patient at bedside, had coversation with family that patient may recover if INR is reversed quickly. Patient was given another unit of FFP and transfered to the MICU for further management in setting of mental status and concern for potential respiratory instability. Of note, patient was also noted to be having loose stools on the floor. Stool sample was sent for c diff prior to MICU transfer. On arrival to the MICU, patient was somnolent and tachypneic, unable to converse Past Medical History: 1. Hypertension. 2. Hypothyroidism. 3. Polymyalgia rheumatica off prednisone for >2yrs 4. History of upper extremity peripheral neuropathy. 5. Peptic ulcer disease with history of GI bleed secondary to aspirin 7 years ago. 6. Status post cholecystectomy. 7. Diverticulitis 8. Complete heart block s/p DDD pacer in 5/00 9. COPD 10. CVA in past with no residual deficit on plavix qod for GIB 11. insulin resistance-with prednisone use in past 12. A fib - on coumadin since [**2128-10-25**] 13. ? Polio when she was a child whicmh may have lead to her neuropathy? Social History: She lives in [**Location (un) 538**] in senior housing independent living. She gets dinner and she makes her other meals. Her daughters buy her food. She is independent of ADLS and independent of accounting and meal preparation for breakfast and lunch. She does her own medications. Her husband passed away 10 years ago. She uses a rolling walker to ambulate. She has 6 children - 4 sons and 2 daughter who are involved in her care. She does not smoke or drink alcohol but smoked 1ppd for approx 20 years up to age 62 (20 pack-years). No IVDU. Her HCP: [**Name (NI) **] [**Last Name (NamePattern1) 21598**] [**Telephone/Fax (1) 21599**]- she lives in [**Hospital1 789**] RI Retired billing supervisor at the [**Hospital1 882**] Family History: Father: died of MI at 75 Mother: died at 84 of heart attack brother: died of MI No other hx of COPD, CA, DMII or CVA. Physical Exam: Admission Physical Exam: Vitals: T: 97.5 BP: 146/46 P: 75 R: 36 O2: 96% on 2L NC General: sleepy appearing, not oriented, responding to name HEENT: Sclera anicteric, pupils 2mm bilaterally and responsive to light Neck: supple, JVP elevated Lungs: harsh bibasilar crackles and bilateral expiratory wheeze CV: Regular rhythm, normal rate Abdomen: soft, non-tender, non-distended GU: foley draining very light yellow urine Ext: warm, palpable DP pulses, no peripheral edema Neuro: pupils symmetric and reactive, cannot cooperate with full neuro exam but moving all extremities on her own Discharge Physical Exam: Vitals: T: 97.8 HR 75 RR 15 BP 145/53 O2% 94% 2LNC General: Lethargic but arousable. Waxing and [**Doctor Last Name 688**] levels of conciousness. She squeezes fingers and wiggles toes with request. Looks at you after hearing her name but appears aphasic and doesnt respond verbally. She appears in pain but is in NAD HEENT: Sclera anicteric, pupils 2mm bilaterally and responsive to light Neck: supple, JVP not elevated Lungs: patient not able to follow commands to breath deeply but sounds clear to auscultation CV: Regular rhythm, normal rate, 2-3/6 systolic mumur heard throughout the precordium Abdomen: soft, non-tender, non-distended, good bowel sounds. Tenderness over iliac crest and patient points to iliac crest when in pain GU: foley draining yellow urine Ext: Cool but palpable DP pulses, no peripheral edema Neuro: pupils symmetric and reactive, cannot cooperate with full neuro exam but moving all extremities on her own. Arousable to name and squeezes hands and moves toes on request Pertinent Results: Admission Labs: [**2133-8-30**] 07:10AM BLOOD WBC-20.6* RBC-3.93* Hgb-12.4 Hct-35.3* MCV-90 MCH-31.6 MCHC-35.2* RDW-14.2 Plt Ct-314 [**2133-8-30**] 07:10AM BLOOD Neuts-90* Bands-0 Lymphs-4* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2133-8-30**] 07:10AM BLOOD PT-26.9* PTT-35.7* INR(PT)-2.6* [**2133-8-30**] 07:10AM BLOOD Glucose-143* UreaN-30* Creat-1.1 Na-135 K-5.6* Cl-99 HCO3-24 AnGap-18 [**2133-8-30**] 04:19PM BLOOD Type-ART pO2-65* pCO2-36 pH-7.44 calTCO2-25 Base XS-0 Discharge Labs: [**2133-9-7**] 04:25AM BLOOD WBC-17.2* RBC-3.74* Hgb-11.3* Hct-33.3* MCV-89 MCH-30.2 MCHC-33.9 RDW-14.1 Plt Ct-243 [**2133-9-7**] 04:25AM BLOOD PT-12.9 INR(PT)-1.1 [**2133-9-7**] 04:25AM BLOOD Glucose-168* UreaN-29* Creat-1.0 Na-145 K-4.0 Cl-108 HCO3-29 AnGap-12 [**2133-9-7**] 04:25AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.3 INR: Supratherapuetic 4.9 on floor before transfer to ICU. In ICU: After Vitamin K and 2 units FFP [**2133-9-2**] 03:50PM BLOOD PT-18.4* PTT-27.9 INR(PT)-1.7* [**2133-9-3**] 12:52AM BLOOD PT-13.7* PTT-25.1 INR(PT)-1.2* [**2133-9-3**] 04:51AM BLOOD PT-13.2 PTT-24.8 INR(PT)-1.1 [**2133-9-3**] 07:03PM BLOOD PT-13.0 INR(PT)-1.1 [**2133-9-7**] 04:25AM BLOOD PT-12.9 INR(PT)-1.1 Imaging: CT Head [**9-2**] New extra-axial collection measuring up to 6 mm in greatest thickness, ithout significant mass effect. No fracture Serial CT Heads CT Head [**9-2**] 1. Dramatic short-interval increase in the left subdural collection, as well as new right-sided subdural collection, with foci of hypodensity in both representing hyperacute bleeding. Increased associated mass effect with effacement of the ventricles and sulci as well as stable 6-mm rightward shift of the normally-midline structures. 2. Trace amount of new subarachnoid hemorrhage inover the left parietal lobe Serial CT Heads without interval change x 4 (most recent [**2133-9-5**]) Hip X-Ray [**9-4**]: AP view of pelvis, two views left hip done with portable technique. There is large amount of bowel gas obscuring visualization of the pelvis. Severe degenerative changes in the lumbar spine and sacroiliac joints. No discrete fracture of the proximal femur identified, but if this is clinically suspected, then CT or MRI would be more sensitive for detection of subtle fractures radiographically occult. There is mild degenerative change of the femoro-acetabular joints. Wrist X-Ray [**9-3**]: No Fracture Elbow X-Ray [**9-3**]: No Fracture Shoulder X-Ray [**9-3**]: No Fracture Brief Hospital Course: [**Age over 90 **]yo F PMHx Afib on coumadin, diastolic heart failure, who initially presented to [**Hospital1 18**] w hypoxia and shortness of breath, found to have a pneumonia and acute on chronic heart failure, course complicated by fall and bilateral subdural hematomas, now w improved respiratory status, residual stable confusion being discharged to rehab . ACTIVE # Pneumonia and Acute Diastolic CHF: Pt w O2 requirement, leukocytosis, initially treated for healthcare-associated pneumonia and heart failure exacerbation. Pt was given vancomycin, pipercillin/tazobactam, and azithromycin. In setting of fall (see below) she was switched to vancomycin and cefepime [**3-4**] concern that azithromycin could increase her INR. Patient was diuresed w prn lasix with improvement in respiratory function. Patient completed a full course of abx prior to discharge. . # Subdural hematoma: Course was complicated by unwitnessed fall [**2133-9-2**]. STAT NCHCT demonstrated subdural hematoma. F9 Complex, FFP, and vitamin K were given for anticoagulation reversal. Patient was initally AOx3 and attentive, but subsequently she developed HA and dysarthria. Patient subsequently had rapid deterioration of mental status, but she remained without focal neurologic signs. Repeat NCHCT demonstrated increased Lsided subdural collection and new Rsided subdural collection, small L parietal subarachnoid hemorrhage and mass effect. She was transferred to the ICU. Neurosurgery did not feel surgery was indicated [**3-4**] her comborbidities. Per neurosurgery recommendations, serial CT imaging was performed, without significant worsening. Patient remained w waxing and waining mental status, and she developed worsening dysarthric, eventually demonstrating both expressive and receptive aphasia. Per Neurosurgery, this course is expected and she will likely have waxing and wainig mental status for some time before she returns back to baseline. . # Altered Mental Status: As above, pt w waxing and waining mental status in setting of fall and subdural. Pain was also felt to likely be contributing as well and was treated w tylenol, morphine and lidoderm patch. . # Leukocytosis: Patient w chronic leukocytosis, without significant findings on culture data or physical exam during this hospital stay. . # Atrial fibrillation - Patient on chronic coumadin, found to have a supratherapeutic INR of 4.9. In setting of fall, coumadin was held and INR was reversed. At time of discharge INR was 1. Per neurosurgery consult, anticoagulation should continue to be held for one month after fall. Would recommend conversation with family regarding risk/benefits of restarting anticoagulation vs future falls. . # Hyperglycemia - Patient was found to have elevated blood sugars during this admission, in the setting of several doses of steroids; she was placed on an insulin sliding scale. Her sugars will need to be followed, with plan for eventual evaluation for diabetes . INACTIVE # Hypothyroidism - Continued home levothyroxine dose. . # Hyperlipidemia - Continued home statin therapy. . Transitional Issues: 1. Code status - Patient DNR/DNI 2. Pending - at time of discharge Blood Cultures from [**9-3**], [**9-5**] remained pending and will need to be followed up by rehab facility 3. Transition of Care: - [**Hospital1 18**] Neurosurgery Follow up in 4 weeks ([**2133-10-14**] at 10:30 for CT imaging, office appointment 11:15am) - Blood pressure goal is SBP<160 - Hold anticoagulation for one month after fall, can resume [**2133-10-3**] once discussion with family re: risks/benefits has been conducted Medications on Admission: Home Medications: 1. Maalox as needed. 2. Simvastatin 20 mg q.p.m. 3. Simethicone 80 mg p.o. before meals. 4. Lisinopril 5 mg daily (started at the [**Hospital1 18**] in [**Location (un) 86**] during her recent hospitalization). 5. Amlodipine 10 mg daily. 6. Bumex 2mg daily. 7. Levothyroxine 75 mcg daily. 8. Spiriva 18 mcg daily. 9. Vitamin D3 1000 units daily. 10. Oxazepam 30 mg at bedtime p.r.n. insomnia. 11. Tylenol p.r.n. 12. Coumadin as directed. Discharge Medications: 1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB. 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed for SOB. 7. bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q8H (every 8 hours) as needed for pain/fevers. 10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for body pain. 11. Saline Flush 0.9 % Syringe Sig: One (1) 3ml Injection twice a day: Please Flush PICC line with Saline only. Please do not flush line with Heparin. 12. morphine 2 mg/mL Syringe Sig: 0.5 ml Injection Q4H (every 4 hours) as needed for Pain Refractory to Tylenol. 13. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 14. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*3* 15. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea/vomiting. Disp:*40 Tablet, Rapid Dissolve(s)* Refills:*0* 17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 18. insulin lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous ASDIR (AS DIRECTED): Per printed sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Pneumonia Acute on chronic heart failure Bilateral subdural hematomas ?COPD ?Diabetes mellitus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Awake, but periods of rousable lethargy. Activity Status: Out of bed with assist. Fall precautions. Discharge Instructions: Dear Ms. [**Name13 (STitle) 4027**], It was a pleasure treating you during your hospitalization. You were initially admitted to the hospital for pneumonia and acute worsening of your heart failure. You were treated with IV Vancomycin and Cefpodoxime/Cefepime antibiotics for your pneumonia and you improved. Your heart failure was treated with oxygen and taking your extra fluid off. During your hospitalization, you experienced a fall while in your room. As a result of the fall you developed subdural hematomas (bleeding in the brain) both on the left and right side of your head. Because you were on Coumadin, your blood was thin and made you more prone to bleeding into your brain injury; this was fixed by giving you Factor 9 Complex, Vitamin K and Fresh Frozen Plasma. Your initial Head CT showed subdural hematomas but serial CT scans after correcting your anticoagulation did not show changes in the hematomas (they were stable). You were occasionally confused and sleepy, which were felt due to the bleeding in your brain. According to Neurosurgery, this is the normal course for subdural hematoma and you were discharged in stable condition to Rehab for monitoring mental status, physical therapy and improvement in subdural hematomas. The following changes to your medications were made: - Please do not take your home Coumadin - Please do not take any medications that can cause blood thinning including Aspirin, Plavix or ibuprofen, naproxen or any other non-steroidal anti-inflammatories. - Please Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] Specialty: INTERNAL [**First Name3 (LF) 662**] Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**]-[**Location (un) **]/WESTW Address: [**Street Address(2) 21600**], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 9310**] Phone: [**Telephone/Fax (1) 17753**] Please discuss with the staff at the facility the need for a follow up appointment with your PCP when you are ready for discharge. . Department: RADIOLOGY When: WEDNESDAY [**2133-10-14**] at 10:30 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 [**2133-10-14**] at 11:15 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

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11717, 12217

264, 285

357, 3002

6135, 6602

14904, 15052

3024, 3587

3603, 4333

5097, 6099

13,542

100,958

42660

Discharge summary

report

Admission Date: [**2105-11-30**] Discharge Date: [**2105-12-7**] Service: MEDICINE Allergies: Penicillins / Quinine / Sulfonamides Attending:[**First Name3 (LF) 317**] Chief Complaint: Hypotension, chest pain, SOB Major Surgical or Invasive Procedure: Cardiac cath History of Present Illness: 84 yo F with PMHx of ischemic cardiomyopathy, MI and CABG in '[**81**], PTCA [**October 2096**] with stent to SVG/LAD, rpeat stent to SVG/LAD in '[**98**], stent to LMCA-LCX in '[**99**], brachytherapy for LMCA-LCx RCA and PDA in [**December 2100**], LMCA intervention in [**May 2101**]. Recently ([**Date range (1) 92238**]), had 2 serial cath. 1sst with ulcerated 80% lesion of the proximal SV to LAD graft s/p stent. 2nd LCx w/ serial 70% lesions at themid segment. The SVG-LAD was patent. Mid LCx was successfully stented at that time. Pt presented to [**Hospital3 1196**] after having anginal sx, DOE prior to admission, went to scheduled HD and was sent to ED for worsening dyspnea and CP. Pt also complained of cough over the last few days with sputum. ROS: +orthpnea, +dietary indiscretion consuming [**4-30**] 8 oz glasses of fluid/day, not adhering CHF/renal diet. In OSH ED, BP 145/66 followed by hypotension. In OSH ED, she got neb, CXR w/ bilateral patchy infiltrates/? consolidation. WBC 19.1 Given a dose of ceftriaxone and azithromycin. Pt given morphine for CP/SOB and BP dropped to 74/42->66/39. Started on Dopa drip. EKG with LBBB (old). She was ruled in by enzymes toponin 3.1->5.1->3.7. Pt in CHF with elevated JVP, BNP of 2168. On [**11-28**], pt was diazlyzed 2 L. Echo at OSH showing EF 25%, significant AS, 2+MR, trace TR. Heparin not started for guiac positive. [**11-30**], Started dialysis at 11am but was dropping blood pressure/ no fluid removed. Pt then developed chest pressure. At 1:30pm, pt having CP, tachycardic in 120-130's, and was more tachypneic, BP 55/39. EKG w/ same LBBB. Dopa increaed to 20 mcg/kg/min and BP improved to 100/60. Heparin gtt was then started. Due to tachypneia, pt was on 100% NRB then pt was intubated and transferred to [**Hospital1 18**]. In [**Hospital1 18**] cath lab: Pt found to have LAD occluded proximally, LCX with 90% leision in the mid-distal segment, RCA without lesions, SVG-LAD patent with previous proximal stent [**90**]% lesion. S/P Cypher stent to LCx, and SVG-LAD. PCWP 20 mmHg Cardiac index was preserved at 2.5 L/min/m2 by Fick. Past Medical History: 1. CAD - s/p CABG '[**81**], multiple stents 2. HOCM 3. CRF (creatinine 3.0) s/p fistula placement rt. arm 4. HTN 5. CHF - EF 30-35% in [**Month (only) **]/04 6. HTN 7. Gout 8. LLL lung resection for carcinoid 9. s/p cholecystectomy [**10**]. s/p abd hysterectomy 11. s/p rt ant tib surgery [**12**]. rt. hip fracture [**10-28**], now with artificial hip Social History: Pt is a nonsmoker, does not use alcohol, retired and lives with her husband. Family History: significant CAD in family Physical Exam: VS: T 97.6 BP 120/50 HR 76-52 Wt. 47.5 kg GEN: Pt intubated, sedated. HEENT: NC/AT: [**Name (NI) 2994**], pt intubated, neck supple. +R IJ COR: RRR, S1, S2, III/VI high pitched vibratory systolic murmur heard along left sternal border. Also holosystolic murmur at apex. No S3. LUNGS: +coarse breath sounds bilaterally. +cracklesat bilateral bases. ABD: +BS, soft, NTND EXT: trace edema, no femoral bruit, 2+ DP bilaterlally. NEURO: Pt intubated and sedated. No posturing, no facial asymmetry. Pertinent Results: CATH: 1. Coronary angiography of this right dominant system demonstrated multivessel coronary artery disease. The LMCA had no angiographically apparent, flow-limiting disease. The LAD was totally occluded proximally. The LCx had serial 90% lesions in the mid to distal segment. The RCA was without flow-limiting disease. The SVG-LAD had a proximal 90% in-stent restenosis and diffuse noncritical distal disease. 2. Resting hemodynamics revealed elevated filling pressures with mean PCWP 20 mmHg. Central blood pressure was 102/61 mmHg on dopamine IV. Pulmonary pressures were elevated with PA systolic 40 mmHg. Cardiac index was preserved at 2.5 L/min/m2 by Fick. 3. Left ventriculography was not performed due to emergent nature of the procedure and to minimize contrast administration in patient with known renal failure. 4. Successful placement of 2.5 x 28 mm Cypher drug-eluting stent in LCx postdilated with a 3.0 mm balloon. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). 5. Successful placement of 3.5 x 23 mm Cypher drug-eluting stent in SVG-LAD postdilated with a 4.0 mm balloon. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). ECHO: 1. The left atrium is moderately dilated. 2. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis with some preservation of basal lateral and basal inferior wall motion. Overall left ventricular systolic function is severely depressed. EF 20-25% 3. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. Trace aortic regurgitation is seen. 4. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. Severe (4+) mitral regurgitation is seen. 5. There is mild pulmonary artery systolic hypertension. 6. Compared to the findings of the prior study of [**2105-9-30**], left ventricular systolic function has deteriorated, and the severity of mitral regurgitation has increased. Brief Hospital Course: 1)Hypotension: Unclear as to what triggered her hypotension. DDx: 1)HD related hypotension which caused chest pain secondary to decreased coronary perfusion 2)Cardiogenic shock after NSTEMI but CI 2.5 so unlikely. 3)Sepsis from pneumonia causing hypotension then angina from decreased coronary persusion. Pt reports SOB/Cough that came before chest pain which may suggest pneumonia/sepsis -> hypotension ->angina. Pt was initially on Neosynephrine gtt after cath to keep her MAP>60 but was able to wean off 2 days post-cath/extubation. Eventually, she was able to tolerate po metoprolol 12.5 mg po bid and lisinopril 2.5 mg po qd with good BP. 2)CAD: Pt presented with NSTEMI with positive enzymes. Peak CK 360 and MB 68, and troponin 3.29. Pt got stents to LCx and SVG-LAD. Pt was initially on Neosynephrine drip to keep her MAP>60 but was able to wean off and able to start po metoprolol. She was continued on [**Last Name (LF) **], [**First Name3 (LF) **], Lipitor; and was started on metoprolol 12.5 mg [**Hospital1 **] and lisinopril 2.5 mg po qd. 3)Pump: Last echo done at [**Hospital1 **] showing EF 30-35% with 3+MR, mil-mod AS. Echo done on [**12-1**] showing EF 20-25% (worsened), 4+ MR, mild pulm HTN. Worsened EF most likely secondary to ischemia from the LCx and SVG-LAD territory prior to intervention. Pt was discharged with po metoprolol and lisinopril. 4)Rhythm: Pt has LBBB with underlying sinus. 5)Renal: Pt has chronic renal failure and HD dependent. Cr 3.8 on admission. Pt gets dialyzed 3x/week and has AV fistula that is working well. Pt also came in with HD tunnel catheter on her L chest. Pt was seen by renal and got HD with adequate ultrafiltration, given EPOGEN, and PRBC transfusion. Pt received Sevelamer 1600 mg po tid and Nephrocap 1 cap po qd. Since her right arm AV fistula working well, her tunnel cath was successfully removed by the transplant surgery. 6)Pulm: Pt intubated on arrival, but self-extubated on [**12-1**]. Pt was maintaining good O2 sat initially with NC and later on RA after HD with adequate fluid removal. Pt also had pneumonia on CXR and productive cough on admission. Her symptoms improved after treatment with ceftriaxone and azithromycin. Pt completed 5 day course of azithromycin 500 mg qd and Ceftriaxone was continued. She will complete a total of 14 day course of Ceftriaxone, last day [**12-14**]. 7)ID: Pt was started on ceftriaxone and azithromycin for possible PNA seen on CXR at OSH and WBC of 19. Pt showed clinical improvement with lowering WBC and afebrile with these antibiotic regimen. Azithromycin was later discontinued. She was discharged with a 14 day course of ceftriaxone. 8)GI: Pt noted to have guiac+ on rectal exam at OSH. No evidence of acute Hct drop during this admission. Pt was getting Protonix 40 mg po qd. 9)Neuro: Pt noted to fell off from a bed and hit her head on the night of [**12-5**]. Exam noted for 6-7 cm scalp hematoma on the vertex. Complete neurological exam was intact. Pt denied headache, visual changes, or changes in mental status. Head CT was not obtained due to stable neurological exam. However, if she were to develop worsening headache, changes in mental status, or focal neuro findings, pt should get a STAT head CT to rule out subdural/epidural hematoma. Medications on Admission: Captopril 6.25 mg po tid on non HD days, qhs on HD. Lopressor 25 mg po bid Lasix 60 mg po qd Dig 0.0625 mg po qd [**Date Range **] 75 mg po qd Folic acid 1 mg po qd Lipitor 20 mg po qd Vit B6 200 mg po qd Vit B12 200 mg po qd Protonix 40 mg po qd Zyprexa 2.5 mg po qd Colace 100 mg po bid Senna 8.5 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 Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital **] TCU Discharge Diagnosis: CAD Pneumonia Hypotension Chronic renal failure Discharge Condition: Hemodynamically stable, patient breathing on room air. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2 L Patient was instructed to take all of the medcations as instructed. Pt needs to resume her scheduled dialysis. Pt needs to seek medical attention if she were to develop chest pain, SOB, dizziness, palpitation, diaphoresis, or any other concerning symptoms. Pt needs to follow up with her PCP and nephrologist as soon as possible. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D. Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2106-2-22**] 10:00 Completed by:[**2105-12-7**]

[ "996.72", "410.71", "E878.2", "V15.81", "458.8", "V45.81", "403.91", "486", "424.0", "518.81", "V58.3", "272.4", "414.01", "792.1", "428.0", "920" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.07", "36.05", "86.05", "37.23", "99.04", "39.95", "96.71" ]

icd9pcs

[ [ [] ] ]

10273, 10319

5659, 8962

273, 287

10411, 10467

3517, 5636

10971, 11204

2957, 2984

9322, 10250

10340, 10390

8988, 9299

10491, 10948

2999, 3498

205, 235

315, 2455

2477, 2846

2862, 2941

234

134,944

22654

Discharge summary

report

Admission Date: [**2106-4-4**] Discharge Date: [**2106-4-23**] Date of Birth: [**2052-7-28**] 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: [**2106-4-4**] - Cardiac catheterization with IABP placement [**2106-4-6**] - CABGx3(svg->lad, svg->om1, svg->pda), AVR(23mm [**Doctor Last Name **] Magna pericardial Valve) re- exploration of mediastinum and PICC line placement [**2106-4-9**] History of Present Illness: 52yo male w/ MMP who presented to OSH after the onset of CP at rest. Described CP as pressure in the center of his chest that radiated across the base of his chest bilaterally and up to his throat. It was not associated w/ SOB, n/v or diaphoresis. It lasted for about 15 mins, but he had no nitro in the house, so he called EMS. Was given 4 baby ASA by EMS and nitro x1 in the ER before his CP resolved. First set CE at OSH were negative. Had repeat episode of CP at 5am, resolved on its own. Again, had another episode of CP while boarding the helicopter for transport here. Was given fentanyl w/ resolution of his pain. . Last episode of CP was [**2106-3-22**] at [**Hospital3 417**] Hospital. Was there for L subclavian vein stenting and in PACU, developed CP similar in character to what he felt last night. Was kept in the hospital for 1 week and underwent a chemical stress test which he says revealed "abnormalities" but nothing that had to be dealt with immediately. On discharge, he was told to resume taking ASA daily. He had not been taking ASA or plavix since [**7-12**] when he underwent surgery for his decubitus ulcers. . Last evening, at OSH, he was given ASA 325 + SL ntg w/ relief of his CP. EKG on admission showed ST depression in V5-6, with ? TWI I, II. Q waves in III, avF. Overnight, he did well until 5am when he developed chest heaviness. It resolved on its own, but his EKG showed worsening ST depressions in V5 and V6 and his tropI increased from <0.1 to 1.6 (CK 45 -> 54). The decision was made to transfer him to [**Hospital1 18**] for emergent cath. He was set for ground transport when he began to develop CP again. He was instead MedFlighted here as his BP was also tenous (SBPs in 80s-90s). He was started on reopro, heparin, and plavix (600mg x1) and was transferred straight to the cath lab. In the cath lab, it was found that he has in-stent restenosis and needs surgical intervention. Plan is to take him to CABG once vascular imaging performed to identify suitable grafts. IABP placed in cath lab and referred to Dr. [**Last Name (STitle) 914**] for urgent CABG. Past Medical History: 1. CAD s/p DES in [**2-11**] LAD and CX 2. DM - on RISS for FS >200, mostly diet controlled 3. HTN 4. ESRD, s/p LRRT IN [**2099**] on chronic immunosuppression, but transplant failed [**5-11**], now on HD Tu/Th/Sat 5. COPD/Asthma 6. h/o recurrent UTI's w/ VRE and resistant Proteus (s/p kidney/bladder removal with neobladder formation and urostomy) 7. h/o MRSA in sputum 8. Spina Bifida (wheel chair dependent) 9. Stage III/IV sacral decubitus ulcers 10. Anemia, h/o guaiac positive stools and hemmorrhoids 11. possible newly dx HCV 12. possible h/o calciphalaxis(?) 13. NSTEMI Social History: Lives alone at home. No tob currently, no EtOH, no IVDU. Smoked 1.5 packs/day x 5 years, quit 30 yrs ago. Thinks received Hep C from blood tx or kidney transplant. Family History: Brother died of MI in 50s; sister w/ angioplasty in her 50s; M and MGM w/ CAD, died of MIs in 50s. Physical Exam: VS: T 96.2, HR 86-96, BP 85-100/47-60, RR 19, sats 97% on 2L IABP: ass systole 82, [**Month (only) **] diastole 84, BAEDP 60, IABP mean 79, sys unloading 18, diastolic unloading 1 Gen: Obese male, lying in bed, in NAD. HEENT: NCAT, sclera anicteric, MMM. Neck: Neck obese, JVP not appreciated. CV: RR, normal S1, S2. III/VI systolic murmur, best heard at LUSB, does not radiate to apex. Lungs: CTA anteriorly. No crackles/wheezes/rhonchi. Abd: Soft, protuberant abdomen. Multiple scars, large post-surgical hernia. Urostomy bag in LLQ, site clean, no erythema or tenderness. Mild tenderness in RLQ, but no ecchymosis. Ext: WWP. R groin w/ balloon pump in place. No c/c/e. 1+ PT and DP pulses bilaterally. 2+ radial pulses bilaterally. L forearm AVF w/ palpable thrill. Skin: No rashes. Neuro: CN II-XII grossly intact. Pertinent Results: Labs on admission: [**2106-4-4**] 10:30AM BLOOD WBC-5.6# RBC-3.30* Hgb-10.8* Hct-32.1* MCV-97 MCH-32.8* MCHC-33.6 RDW-17.3* Plt Ct-155 [**2106-4-4**] 10:00AM BLOOD PT-13.1 PTT-45.5* INR(PT)-1.1 [**2106-4-4**] 10:30AM BLOOD Glucose-93 UreaN-58* Creat-5.6* Na-139 K-4.6 Cl-98 HCO3-25 AnGap-21* [**2106-4-4**] 10:30AM BLOOD ALT-7 AST-14 CK(CPK)-49 AlkPhos-145* DirBili-0.1 [**2106-4-4**] 10:30AM BLOOD CK-MB-NotDone cTropnT-0.29* [**2106-4-4**] 10:30AM BLOOD Albumin-3.5 Calcium-9.2 Phos-7.6*# Mg-1.6 Cholest-96 [**4-23**]: NA 138 K 5.4 chloride 96 bicarb 26 BUN 53 creat 5 C. diff. negative WBC 8.2 Hct 30.8 plts 116 gluc 103 Micro: . Imaging: CATH [**2106-4-4**]: LMCA 80% discrete LAD 80% discrete LCx proximal 80% RCA 100% . 1. Selective coronary angiography in this right dominant circulation demonstrated severe three vessel coronary artery disease. The LMCA stents had moderate distal instent restenosis. The proximal LAD had an 80-90% instent restenosis. The distal LAD had only mild luminal irregularities. The D1 was a small vessel, but D2 was large and had no flow limiting disease. The LCx also had an 80-90% instent restenosis. The mid LCx was widely patent. The OM1 was a moderate size vessel and OM2 was a large vessel. Neither had any flow limiting disease. The RCA had a proximal total occlusion. There were left to right, as well as, some right to right bridging collaterals noted. 2. Non-selective angiograms of the RIMA and LIMA demonstrated patent vessels. There was a left subclavian vein stent noted. 3. Opening central aortic pressure was 89/59mmHg. 4. An 8Fr 40cc IABP was placed successfully from the right common femoral artery. . FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe instent restenosis of LM into LAD and LCx stents. 3. IABP placement. 4. Patent RIMA and LIMA. . CXR [**4-4**]: (my read) - mild perihilar haziness, R costophrenic angle slightly blurred, no evidence of infiltrate, heart regular size [**2106-4-14**] 05:32AM BLOOD WBC-9.8 RBC-3.06* Hgb-9.7* Hct-30.2* MCV-99* MCH-31.6 MCHC-32.0 RDW-17.4* Plt Ct-214 [**2106-4-14**] 05:32AM BLOOD Plt Ct-214 [**2106-4-14**] 05:32AM BLOOD Glucose-107* UreaN-36* Creat-4.8*# Na-141 K-4.3 Cl-101 HCO3-27 AnGap-17 [**2106-4-5**] ECHO The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular systolic function is normal. The ascending aorta is mildly dilated. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is moderate thickening of the mitral valve chordae. There is mild mitral stenosis. Mild to moderate ([**2-8**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. [**2106-4-6**] ECHO Prebypass: No atrial septal defect is seen by 2D or color Doppler. There is mild global right ventricular free wall hypokinesis. LV is mildly hypokinetic with lvef 50%. LV is moderately dilated with borderline lvh. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation and mild Mitral stenosis is seen. Nonmobile atheroma seen in arch. IABP in descending aorta. Post bypass: Preserved biventricular function LVEF 45-50% with no change in wall motion. Bioprosthetic #23 aortic valve instiu. No AS (peak gradient 8, mean 4), No AI, no perivalvular leaks. MS remains mild (mean gradient 4), MR [**2-8**]+. Aortic contours preserved. IABP position unchanged in descending aorta. Remaining exam unchanged. Results discussed with surgical team at time of study. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2106-4-4**] for further management of his myocardial infarction. A cardiac catheterization was performed which revealed severe three vessel disease and a intra-aortic balloon pump was placed. Heparin was continued for anticoagulation and he remained pain free. Given his history of end stage renal disease on hemodialysis, the renal service was consulted for assistance with his management. Given the severity of his disease, the cardiac surgical service was consulted for surgical management and Mr. [**Known lastname **] was worked-up in the usual preoperative manner. He underwent hemodialysis on [**2106-4-5**] in preparation for surgery without complication. An echocardiogram was performed which showed an ejection fraction of 55%, [**2-8**]+ mitral regurgitation and moderate aortic valve stenosis with a valve area of 0.9cm2. The plastic surgery service was consulted for evaluation of his sacral decubitus ulcer and no surgical intervention was recommended at this time. The wound care nurse was asked to assist in his care throughoout his hospital stay. The infectious disease service was consulted given his history of mutiple infectious disease issues and vancomycin and zosyn were recommened perioperatively for prophylaxis. On [**2106-4-6**], Mr. [**Known lastname **] was taken to the operating room where he underwent coronary artery bypass grafting to three vessels as well as an aortic valve replacement utilizing a 23mm [**Doctor Last Name **] magna valve. Afterward he was transferred to the Cardiac surgery recovery unit in stable condition and awakened neurologically intake. He required post op IABP and pressor support due to low cardiac output which was successfully weaned. On POD 2 He was transfused 2U PRBC for a low HCT during HD. He was aggressively diuresed toward his preoperative weight with HD, aspirin therapy was resumed, and physical therapy service was consulted to assist with his postoperative strength and mobility. Electrolytes were repleted as needed. On POD 3 He had a PICC line placed for continued perioperative IV vancomycin and Zosyn given his history of UTI, sacral decubitis infection, and intramuscular abscess. His epicardial pacing wires were removed. He subsequently became hypotensive, arrested and CPR was started. TEE showed hemopericardium for which he had his sternotomy opened. An avulsed side branch of the SVG->RCA graft was isolated and ligated with 7-0 prolene at the bedside. Mr. [**Known lastname **] regained pulses and his hemodynamics stabilized. He continued to require pressor support and diuresis was accomplished using CVVHD at the bedside. On POD [**6-8**] His chest tubes were removed without complication. On POD [**8-10**] his pressor support was weaned and CVVHD was discontinued. He was transferred to the cardiac step down unit for further recovery. He was initially requiring daily HD until POD [**11-13**]. At which time he resumed his qod schedule. Given his need for sternal precautions his activity level was OOB to chair via [**Doctor Last Name 2598**] lift. Plastic surgery was consulted for decubitus evaluation, and wound care team continued to follow him. He had some nausea on POD 14/11, amylase was 258, KUB was unremarkable. Repeat amylase was 124. HD continued per renal service. Pain meds were changed and nausea was relieved. OT evaluation also done. HD done on [**4-23**] and pt. cleared for discharge to rehab on POD 17/14. Please see discharge plan for required follow- up instructions. Medications on Admission: Prednisone 5mg QD Toprol XL 50mg [**Hospital1 **] Tizanidine 4mg QD Lisinopril 5mg QD Lipitor 80mg QD Imdur 30mg QD Nephrocaps Lanthanum 500mg TID Neurontin 100mg Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 11. Lanthanum 250 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 13. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-8**] Puffs Inhalation Q6H (every 6 hours). 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. 17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 ml (200 units) heparin each lumen daily and PRN. 18. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 mg Intravenous Q8H (every 8 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 2542**] - [**Hospital1 1474**] Discharge Diagnosis: s/p AVR/CABG x3 Anemia Tamponade with re-exploration of mediastinum Sacral decubitus ulcer Hstory of MRSA Hstory of recurrent urinary tract infections with VRE and resistant proteus. s/p Bladder and kidney removal CAD Diabetes HTN ESRD on HD (last HD today [**4-23**]) COPD Asthma Spina bifida NSTEMI Discharge Condition: Stable 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) Adhere to 2 gm sodium diet, low fat, low cholesterol. 5) No creams, powders or lotions to wounds until they have healed. 6) No lifting greater then 10 pounds for 10 weeks. 7) No driving for 1 month. [**Last Name (NamePattern4) 2138**]p Instructions: Follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks. Follow-up with Cardiologist Follow-up with primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 2 weeks. Follow-up with nephrologist as instructed. Call all providers for appointments. Completed by:[**2106-4-23**]

[ "285.9", "423.9", "997.1", "996.72", "250.41", "585.6", "707.03", "414.01", "493.20", "424.1", "344.1", "410.71", "403.91", "741.90" ]

icd9cm

[ [ [] ] ]

[ "34.1", "88.56", "37.61", "36.13", "39.61", "38.93", "37.22", "39.95", "35.21" ]

icd9pcs

[ [ [] ] ]

14197, 14267

8645, 12220

330, 576

14612, 14621

4463, 4468

3508, 3608

12433, 14174

14288, 14591

12246, 12410

6144, 8622

14645, 15055

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184,331

45576

Discharge summary

report

Admission Date: [**2110-4-13**] Discharge Date: [**2110-4-15**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7651**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Righ Internal Jugular Central Venous Line History of Present Illness: Mr. [**Known firstname **] [**Known lastname 4640**] is a [**Age over 90 **] year old man with history of advanced multi-infarct dementia, severe AS (0.8-1.0cm2), HTN, HL who presents from his nursing home with hypotension, hypoxia (90% on 2L), and altered mental status. Patient began to feel somewhat unwell 4 days ago. He had increasing episodes of sundowning and a fall after trying to enter another patient's bathroom. He also had difficulty recognizing his grandaughter. Per nursing home records and son's report, patient was having hallucinations after lunch today and appeared short of breath. He underwent CXR which was negative for volume overload, effusion, or consolidation. UA was negative for infection. Due to persistent shortness of breath, moderate oxygen desaturations, tachycardia to 140 and eventual hypotension he was brought to the Emergency Department. . In the ED, initial vitals were T 98.8 HR 100 BP 80/49 RR 16 97% 4L. Patient developed increased heart rates to 130 sinus tachycardia coinciding with increased temperatures to 100.8 F. Patient's hypotension was initially responsive to IV fluids and he was given a total of 3150 cc NS. However, in response to IV fluids his oxygen saturations fell to the low 80s and patient became more somnolent. CPAP was initiated and patient's mental status had mild improvement in alertness. Initial CXR on presentation showed diffuse interstitial opacities concerning for flash pulmonary edema. Intravenous fluids were then held, central venous line was placed and levophed was started to maintain MAPs > 60. CVP was measured at 7-8. Repeat CXR was more concerning for possible aspiration or infection. Patient was started on vancomycin and zosyn for empiric coverage. Labs were notable for WBC 11.8, troponin of 2.54, CK MB 21, cr 1.3, lactate 5.4, UA negative for evidence of infection. EKG showed sinus tachycadia with new significant ST depressions in V4-6. He was given aspirin 300 PR and started on heparin IV out of concern for ACS. Patient received acetaminophen 650 mg, and zofran 4 mg IV for symptomatic relief. Given concern that patient's hypotension may be related to poor cardiac function and recent ischemic event he was admitted to the CCU service. . Review of symptoms were unable to be obtained to patient's mental status. When asked, patient denied chest pain, abdominal pain, shortness of breath (though obviously tachypneic) Past Medical History: - Multifactorial gait disorder - Dementia (4 years) worsened last 6 months - Severe AS on ECHO [**4-/2109**], LVH without hypokinesis, EF>55% - Hypertension - Hyperlipidemia - Left MCA stroke [**2105**], without defecits - History multiple falls: possibly relating to syncope, BPPV, gait disorder. Resulting in several broken bones including tibia, fibula, wrist - last broken bone one year prior - Glaucoma - Colon neoplasm- s/p resection in [**2079**]'s (curative). - Prostate Cancer- [**Doctor Last Name **] 7, CT [**2101**] w/out mets Social History: Lives at [**Hospital3 **] for past 3 years. Wife passed away several years ago. Used to be a bookmaker. One Son. Quit smoking Cigars in [**2057**]. Rarely drinks ETOH. No IVDU/hx illicit substances. Family History: No known history of stroke, seizure, or MI Physical Exam: Admission Exam: VS: T= 94.8 BP= 107/66 HR= 115 RR= 27 O2 sat= 99% on nonrebreather CVP 5. GENERAL: WDWN appears younger than stated age, lethargic, labored breathing, oriented x1. NRB in place HEENT: NCAT. Sclera anicteric. surgical pupils-not reactive, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP at level of the clavicle while lying with head elevated 20 degrees. 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: tachypneic, course rhonchorous breath sounds diffusely ABDOMEN: Soft, NTND. No HSM or tenderness. Decreased bowel sounds. EXTREMITIES: No c/c/e. initially sl. cool extremities then temperature difficult to asses with warming blankets in place. Distal pulses 1 +. SKIN: No stasis dermatitis, ulcers, scars Discharge Exam: Pt deceased. No heartbeats on cardiac auscultation. No spontaneous respirations. No corneal reflex. Pt not responsive to stimuli. No palpable pulses on exam. Pertinent Results: Admission Labs ([**2110-4-13**]): WBC-11.8*# RBC-4.11* Hgb-12.1* Hct-36.0* MCV-88 MCH-29.4 MCHC-33.6 RDW-15.2 Plt Ct-184 PT-13.8* PTT-28.0 INR(PT)-1.2* Glucose-132* UreaN-34* Creat-1.3* Na-138 K-5.7* Cl-102 HCO3-22 AnGap-20 ALT-35 AST-132* LD(LDH)-648* CK(CPK)-400* AlkPhos-58 TotBili-0.4 CK-MB-21* proBNP-[**Numeric Identifier 97193**]* Calcium-9.0 Phos-3.5 Mg-2.1 Lactate-5.4* Other Tests: Cardiac Enzymes: [**2110-4-13**] 08:17PM BLOOD cTropnT-2.54* [**2110-4-14**] 03:23AM BLOOD CK-MB-52* MB Indx-13.0* cTropnT-3.47* [**2110-4-14**] 12:20PM BLOOD CK-MB-46* MB Indx-13.3* cTropnT-3.74* [**2110-4-14**] 07:23PM BLOOD CK-MB-31* MB Indx-12.6* cTropnT-3.69* Lactate Trend: [**2110-4-14**] 03:38AM BLOOD Lactate-2.2* [**2110-4-14**] 05:39AM BLOOD Lactate-2.3* [**2110-4-14**] 10:39AM BLOOD Lactate-1.7 [**2110-4-15**] 01:04AM BLOOD Lactate-9.9* Urine Studies: [**2110-4-14**] 10:22AM URINE Hours-RANDOM UreaN-1007 Na-12 K-98 Cl-15 [**2110-4-14**] 10:22AM URINE Osmolal-630 [**2110-4-14**] 10:22AM URINE Eos-NEGATIVE [**2110-4-13**] 08:35PM URINE CastHy-31* Micro: Urine Cx ([**4-14**]): negative Blood Cx ([**4-14**]): NGTD Radiology: PCXR ([**2110-4-13**]): IMPRESSION: Extensive interstitial opacities typically more characteristic of volume overload and interstitial edema. Given the presence of a normal-sized heart, alternate etiologies other than cardiogenic are suspected such as renal failure, flash edema from myocardial infarction, drug reaction, or other atypical presentation. Correlate clinically. Cardiac ECHO - TTE ([**2110-4-14**]): Conclusions The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with near akinesis of the inferolateral wall and mild hypokinesis of the remaining segments (LVEF = 35 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Critical aortic valve stenosis. Mild regional and global left ventricular systolic dysfunction. Moderate mitral regurgitation. compared with the prior study (images reviewed) of [**2109-4-15**], the severity of aortic stenosis has progressed, left ventricular systolic function is now depressed, and the severity of pulmonary artery hypertension has advanced. CLINICAL IMPLICATIONS: The patient has severe aortic stenosis. Based on [**2105**] ACC/AHA Valvular Heart Disease Guidelines, if the patient is symptomatic (angina, syncope, CHF) and a surgical candidate, surgical intervention has been shown to improve survival. Brief Hospital Course: Mr. [**Known firstname **] [**Known lastname 4640**] is a [**Age over 90 **] year old man with history of advanced dementia, severe AS, HTN, HL who presents from his nursing home with hypotension, hypoxia, and altered mental status . # Sepsis vs Cardiogenic shock: Patient's persistent hypotension, fever, elevated WBC count, and relatively low CVP in the setting of aortic stenosis were suggestive of sepsis. Patient's CXR is concerning for aspiration pneumonia which was consistent with patient's clinical picture and explain the patient's source of infection. Patient's hyperdynamic cardiac function in setting of underlying aortic stenosis may have caused flash pulmonary edema and ultimately the ischemia responsible for his elevated cardiac enzymes. However, also possible that the patient's initial event may have been ACS which would be responsible for his elevated cardiac enzymes and EKG changes. With significant infarct and patient's underlying aortic stenosis, ACS may may have caused decreased cardiac output leading to hypotension and pulmonary edema. His low grade fever and leukocytosis could also be attributed to cardiac ischemia. Pt was started on Vancomycin and pipercillin/tazobactam for HCAP vs Asp PNA. Blood and urine cultures were sent while sputum sample was unable to be obtained. Pt had central line placed in ED and norepinephrine was started to stabilize his hypotension to MAP > 60. ECHO was obtained the next morning and showed worsening compared to prior- severity of aortic stenosis has progressed, left ventricular systolic function is now depressed (EF 35%), and the severity of pulmonary artery hypertension has advanced. Pt developed new afib in setting of increasing norepinephrine doses with new ST depressions in lateral leads. Afib persisted with subsequent hypotension and hypoxia and new CXR showed worsening pulmonary edema. Family was contact[**Name (NI) **] about goals of care and decision was made to see how he did overnight and address possible CMO status in the morning. By morning clinical situation was unchanged and family made the decision to make CMO status. Pt passed shortly thereafter on AM of [**2110-4-15**]. . # ACS: Patient with history of HTN, HL, and CVA. No documented history of CAD. Patient's elevated troponin, CK-MB, and ST depressions on EKG were concerning for cardiac infarction. It was unclear whether this was the inciting event or secondary to sepsis. [**Name (NI) **] son would not want to pursue cath as not consistent with goals of care. Pt was started on heparihn gtt and high dose statin. Home ASA continued. Pt made CMO and care withdrawn the next day as noted above. . # PUMP: Patient's most recent echo was performed [**4-/2109**] confirming severe aortic stenosis, moderate MR, and EF > 55%. Patient did not appear volume overloaded with CVP of 7 and without LE edema, crackles on lung exam. Patient required pressors and was given fluids to treat septic shock. Repeat CXRs showed pulm edema and ECHO was perfored in AM which showed worsening of aortic stenosis. . # Acute renal failure: Creatinine 1.3 on presentation up from baseline creatinine 0.8. Patient's hypotension was consistent with prerenal etiology, increased number of casts may also point to ATN from prolonged hypotension. Urine lytes were sent and urine Eos negaitve. Medications on Admission: Vitamin D2 50,000 u capsule qweek Cyanocobalamin 1000 mg inj qmonth Lactase caplet 3000 unit po daily Aspirin 325 mg daily Multivitamin daily Omeprazole 20 mg daily Buspirone 5 mg po bid Namenda 5 mg po bid Docusate 100 mg po bid Calcium carb 500 mg tid Xalatan 0.005% eye gtt bilaterally qhs Bisacodyl 10 mg supp dialy prn constipation Acetaminophen 650 mg po q4h prn Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Patient deceased Discharge Condition: Patient deceased Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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37385

Discharge summary

report

Admission Date: [**2184-10-24**] Discharge Date: [**2184-11-8**] Date of Birth: [**2137-9-17**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: WHOL after coughing episode Major Surgical or Invasive Procedure: [**2184-10-25**] EXTERNAL VENTRICULAR DRAIN PLACEMENT [**2184-10-25**] CEREBRAL ANGIOGRAM WITH COILING OF ACOMM ANEURYSM [**2184-11-3**] VP SHUNT PLACEMENT History of Present Illness: HPI: This is a 47 year old male who developed an acute, severe headache today at 1600 follow a cough. It has been unrelenting and a [**9-4**], primarily to the back of his head. He was seen at an OSH which demonstrated extensive SAH, extending into the circle of [**Location (un) 431**]. In the ED, he is A&Ox3 and continues to complain of a posterior HA. He does have nausea, and has had one episode of emesis, but denies any motor or sensory deficits to his extremities. Past Medical History: 1. Chronic Kidney Stones Social History: Social Hx: Lives alone. Works as a bar tender. No smoking history. Drinks approximately 25 drinks per week. Family History: Family Hx: Father deceased age 42 from MI Physical Exam: On Admission: PHYSICAL EXAM: O: T: 97.8 BP: 177, 126, rechecked at 133/105 HR: 103 R: 16 O2Sats: 96% Gen: WD/WN, comfortable, NAD. HEENT: Normocephalic, atraumatic. Pupils: [**2-27**] brisk EOMs intact Neck: In C-Collar Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to 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 [**3-30**] throughout. No pronator drift Sensation: Intact to light touch, proprioception, pinprick and vibration bilaterally. Upon Discharge: AOx3, MAE [**3-30**], nonfocal exam. Head and abdomen incision C/D/I with staple Pertinent Results: CTA Head IMPRESSION [**10-24**]: 1. 5-mm aneurysm arising from the junction of the anterior communicating artery complex and the right anterior cerebral artery as detailed above. 2. Extensive subarachnoid hemorrhage, not significantly changed since the prior examination, with perisylvian involvement as well as extension to involve the cisterns at the base of the brain. 3. Diminutive nature of the left A1 segment may represent a congenital variant with hypoplasia versus vasospasm depending on the timing of the current study to the onset of symptoms. 4. Unremarkable CTA of the neck. CT Head [**11-1**] IMPRESSION: 1. Right frontal approach ventriculostomy catheter in slightly different configuration than on the prior CT. 2. Interval decrease in size of lateral ventricles. 3. Interval decrease in amount of subarachnoid and intraventricular blood, with small amount layering dependently in the lateral ventricles and along a left posterior parietal sulcus. 4. No new intracranial bleeding or abnormality. Brief Hospital Course: Pt was admitted to the hospital after transfer in from OSH for SAH secondary to Acomm aneurysm rupture. On admission, he descrived developin an acute, severe headache following a cough. It had been unrelenting and a [**9-4**], primarily to the back of his head. He was admitted to the ICU for close neurological observation. He was placed on nimodipine and dilantin. Overnight on the day of admission he had altered mental status with non obstructive hydrocephalus on CT. An emergent EVD was placed after the pt was intubated. Early the am of [**2184-10-25**] he self extubated and was re-intubated without sequele. He was brought to the angio suite shortly thereafter and his Acomm Aneurysm was coiled. After he returned to the ICU he was extubated. His EVD remains at 15cm of H20 and open. He was started on ASA, Plavix and heparin gtt. The heparin gtt was d/c'd the am of [**2184-10-26**]. Diet was adavanced and he was allowed OOB to chair. He remained in ICU for vasospasm watch and his EVD was attempted to be weaned. He then failed wean and will need VP shunt placed on Wed. His Plavix was D/c'd 7 days prior and he was transferred to step down. On [**11-5**] he was transferred to the floor and Physical Therapy was initiated. PT clearance was received on [**11-7**]. On [**11-8**] he remained neurologically stable and was discharged home without any services. Medications on Admission: potassium chloride Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Headache. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 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: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours) for 4 days. Disp:*24 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for headache. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: SUBARACHNOID HEMORRHAGE/ ANTERIOR COMMUNICATING ARTERY ANEURYSM ALTERED MENTAL STATUS RESPIRATORY FAILURE NON OBSTRUCTIVE HYDROCEPHALUS Discharge Condition: NEUROLOGICALLY STABLE Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Take Plavix (Clopidogrel) 75mg once daily. ?????? 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 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 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 ?????? 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) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: PLEASE RETURN TO THE OFFICE FOR STAPLE REMOVAL ON THURSDAY [**11-11**] AT 11:00 AM AT [**Hospital **] Medical Building [**Hospital Unit Name 84053**] (behind the clinical center) YOU WILL NEED TO FOLLOW-UP WITH DR [**First Name (STitle) **] WITH A HEAD CT ON: CT: [**First Name9 (NamePattern2) 5929**] [**12-10**] 1:15 PM Clinical Ctr [**Location (un) 470**] Appt: [**First Name9 (NamePattern2) 5929**] [**12-10**] at 2:15 PM [**Hospital **] Medical Building [**Hospital Unit Name 12193**] [**Last Name (NamePattern1) 439**] Please call Takeisha at [**Telephone/Fax (1) 4296**] to make any changes. *** Please follow-up with your PCP within one week regarding your blood pressure and its med regimen Completed by:[**2184-11-8**]

[ "V13.01", "430", "599.0", "787.01", "276.1", "331.4", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "02.34", "88.41", "96.71", "02.39", "39.72" ]

icd9pcs

[ [ [] ] ]

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346, 504

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54,811

145,790

36602

Discharge summary

report

Admission Date: [**2154-6-28**] Discharge Date: [**2154-8-5**] Date of Birth: [**2082-9-17**] Sex: M Service: CARDIOTHORACIC Allergies: Benadryl Attending:[**First Name3 (LF) 5790**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**2154-6-28**] Cervical tracheal resection and reconstruction bronchoscopy with bronchoalveolar lavage. [**2154-7-4**] Bronchoscopy [**2154-7-8**] Bronchoscopy History of Present Illness: The patient is a 71 yo M w/a hx of CAD s/p emergent CABG c/b wound dehiscence, infection, and overall prolonged hospital stay requiring tracheostomy in [**2149**] who developed post intubation tracheal stenosis. Since his decannulation and departure from the hospital, the patient has had persistent difficulties breathing. For example: He is unable to lie flat; lying flat he feels as though he will suffocate and becomes severely short of breath. While talking he becomes short of breath subjectively, and has to cough in order to relieve his symptoms. He needs to cough to feel better multiple times per hour. He does continue to become short of breath walking (can walk approximately one block prior to SOB, and one flight of stairs); interestingly, this is actually worse per the patient since prior to his CABG. Per report, he has actually had five hospitalizations since his CABG for the same complaint. These symptoms are persistent and have not improved at all since his prolonged hospitalization in [**2149**]. Again, last week he developed a "cold," describing a runny nose, dry, non-productive cough, unrelieved w/OTC meds, feeling "warm" but no fever or chills; symtoms were similar to a cold he had in the fall [**2153**]. The cough occurred "nonstop"; he was unable to sleep, and so went to the ED at [**Hospital **] Hospital. There, he was admitted for URI and possible asthma exacerbation; CXR was unremarkable, however, given recurrence of his symptoms he underwent pulmonology consultation; the pulmonologist was concerned with his symptoms as described above, and so the patient underwent CT scans. CT scan of the neck revealed focal stenosis of the trachea at the level of the thyroid gland in both inspiration and expiration; severe bronchomalacia involoving the right [**Hospital1 **], and less severe bronchomalacia involving the left main stem bronchus; Chest CT revealed chronic obstruction of right lower lobe airways, plate-like bibasilar atelectasis Past Medical History: DM, type II, CAD s/p emergent CABG (w/radial and venous grafts) c/b wound infection, dehisence "plastic surgery," c/b infection, tracheostomy, colon ca s/p partial colectomy, s/p cholecystectomy, diastolic CHF, asthma, CRI, mild aplastic anemia, likely DM neuropathy and retinopathy Social History: divorced, lives alone, has three sons, able to do most ADLS (cooking, cleaning); no hx or current smoking, no EtOH, used to work as commerical photographer for [**Company 2676**]; has partner (female) Family History: non-contributory Physical Exam: Vital Signs: General: Cardiac: Lungs: Abd: Ext: Wound: Pertinent Results: [**2154-6-28**] 11:55AM BLOOD WBC-7.6 RBC-3.36* Hgb-9.9* Hct-29.2* MCV-87 MCH-29.5 MCHC-34.0 RDW-14.1 Plt Ct-278 [**2154-7-8**] 07:10AM BLOOD WBC-12.6*# RBC-3.30* Hgb-9.7* Hct-30.2* MCV-91 MCH-29.2 MCHC-32.0 RDW-13.9 Plt Ct-319 [**2154-7-8**] 07:10AM BLOOD Plt Ct-319 [**2154-7-8**] 07:10AM BLOOD Glucose-150* UreaN-22* Creat-1.5* Na-141 K-4.1 Cl-102 HCO3-30 AnGap-13 [**2154-7-1**] 06:20AM BLOOD Glucose-166* UreaN-66* Creat-2.7* Na-146* K-5.3* Cl-111* HCO3-13* AnGap-27* [**2154-6-28**] 06:12PM BLOOD Glucose-132* UreaN-49* Creat-2.1* Na-142 K-4.5 Cl-111* HCO3-22 AnGap-14 [**2154-7-8**] 07:10AM BLOOD CK(CPK)-132 [**2154-7-2**] 02:45PM BLOOD CK(CPK)-334* [**2154-7-2**] 01:10AM BLOOD CK(CPK)-508* [**2154-7-8**] 07:10AM BLOOD CK-MB-6 cTropnT-0.14* [**2154-7-3**] 01:51AM BLOOD proBNP-[**Numeric Identifier 82825**]* [**2154-7-2**] 02:45PM BLOOD CK-MB-11* MB Indx-3.3 cTropnT-0.24* [**2154-7-5**] 06:35AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.1 [**2154-7-4**] 12:12AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.1 [**2154-6-28**] 06:12PM BLOOD Calcium-8.0* Phos-4.1 Mg-1.8 [**2154-7-8**] 08:08AM BLOOD Type-ART O2 Flow-2 pO2-76* pCO2-49* pH-7.40 calTCO2-31* Base XS-3 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2154-6-28**] 01:52PM BLOOD Type-ART pO2-204* pCO2-26* pH-7.50* calTCO2-21 Base XS-0 Intubat-INTUBATED [**2154-7-2**] 01:32AM BLOOD Glucose-173* Lactate-0.9 [**2154-6-28**] 01:52PM BLOOD Glucose-101 Lactate-1.0 Na-139 K-4.1 Cl-109 Brief Hospital Course: Pt was seen in outpatient clinic and found to have tracheobronchomalaicia involving the right bronchus intermedius as well as the left main stem bronchus and was scheduled for tracheal reconstruction on [**2154-6-28**]. The patient tolerated the procedure and was admitted to the unit for acute management of respiratory distress. The patient was started on mucomyst as well as humidified air to assist in clearing his airways, and continued to have occasional desaturations. On [**7-1**] the patient was found to be mildly acidotic, and also was having acutely worsening chest pain and respiratory status. Trops were sent and were stable at .1-.2, and an ekg was taken. The patients findings were attributed to demand ischemia as well as underlying renal dysfunction (Cr to ~3), and the patient was transfused 1 U pRBC's with sig resolution of his abnormalities. Renal function & UOP improved and the pt's symptoms resolved. Cardiology was consulted, and the patients meds were changed according to their recommendations. On [**7-4**] the patient was noted to have continuing hoarseness and bronchoscopy was performed which showed mild edema of one vocal cord, but no vocal cord dysfunction. The patient was determined to have adequate swallow function and his diet was advanced appropriately. The patient was moved to the floor and followed until his stay suture could be removed on [**Month (only) 205**] fourth. He was seen by PT and scheduled for outpatient follow up. [**7-6**] stay suture removed continue with ambulation -adv diet rehab screening. [**2154-7-8**] patient developed stidor, stable o2 sats and abg. serial cardiac enzymes ordered EKG unchanged. Treated with sl NTG. and give 0.25mg of ativan. Bronchoscopy by IP-wealling at vocal cords and some sloughing at anastamosis. Protonix 4omg [**Hospital1 **] to protect site. Lower extremity edema with blisters. Wound care counsult acquecel dressing bilaterlly elevation dressing to be changed daily. Lasix 40 mg IV daily pre-op weight 108 kg on [**2154-7-10**] wt 117 kg. Following Cr on [**7-10**] level 1.7 up from 1.5. Geriatrics consult reccommends lorazepam at night 0.25mg for sleep and one to two doses per day prn for anxiety. On [**2154-7-11**] repeat Btonchoscopy patient found to have 60% necrosis of trachea patient brought to Operating Room on [**2154-7-11**] at 3:35pm.The patient was taken to the OR emergently for revision/T-tube/muscle-flap. The patient remained intubated using ETT in the unit until the surgical repair healed for nearly 2 weeks. The vac was placed to trach site was placed since last surgery. on [**2154-7-12**] the Picc line was placed. He was empiric covered with Vancomycin, ciprofloxacin, Flagyl, and fluconazol for contamination of neck wound. on [**7-15**]: G-tube placed. On [**7-16**]: Bedside ECHO c/w decreased intravascular fluid we discontinued lasix. TFs started.[**7-17**]: Transfused x1U for low UOP, nl pressures. BS 300 - started on Lantus. he was Somnolent overnight - midaz stopped. [**7-18**]: Patient returned to the OR as the ETT has dislodged and migrated out of the t-tube. VAC changed, granulation tissue appears well, chin resutured to the chest. Restarted Midazolam as pt tried to pull on the tube. Lantus and insulin gtt started for BG control.[**7-19**]: Patient still on MMV with adequate overbreathing. Attempting to keep midaz to minimum. Large, loose amt of stool, Cdiff toxins sent. Lasix inc to 20mg tid w/ goal of -1L. Wound vac with poor suction. [**7-22**]: Patient oxygenating well on CPAP. Continued increased yellow thick sputum - cx: 4+ gram neg diplococci. Elevated white count. Minimizing midaz but adding prn and qhs .25 ativan for anxiety, goal to keep pt awake during day. Continue diuresis, goal -1L. Cdiff negative, d/c flagyl. Lantus increased to 65 qAM, d/c'd drip, restared RISS. Increased BP, pain overnight - increased lopressor, started Roxicet. Overnight, pt's UOP decreased w increasing BUN - bolused with albumin. [**7-25**]: Pt to OR for successful extubation. HTN to 210s in OR, desat w rigid bronch. Stable resp post-op. Trop 0.12 w nl EKG. Cards consulted: likely demand ischemia. [**7-27**]: Na up to 149 - urine and serum osms high, giving D5W. Off abx. Cl=120 - incorrect according to lab, actual was 109. [**7-28**]: Benzo w/d - started on valium CIWA. Free water flush + D5W - normalized Na. Now KVO, holding Lasix. Hypoglycemic to 43 - given D50, placed on D5 [**1-4**]. Agitated o/n requiring Haldol. [**7-29**]: minimize benzos, haldodl for agitation, holding diuretics [**7-30**] - LENIs negative, decr fent patch, off Valium. Became hypoglycemic to 30 in the evening due to pause in tube feeds, then became hypothermic, hypotensive, bradycardic. Given D50, started on D10W. Pancultured. ECG and trop neg. Head CT per primary team -negative. Removed fent patch per primary team. [**7-31**]: Hypoglycemia tx'd w D10, decreased Lantus to 20U. Decreased protein in TFs. Hyperkelemic to 5.3. Restarted Lasix. Prolonged QT: changed PRN Haldol to Zyprexa [**8-1**]: Cr increased to 2.2-->2.4 after diuresis with lasix, likely prerenal etiology. Back down to 1.9 and falling BUN [**8-5**] with fluids. Stopped diuresis with lasix, renal consult recommended maintaining SBP 130s-140s to adequately perfuse kidneys. Briefly:71M s/p neck exploration for breakdown of previous tracheal anastomosis s/p revision of tracheal reconstruction, intubated through T-tube, now s/p extubation w T-tube in place. upon dischrge to the rehab Neurologic: No underlying neuro disorder. Communicative, oriented. Agitated nightly. - delirium: seroquel to 50 tid, haldol prn when no increased QT interval on ECG, started Zyprexa; avoid benzos. Pain: fentanyl patch decreased to 50mcg, and off for several hours 7/29 per primary team, then restarted. Will decrease fentanyl patch to 25 mcg/hr. Will start anti-depresant Cardiovascular: - HTN: cont PO lopressor and PO hydralazine - CAD ASA qAM, Stable HD - CHF: Lasix for even I/O Pulmonary: - tracheal necrosis: T-tube in place; on trach mask. Glycopyrrolate and humidified O2 for secretions. Aggressive pulmonary toilet. - atrovent + PRN albuterol for wheezing. Gastrointestinal / Abdomen: Increasing BUN - likely related to over-feeding. Changed TFs to renal formula @ 40. Nutrition: Renal: K = 5.3 for past 24hr, normalized pH. EKG unchanged. Restart Lasix and using renal TF. Will re-check in PM - CRI: B/L Cr 1.5, now 1.8. Increased BUN & Cr likely related to overfeeding. Changed to renal TFs. - I/O even goal Hematology: Hct 23 (slow decreasing in Hct) Endocrine: Hypoglycemia, several episodes [**7-31**]. Lantus decreased to 20 qAM + ISS. Infectious Disease: Off all abx, high risk for aspiration, pancultured for hypothermia 7/29AM, f/u CXRs and cultures. BCx from A-line showed GPCs. A-line d/c??????d. BC from PICC line is negative so far. Will monitor closely and hold off on Abx for now. Lines / Tubes / Drains: Foley, t-tube, pIV, PICC, G(clamped)/J(TF) DVT: Boots, SQ UF Heparin Stress ulcer: H2 blocker VAP bundle: HOB elevation, Mouth care The patient was dischrged from the hospital in fair condition, tolera trach mask well, with adequate urine output. He will be following with Dr [**Last Name (STitle) **] in [**2-5**] weeks in Clinic Medications on Admission: lantus 55 qAM lasix 40mg qday singular 10mg PO qday plavix 75mg po qday benicar 20mg po qday gabapentin 100mg PO TID toprol XL 100mg PO qday lipitor 40mg po qday asa 81mg PO qday claritin 10mg PO qday advair 250/50 2 puffs [**Hospital1 **] Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Post tracheostomy tracheal stenosis. tracheal resection and reconstruction necrosis at anastamosis site-->emergent revision/T-tube/muscle-flap Discharge Condition: deconditioned Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production. -Chest pain.or any symptoms of concern Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] [**2155-8-13**]:30 am in the [**Hospital Ward Name 121**] Building Chest Disease Center [**Location (un) **]. [**Hospital1 **] I Report to the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology Department for a Chest X-Ray. Completed by:[**2154-8-5**]

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icd9cm

[ [ [] ] ]

[ "31.79", "31.42", "97.23", "46.39", "96.04", "31.5", "33.24", "38.93", "96.6", "83.82" ]

icd9pcs

[ [ [] ] ]

12135, 12217

4582, 11844

282, 445

12404, 12420

3113, 4559

12671, 12995

3005, 3023

12238, 12383

11870, 12112

12444, 12648

3038, 3094

235, 244

473, 2463

2485, 2770

2786, 2989

30,754

129,814

50393

Discharge summary

report

Admission Date: [**2149-1-31**] Discharge Date: [**2149-2-4**] Date of Birth: [**2073-6-24**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4765**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 75yo male with ESRD on HD, CAD s/p overlapping DES to LAD [**6-27**] then [**8-29**] and CABG, hyperlipidemia, HTN, DM2 who presents with respiratory distress. . The patient reports symptoms of shortness of breath and productive cough for the past 6 days. Leg swelling is mildly increased as well. His weight is up 2lbs. He denies fevers, chills, nausea or vomiting. The patient has an extensive cardiac history but denies chest pain, palpitations, dizziness, lightheadedness, orthopnea, PND or syncope. . On Saturday, he reported dyspnea to his PCP and was prescribed azithromycin but did not improve. He contact[**Name (NI) **] his PCP today and was sent to the the ED for his symptoms. He denies increased fluid intake, recent hospitalization, medication changes, increased salt intake, recent travel or sick contacts. [**Name (NI) **] denies any angina. He has been compliant with all his medications. . On arrival to the ED, vital signs were T- 97.2, HR- 72, BP- 130/67, RR- 24, SaO2- 94% RA. Given marked respiratory distress, he was placed on BiPAP with rapid improvement in his clincal status. He also received albuterol and ipatropium nebulizers. Imaging was consistent with pulmonary edema and possible pneumonia, for which he received lasix 20mg IV x 1 and levofloxacin. BNP near his baseline at [**Numeric Identifier 7206**] and first set of cardiac enzymes was negative. EKG revealed a ventricular paced rhythm that did not meet Sgarbossa criteria for ischemia. Given tenous respiratory status, he is being admitted to the CCU. . On arrival to the CCU vital signs were T- 98.4, HR- 74, BP 139/67, RR-17, SaO2- 97% on 2L NC. Patient reports improvement in his symptoms and is currently satting 97% on 2L NC. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: DM II Hypertension CHF- EF 50% 8/09 Hyperlipidemia Heart block s/p pacemaker [**2-/2142**] Bilateral adrenal adenomas Diverticulosis Antral polyps Cholelithiasis by CT on [**2143-7-16**] S/P right CFA pseudoaneurysm repair [**2143-7-16**] for wound cellulitis S/P right arm AV fistula [**3-/2143**] - ESRD [**1-23**] DM nephropathy s/p DCD Renal transplant ([**8-/2146**]) c/b DGF, ATN, donor disease IgA nephropathy, s/p acute cellular and ab-mediated rejection h.o UGI bld ([**9-/2144**], located 2nd and 3rt part of duodenum) h.o gastric antral polyps, colon polyps (bx: adenomas), gastric antral erosions on prior endoscopies/colonoscopies CAD s/p stent to the LAD on [**2142**] then overlapping DES to the LAD on [**2144-8-26**] and ISR of LAD with taxus stent placed [**11-28**] Social History: Mr. [**Known lastname 105012**] works as a restaurateur. He lives with his wife. [**Name (NI) **] does not drink alcohol or use tobacco. He quit smoking in [**2117**] (40 pk-yr history). No illicit drug use. Family History: Family history is negative for coronary artery disease. Mother: died of multiple myeloma at age 84. Father: Died at age 30 as a casualty of war. Physical Exam: ADMISSION PHYSICAL EXAM: T- 98.4, HR- 74, BP 139/67, RR-17, SaO2- 97% on 2L NC GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. CARDIAC: Irregular rhythm, normal rate S1, S2. No m/r/g. LUNGS: Bibasilar crackles with scattered expiratory wheezes. Resp were unlabored, no accessory muscle use. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 2+ edema in bilateral lower extremities SKIN: Mild stasis dermatitis in b/l lower extremities. NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps, wrist, knee/hip flexors/extensors, 2+ reflexes biceps, brachioradialis, patellar, ankle. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . DISCHARGE PHYSICAL EXAM: lungs CTAB, cardiac exam unremarkable, no pedal edema Pertinent Results: Admission: [**2149-1-31**] 03:50PM BLOOD WBC-5.6 RBC-3.59* Hgb-10.0* Hct-31.2* MCV-87 MCH-27.7 MCHC-31.9 RDW-14.9 Plt Ct-158 [**2149-1-31**] 03:50PM BLOOD PT-11.9 PTT-38.1* INR(PT)-1.1 [**2149-1-31**] 03:50PM BLOOD Glucose-254* UreaN-92* Creat-2.6* Na-137 K-4.5 Cl-103 HCO3-22 AnGap-17 [**2149-1-31**] 03:50PM BLOOD CK-MB-5 proBNP-[**Numeric Identifier 105022**]* [**2149-1-31**] 04:02PM BLOOD Lactate-1.2 [**2149-1-31**] 03:50PM BLOOD cTropnT-0.09* [**2149-1-31**] 05:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Pertinent Studies: CXR: 1. Mild-to-moderate alveolar pulmonary edema. Given that a concomitant bibasilar infectious process cannot be excluded, post-diuresis radiographs are recommended. 2. Probable small bilateral pleural effusions. 3. Mild-to-moderate cardiomegaly, not significantly changed. [**2149-1-31**] 03:50PM BLOOD cTropnT-0.09* [**2149-1-31**] 10:00PM BLOOD cTropnT-0.08* [**2149-2-1**] 03:13AM BLOOD CK-MB-4 cTropnT-0.08* Brief Hospital Course: Mr. [**Known lastname 105012**] is a 75 year old man who presented with acute on chronic diastolic HF thought to be due to secondary to pneumonia. . #.DYSPNEA: likely multifactorial in the setting of pneumonia with acute on chronic diastolic CHF exacerbation. Another possibility is new atrial fibrillation with worsening CHF. On admission, he was found to have bilateral crackles, elevated BNP (althought not drastically above previous levels), lower extremity and cardiac wheeze on exam which were consistent with CHF exacerbation. The patient responded well to lasix 20mg IV in ED (1L output in 6 hours), which is essentially was his home dose. Diuresis was continued (approximately 2L/day net negative). Besides new afib, another potential trigger for CHF exacerbation is likely infection given PNA on CXR. Levofloxacin ws started for planned 8 day course. In light of CHF exacerbation and history of AS a repeat echo was obtained and demonstrated normal cavity size and global systolic function (LV > 55%) as well as minimal aortic stenosis with a peak gradient of 21 torr. Mr. [**Known lastname 105012**] was discharged on torsemide 40mg PO daily and metolazone as needed (take 2 tabs if weight gain) as well as metoprolol and nitroglycerin. #.ATRIAL FIBRILLATION: New AF for patient. Given comorbidities and CHADS2 score of 4, we initially elected to bridge with heparin while coumadin became therapeutic but in light of prior bleed decided to hold on anticoagulation. Rate control was achieved with Metoprolol Tartrate 50mg [**Hospital1 **]. TSH was within normal limits. #.CAD: We doubted ischemia as a cause for the CHF exacerbation as he denied chest pain, CE were negative, and EKG does not meet Sgarbossa criteria. Patient on appropriate cardiac medications except for a statin (as patient has had a low LDL off statins) and ACE-I (no history of systolic dysfunction and CKD). . #.IDDM: Home insulin regimen was continued. . #.ESRD s/p TRANSPLANT: Cr 2.6 on admission which is close to baseline for him. Home cellcept and prograf were continued as was PCP prophylaxis with bactrim. . #.RIGHT INDEX FINGER PAIN: While admitted, Mr. [**Known lastname 105012**] complained of right index finger pain secondary to presumed gouty arthritis. He underwent surgery for this chronic index finger pain in [**2148-12-22**]. He espoused decreased range of motion and pain consistent with prior flares of arthritis. He did not demonstrate any warmth or erythema concerning for infection. Consideration for in house hand consultation was made, but Mr. [**Known lastname 105012**] insisted on outpatient management. Medications on Admission: AMITRIPTYLINE - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 10 mg Tablet - 3 Tablet(s) by mouth daily AMLODIPINE - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 10 mg Tablet - 1 Tablet(s) by mouth daily CALCITRIOL - 0.25 mcg Capsule - 1 Capsule(s) by mouth once a day FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth twice a day HYDROCODONE-ACETAMINOPHEN [CO-GESIC] - 5 mg-500 mg Tablet - 1 Tablet(s) by mouth q4hr as needed for Pain Do not take tylenol while taking, do not exceed 4 grams of APAP daily, do not drive while taking INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 100 unit/mL Solution - 37 units SC daily METOLAZONE - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily MYCOPHENOLATE MOFETIL - 500 mg Tablet - 2 Tablet(s) by mouth twice a day OMEPRAZOLE - (Dose adjustment - no new Rx) - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth daily PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth daily - No Substitution SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth once a day TACROLIMUS - (Dose adjustment - no new Rx) - 1 mg Capsule - 3 Capsule(s) by mouth twice a day - No Substitution . Medications - OTC ACETAMINOPHEN - 500 mg Tablet - [**12-23**] Tablet(s) by mouth three times a day as needed for pain ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily FERROUS SULFATE - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by mouth three times a day INSULIN REGULAR HUMAN [HUMULIN R] - (Not Taking as Prescribed: PT HAS A DIFFERENT INSULIN [**Month/Day (2) **].) - 100 unit/mL Solution - use per sliding scale four times a day glucose 150-200 2 units, 201-250 4 units, 251-300 6 units, > 301 call doctor NPH INSULIN HUMAN RECOMB [HUMULIN N] - (Not Taking as Prescribed: PT STATES HE DOES NOT TAKE THIS.) - 100 unit/mL Suspension - 25 units subcutaneously every morning - No Substitution Discharge Medications: 1. amitriptyline 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Co-Gesic 5-500 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 4. insulin glargine 100 unit/mL Solution Sig: Forty Two (42) units Subcutaneous once a day. 5. metolazone 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for weight gain. Disp:*30 Tablet(s)* Refills:*0* 6. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 7. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily). Disp:*30 packet* Refills:*2* 15. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:*25 Tablet, Sublingual(s)* Refills:*0* 16. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 8 days. Disp:*2 Tablet(s)* Refills:*0* 17. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO three times a day for 7 days: for cough. Disp:*21 Capsule(s)* Refills:*0* 18. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Acute on Chronic Diastolic Congestive Heart Failure Atrial Fibrillation Community Acquired Pneumonia End stage renal disease s/p Transplant Coronary artery Disease Hypertension Diabetes Aortic stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had an acute exacerbation of your congestive heart failure because of an increased heart rate and pneumonia. We have treated the pneumonia with an antibiotic pill and your heart rate is normal now. It is very important that you limit the amount of salt in your diet and educate yourself on foods that are high in salt such as cheese, sausage and soups. Continue to weigh yourself every morning, call Dr. [**Last Name (STitle) 3357**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Your weight at discharge is 223 pounds. . We made the following changes to your medicines: 1. STOP taking furosemide, take torsemide instead to get rid of extra fluid 2. Discontinue Amlodipine 3. Use nitroglycerin as needed for chest pain, you can use one tablet under your tongue, then wait 5 minutes and use another tablet. Do not take more than 2 tablets and call Dr. [**Last Name (STitle) 3357**] or 911 for any chest pain. 4. Start miralax to prevent constipation 5. START levofloxacin to treat your pneumonia, you need to take this medicine every other day. 6. START taking tessilon perles for cough as needed. 7. Take Metolazone only if you see that your weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. You can take two pills for a total of 5 mg. Followup Instructions: Department: TRANSPLANT CENTER When: FRIDAY [**2149-2-21**] at 9:20 AM With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2149-4-16**] at 10:00 AM With: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage . Name: [**Last Name (LF) **],[**First Name3 (LF) **] L. Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **] Address: [**State 4607**], [**Location (un) **],[**Numeric Identifier 588**] Phone: [**Telephone/Fax (1) 4606**] Appointment: Tuesday [**2149-2-11**] 12:45pm

[ "414.01", "585.9", "428.0", "V58.67", "V42.0", "V45.82", "427.31", "250.00", "274.00", "428.33", "403.90", "272.4", "486", "V45.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12352, 12438

5809, 8431

323, 329

12684, 12684

4771, 5786

14137, 15062

3640, 3786

10544, 12329

12459, 12663

8457, 10521

12835, 14114

3826, 4672

264, 285

357, 2588

12699, 12811

2610, 3398

3414, 3624

4697, 4752

70,558

118,134

34994

Discharge summary

report

Admission Date: [**2166-4-3**] Discharge Date: [**2166-4-14**] Date of Birth: [**2143-4-3**] Sex: M Service: NEUROLOGY Allergies: Dilantin / Tegretol Attending:[**First Name3 (LF) 11291**] Chief Complaint: Increased seizure frequency Major Surgical or Invasive Procedure: None History of Present Illness: [**Known firstname 5936**] [**Known lastname 3549**] is a 23 yo RHM with a history of epilepsy, alcohol dependence, hepatitis C, bipolar disorder, ADHD, who presented with an increase in seizure frequency, and unresponsiveness. The history was obtained from Mr [**Known lastname 80032**] mother, [**Name (NI) **] [**Name (NI) **], Dr [**Last Name (STitle) **]. [**Doctor Last Name **] (primary epileptologist) and medical records as the patient was drowsy, and combative. According to [**Last Name (LF) **], [**Name (NI) 5936**] [**Known lastname 80032**] mother, [**Name (NI) 5936**] had an increase of his seizure frequency to ten nocturnal seizures on Tuesday night. Dr [**First Name (STitle) **] was [**Name (NI) 653**], and she made the recommendation of increasing the zonisamide to 300 mg. On Wednesday night, until Thursday early in the morning he had about thirteen seizures. Early on Thursday morning (~2am), [**Known firstname 5936**] became unrousable, vomited and had urinary incontinence. According to his mother, prior to these events, he was averaging two nocturnal seizures per day. However, over the past three weeks, [**Known firstname 5936**] appears to have stopped all of his anti-epileptic medications. According to his mother, he arrived at [**Hospital 6451**] Hospital around 4 am. En route to the hospital, the EMS had given him Ativan as he was in status epilepticus ("grand mal seizures"). At the [**Hospital3 417**] Hospital, he was admitted overnight to the ICU. He was briefly on Propofol which was turned off at 11:45 am, and he was extubated at 12 pm. He was given 500 mg IV Keppra at 8 am, and 1000 mg at 2 pm/ He appears to have a "hepatorenal-type" picture: mild hypokalemia (3.6), elevated creatinine (1.3), transaminitis (AST 356 and ALT 1020, CPK 381). His urinalysis showed 1+ protein and elevated glucose, an some blood, and his Utox was positive for cannabinoids. His CT head and CXR reports were normal, unfortunately a CD with the images was not sent. ROS: unobtainable from Mr [**Known lastname 3549**], according to his mother, no recent illnesses, fevers, or any alcohol consumption. Past Medical History: 1. EPILEPSY (as per Dr[**Name (NI) 7029**] most recent note in OMR): AED / other therapy trials (include VNS, surgery): Dilantin and Tegretol caused rash; Depakote and Lamictal more recently did not improve seizure control. Keppra and Lyrica were most recent AEDs, started during recent hospitalization. His longest seizure free interval has been 3 days. Typical events: Type 1: Complex partial Aura: Ringing in ears, blurred vision, unclear duration Ictal: Upward eye deviation, makes gurgling sound, stiffening of body, head turn to the side, profuse salivation, sometimes gets violent and strikes out at others, either ictal or postictal. TB/incont: Bites cheek, no incontinence Postictal: Headache in AM. First: 1st grade Frequency: [**1-3**]/night Precipitants: sleep, very rare during the day. Sometimes provoked by loud noises. Type 2: Simple partial Aura: Ringing in ears, blurred vision, unclear duration Ictal: none TB/incont: No Postictal: None First: age 6 Frequency: 1/day Precipitants: none Type 3: 2GTC Aura: same Ictal: same, then GTC TB/incont: bites tongue, no incontinence. Postictal: obtunded First: childhood Frequency: rare Precipitants: None 2. Migraine 3. ADHD 4. Depression 5. alcohol abuse 6. Hepatitis C - followed per Dr. [**First Name (STitle) 679**] (GI) and planned to begin Ribavirin and IFN treatment on Monday - therefore Dr [**First Name (STitle) 679**] needs to be [**First Name (STitle) 653**] 7. s/p wisdom teeth removal in [**2161**] Social History: Unemployed due to seizures, 1 ppd tobacco, regular EtOH and cannabis, was in group home in [**Location (un) 8973**] in recent years, lives with mother, has a child with his girlfriend [**First Name8 (NamePattern2) **] [**Name (NI) **] [**Telephone/Fax (1) 80028**]) but they do not currently live together. Family History: No seizures Physical Exam: BP-119/64 HR-85 RR-98% O2Sat Gen: Confused, difficult to assess whether icteric, due to fluorescent lighting, but sclera are not jaundiced HEENT: NC/AT, dry oral mucosa Neck: Parotid fullness noted. CV: S1+2, no added sounds Lung: Coarse crackles at the bases R>L Abd: Hepatomegaly, normal bowel sounds Ext: no edema Neurologic examination: Mental status: Verbalizes "Go away." Falls asleep, trying to pull out tubes and is combative. Cranial Nerves: II, III, IV, VI: Pupils equally round and reactive to light, 6 to 4 mm bilaterally. He would close his eyes shut for fundoscopy, and refused to try to track. V: Corneals intact bilaterally. VII: Facial movement symmetric. IX, X: Good cough [**Doctor First Name 81**]: Shrugs shoulders symmetrically XII: Tongue midline, movements intact Motor: Normal bulk and tone bilaterally. Arms and legs are antigravity, movements are purposeful. Sensation: Moves all 4 limbs away from noxious stimuli. Reflexes: +2 and symmetric throughout. Toes downgoing bilaterally Gait and coordination could not be assessed, as he is too drowsy and uncooperative. Pertinent Results: [**2166-4-3**] 07:41PM BLOOD Glucose-87 UreaN-13 Creat-0.8 Na-138 K-3.9 Cl-106 HCO3-23 AnGap-13 [**2166-4-3**] 07:41PM BLOOD ALT-772* AST-211* AlkPhos-65 TotBili-1.1 [**2166-4-3**] 07:41PM BLOOD CK(CPK)-710* [**2166-4-3**] 07:41PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2166-4-3**] 07:41PM BLOOD PT-16.9* PTT-28.3 INR(PT)-1.5* [**2166-4-3**] 07:41PM BLOOD WBC-13.8*# RBC-4.48* Hgb-13.5* Hct-38.6* MCV-86 MCH-30.1 MCHC-34.9 RDW-13.2 Plt Ct-209 HEAD CT: No acute intracranial abnormality. MRI is more sensitive for detection of intracranial masses. Brief Hospital Course: Patient is a 23 year old man with a longstanding seizure history, presenting in status epilepticus. The increase in frequency of his seizures could be multifactorial, such as alcohol dependence or metabolic/infectious exacerbation but most likely poor compliance with his medications given report per Mom and past hx. Pt had been off medications and then started tapering up zonegran in the days prior to admission. He was not therapeutic on medication. Patient was transferred from [**Hospital3 417**] on [**4-3**] where he was initially intubated and loaded with IV Keppra (20mg/kg). Upon arrive, patient was already extubated and without any respiratory distress but given report of 13 seizures prior to admission at [**Hospital3 **], he was admitted to the ICU initially. He remained intermittently combative overnight but had no observed seizure events. Head CT was repeated without any acute issues. His EEG telemetry started in the morning while in the ICU showing no seizure activity. He was continued on Keppra 1500 [**Hospital1 **]. During this admission zonegran was initiated and rapidly increased up to 300mg QHS. On [**2166-4-6**] Patient removed all EEG leads, and they were replaced in the next day. This recurred on 2 additional days. Several seizures were captured, which seemed to have a right frontal onset. Prior to removal on one occasion he was found to have a lot of increased seizure activity which was felt to cause or contribute to his agitation. Patient reported numerous auras and seizures/day which improved from over 10/night to the [**1-6**] range by the few days before discharge. He had a presurgical evaluation with ictal SPECT and interictal SPECT with increased uptake in the deep right temporal region ictally. He also had 3T MRI during admission. He was treated with standing ativan while tapering AEDs for seizure control, but he still required prn ativan for increased seizures or agitation on occasion. Plan at discharge is to taper off ativan as he tapers up zonisamide. During admission he was evaluated by psychiatry and not concidered to have the capacity to leave AMA. He expressed continued desire to go home despite poor seizure control. Multiple code purples occured to the point of requiring IM haldol 5mg and 3mg ativan on one occasion. He was started on rufinamide 400mg and tapered up to his current dose of 800mg over 3 days with plans to taper up further after discharge. Pt expressed concern that the medication was making him more emotional but this was compounded by his strong desire to be discharged. We had a long discussion with his mother about it being necessary to give his body time to adjust to the medication. We also discussed the importance of not stopping his medications without supervision by his epileptologist and that this would put him at high risk of seizures and status epilepticus. Although he was not considered to be at an ideal seizure control for discharge, it was decided to let him go home with rufinamide up taper and ativan wean at home, after long discussion with the patient and his mother. They expressed understanding that he must get his rufinamide twice daily and his ativan 4x/day initially and his mother was going to wake him in the am and have family check on him during the day to ensure this. He will follow up with VNS nurse and Dr. [**First Name (STitle) **]. Medications on Admission: MEDS: (which he has not been taking reliably) 1. Keppra 1500 [**Hospital1 **] 2. Lyrica 50mg at bedtime 3. Zonegram 200 at bedtime 4. Fioricet PRN Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. 3. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 4. Rufinamide 400 mg Tablet Sig: Two (2) Tablet PO twice a day: Called into CVS [**Hospital1 1474**] on North Pearl St. Disp:*180 Tablet(s)* Refills:*0* 5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) for 10 days: Start 1 tab 4 times/day for 2 days, then 1 tab 3 times/day for 2 days, then 1 tab twice daily for 2 days, then 1 tab daily for 2 days, then off. Disp:*20 Tablet(s)* Refills:*0* 6. Rufinamide 400 mg Tablet Sig: Two (2) Tablet PO twice a day for 3 doses: Called into the [**Location (un) 535**] inside [**Hospital1 **]. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Epilepsy Secondary: Hepatitis C Migraine ADHD Depression alcohol abuse Discharge Condition: Improved Discharge Instructions: You were admitted to this hospital because you had several episodes of seizures after stopping your medications. You were first admitted to the ICU and then transfered to the floor. You had many seizures as well as seizure activity seen on your EEG when there were no auras or outward signs of seizures. Increased EEG activity was seen to be associated with agitation, as well. Your anti-seizure medications were changed in that you were taken of zonisamide and started on rufinamide with the plan to taper up the medication. Ativan was used to suppress epileptic activity with plan to wean ativan as an outpatient. . Please take all medications as perscribed. If you have concerns about the medications, please call Dr. [**First Name (STitle) **] or your PCP before changing the doses or discontinuing them. . Please call your PCP or return to the emergency room if you expereience any worsening in your symptoms or have other concerns. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 876**] Date/Time:[**2166-4-16**] 11:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD Phone:[**Telephone/Fax (1) 5285**] Date/Time:[**2166-4-25**] 4:00 We have requested psychiatry follow up. Please call [**Telephone/Fax (1) 1682**] for an appointment in the next 2-4 weeks. Completed by:[**2166-4-22**]

[ "V15.81", "305.20", "070.70", "296.80", "345.11", "314.01", "303.90", "780.09" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10541, 10596

6104, 9492

308, 314

10712, 10723

5493, 5975

11712, 12165

4345, 4358

9690, 10518

10617, 10691

9518, 9667

10747, 11689

4373, 4691

241, 270

342, 2477

4826, 5474

5984, 6081

4730, 4810

4715, 4715

2499, 4004

4020, 4329

11,032

138,052

16455

Discharge summary

report

Admission Date: [**2184-6-25**] Discharge Date: [**2184-6-28**] Date of Birth: [**2132-12-25**] Sex: F Service: MEDICINE Allergies: Dilantin Attending:[**First Name3 (LF) 759**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 51yo woman w/severe COPD on home O2 and home BIPAP who presented to the ED c/o worsening SOB x2 weeks. She initially developed this 2 weeks ago at which point she called her [**First Name3 (LF) 19039**] who started her on prednisone 40 and azithro. She did not feel any better after five days of azithromycin, so she was then treated with levofloxacin (last day day of admission). She finished the prednisone 2 days prior to admission. She reports increasing shortness of breath to the point where she cannot walk from the bathroom to the bedroom. This is also accompanied by bilateral chest pain that feels like "lung soreness", and resolves with rest. It is also accompanied by mild nausea. She initially had a productive cough of thick green sputum which was somewhat better after the antibiotic treatment but still present. She traveled recently to [**State 760**] via bus and may have had sick contacts. She was originally using her nebulizer treatments up to 4x/day which was helpful, but has stopped doing that lately. In the ED, she was initially saturating 68% on 1L, which increased to 94% on 4L. She then became somewhat confused and so the oxygen was turned down. On admission, she was saturating in the 80s on 1L. She was put on nasal CPAP on her home settings ([**9-11**]). Her ABG was 7.39/56/50. She was given albuterol and atrovent nebulizers, solumedrol, and aspirin. Past Medical History: 1. COPD, followed in pulmonary by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**5-13**] PFTs show FEV1 of 1.04, which is 42 percent of predicted, and a FVC of 2.11, which is 65 percent of predicted. FEV1/FVC ratio is 0.49 Full PFTs from [**10-12**] also showed diffusion capacity 45% pred. Exercise oximetry showed O2 sat 88%RA at rest, which decreased to 80% w/ambulation. ABG at that time 7.34/56/52 on RA. 2. Hep C 3. Hx IVDA, on methadone maintenance 4. Hx seizure d/o Social History: Lives w/husband in [**Name (NI) 3786**], smoked 1.5 ppd x 35 yrs, h/o IVDU, now on methadone maintenance. Family History: Aunt w/CVA. Mother had endometrial ca. Father had lung ca. Physical Exam: PE: T: 100.0 P: 110 ->73 BP: 124/56 -> 74/38 (while asleep) -> 100/50 R: 19 89% on 1L Gen: alert and oriented pleasant female in NAD, speaking in complete sentences, not using accessory muscles HEENT: nasal cpap mask in place, MMM Neck: supple, no LAD Lungs: excellent air movement, diffuse rhonchi, no wheezes, no crackles, prolonged expiratory phase CV: distant, RRR Abd: soft, mildly distended with TTP diffusely, +bs. no rebound or guarding. Ext: no edema Pertinent Results: Admission labs: CBC: WBC-11.8* RBC-3.85* Hgb-11.8* Hct-35.9* MCV-93 MCH-30.7 MCHC-32.9 RDW-14.5 Plt Ct-331# Diff: Neuts-69.7 Lymphs-23.5 Monos-5.8 Eos-0.8 Baso-0.2 Chem 7: Glucose-79 UreaN-14 Creat-1.0 Na-139 K-3.8 Cl-96 HCO3-33* Phos-2.9 Mg-2.3 Other: Anemia studies: Iron-26* calTIBC-358 VitB12-379 Folate-10.2 Ferritn-56 TRF-275 Lipid panel: Cholest-220* Triglyc-167* HDL-62 CHOL/HD-3.5 LDLcalc-125 Cardiac enzymes: [**2184-6-25**] 04:00PM BLOOD CK(CPK)-34 CK-MB-NotDone cTropnT-<0.01 [**2184-6-26**] 05:30AM BLOOD CK(CPK)-40 CK-MB-1 cTropnT-<0.01 [**2184-6-27**] 04:33AM BLOOD CK(CPK)-31 CK-MB-2 cTropnT-<0.01 Micro: Ucx contaminated, sputum cx contaminated, Bcx negative ECG: rate 87, NSR, normal axis/intervals, LAE, old TWI in V1-2 CXR: 1. Linear atelectasis at the left base and residual linear scar or atelectasis at the right base. 2. Interval improvement in interstitial opacities from [**2184-6-15**]. 3. No focal consolidation or pneumothorax. Brief Hospital Course: 51yo woman with COPD admitted to the ICU w/ COPD exacerbation, transferred to the floor after solumedrol, nebulizers, and BiPAP (home settings), with quick resolution to baseline oxygenation. Hospital course is reviewed below by problem: 1. COPD exacerbation: s/p levofloxacin and azithromycin as an outpatient. She was treated with advair, atrovent nebulizers, albuterol nebs (concern for chest pain, see below), solumedrol, BIPAP, O2 prn. She was not given supplemental O2 unless her saturations were <88%, since this caused oxygen narcosis. She was given solumedrol and discharged with a prednisone taper. She was discharged with saturations in the mid-90's on room air. completed courses of levo/azithro prior to admit 2. Chest pain: She had an episode of chest pain prior to admission that was likely related to her COPD exacerbation. She had no EKG changes and cardiac enyzmes were negative. She was monitored by telemetry without events. The pain seemed to be associated with beta-agonists, so these were minimized. She was continued on aspirin and started on atorvastatin for hyperlipidemia. She had an appointment scheduled with Dr. [**Last Name (STitle) **] on discharge to further work up the chest pain, as it sounded cardiac in etiology (left-sided, into left arm, associated with beta agonists). She may benefit from a stress test, or possibly should go directly to catheterization, to be determined by cardiology. 3. Leukocytosis: Thought to be due to steroids or stress response. Bcx were negative. She had already completed levofloxacin and azithromycin courses for COPD exacerbation. She remained afebrile throughout hospitalization. 4. Anemia: Her Hct fell from 36 to 30, which was thought to be due to hydration. Her studies were consistent with iron deficiency. She was started on iron. Would benefit from outpatient work up including colonoscopy. 5. Seizure disorder: She was continued on keppra. 6. IVDU: Her methadone maintenance was continued. Medications on Admission: albuterol/atrovent advair keppra 500 [**Hospital1 **] home O2 1L Discharge Medications: 1. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 5. Methadone 10 mg Tablet Sig: Seven (7) Tablet PO once a day. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer treatment Inhalation QID (4 times a day). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours) as needed. 9. Prednisone 10 mg Tablet Sig: asdir Tablet PO once a day for 24 days: Please take 40mg (4tabs) daily for 4 days, then 30mg (3tabs) daily for 4 days, then 20mg (2tabs) daily for 4 days, then 10mg (1tab) daily for 4 days, then 5mg ([**2-9**] tab) daily for 4 days, then 5mg ([**2-9**] tab) every other day for 4 days. Disp:*43 Tablet(s)* Refills:*0* 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*0* 12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 5 minutes as needed for chest pain: If you experience chest pain, place one tab underneath your tongue and let it dissolve. If the pain continues, you can repeat this every five minutes. If you still have pain after taking 3 tabs, call 911. Disp:*15 tabs* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 6549**] Discharge Diagnosis: Chronic obstructive pulmonary disease exacerbation Anemia Chest pain, unspecified Hypercholesterolemia Discharge Condition: Stable; oxygen saturations 90-93%/RA. Discharge Instructions: Take all medications as prescribed. You will need to slowly taper off the prednisone as instructed. You have been started on a proton pump inhibitor, omeprazole, to protect your stomach while you are on the prednisone. You have also been started on iron supplementation and atorvastatin, a medicine for your cholesterol. If you experience any side effects, including muscle aches, please stop the atorvastatin and call your doctor. You should follow a low fat/low cholesterol diet to decrease your cholesterol and protect your heart. Follow up with Drs. [**Name5 (PTitle) **]/[**Last Name (LF) **], [**First Name3 (LF) **], and the cardiologist. Please call your doctor or go to the emergency room if you have any difficulty breathing, chest pain, fevers, chills, worsening cough, muscle pains, arm pain, jaw pain, heart palpitations, or any other concerning symptoms. Followup Instructions: Please follow up with Drs. [**Name5 (PTitle) **]/[**Doctor Last Name **] ([**Telephone/Fax (1) 250**]) on Wednesday [**7-7**] at 3pm. Please follow up in the cardiology clinic ([**Telephone/Fax (1) 5003**]) with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2184-7-19**] at 1:20pm in [**Hospital Ward Name 23**] 7. If your insurance requires a referral, you must obtain this beforehand from Dr. [**Last Name (STitle) **]. You have an appointment scheduled to see Dr. [**First Name (STitle) **] on [**8-2**]. His office has put you on the cancellation list and will call if he can see you any earlier. You have the following appointments scheduled: Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2184-8-2**] 3:40 Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2184-8-2**] 4:00 Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 5445**] [**Last Name (NamePattern1) 1843**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2184-8-2**] 4:00

[ "V12.09", "V16.1", "305.90", "285.9", "786.59", "780.39", "272.0", "496", "V16.49" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

7835, 7890

3912, 5889

289, 296

8037, 8077

2927, 2927

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2371, 2431

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3347, 3889

230, 251

324, 1712

2943, 3330

1734, 2232

2248, 2355

27,755

155,889

32453+57804

Discharge summary

report+addendum

Admission Date: [**2146-12-2**] Discharge Date: [**2147-1-4**] Date of Birth: [**2097-5-28**] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5667**] Chief Complaint: Motor Vehicle Collision Major Surgical or Invasive Procedure: 1. External fixation of right tibia/fibula fracture 2. External fixation of right proximal tibia & ankle 3. Irrigation & debridement of open right foot & ankle [**12-3**] 4. Right lower extremity fasciotomy [**12-4**] 5. Right lower extremity open washout [**12-7**] 6. Tracheostomy [**12-10**] 7. Percutaneous endoscopic gastrostomy [**12-10**] 8. Right lower extremity washout and closure [**12-10**] 9. Right lower extremity washout and closure with vacuum [**12-16**] History of Present Illness: The patient is a 49 year old male who presented to [**Hospital1 18**] as a basic trauma via [**Location (un) **] following a high speed motor vehicle collision versus telephone pole. He was intubated and transferred from OSH with depressed skull fracture, SVT, and obvious right tib/fib fractures. Past Medical History: Alcoholism Depression Anxiety Social History: Significant for alcoholism---drinks wine and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5261**] daily with history of multiple detox admissions. Pt has suffered loss of employment and strained finances secondary to drinking. Pt is single, never married, lives alone in own [**Last Name (un) **] in [**Location (un) 8117**]. Pt reportedley very depressed and on verge of losing [**Last Name (un) **]. Family History: Noncontributory Physical Exam: Vitals: afebrile, P 80s, BP 110/70, RR 16, 98% on room air General Appearance: NAD, thin man, deconditioned, appearing older than stated age Cor: RRR, no MRG Lung: clear throughout Abd: soft NT, ND, NABS RLE immobilized in brace. VACx2 intact to suction. No surrounding erythema or induration. LLE min edema, WWP otherwise Pertinent Results: [**12-24**] MRA RIGHT LE: . [**2146-12-14**] CXR: INDICATION: Feeding tube placement. Feeding tube has been advanced into the body of the stomach. Tracheostomy tube remains in standard position. Bilateral poorly defined alveolar opacities in the upper and mid lung regions show slight interval improvement compared to the recent radiograph. . [**2146-12-12**] CT CHEST: IMPRESSION: 1. Multifocal bilateral ground-glass opacities with peribronchovascular and subpleural distribution. In the setting of fevers, this may be due to a diffuse infection, but other etiologies including cryptogenic organizing pneumonia and eosinophilic pneumonia should be considered as well. Pulmonary hemorrhage is also possible in the appropriate clinical setting. 2. Small bilateral pleural effusions. 3. Incompletely imaged low attenuation left lobe hepatic lesion for which ultrasound may be considered for more complete assessment if warranted clinically. . [**2146-12-2**] CT HEAD: IMPRESSION: 1. Acute comminuted and depressed fracture of the squamosal left temporal bone with associated temporal contusion, as described. 2. No other intra- or extra-axial hemorrhage, significant mass effect, or shift of the midline structures. 3. Inflammatory changes involving the paranasal sinuses. . [**2146-12-2**] CT LOW EXT: IMPRESSION: 1. Comminuted impacted fracture of proximal tibia involving medial and lateral tibial plateau. 2. Fibular head fracture. 3. Comminuted distal tibial fracture involving medial malleolus and tibial plafond. 4. Comminuted distal fibular fracture. 5. Fracture dislocation of talus. 6. Fractures of cuboid and fourth metatarsal. . [**2146-12-2**] 10:05PM TYPE-ART PO2-152* PCO2-45 PH-7.36 TOTAL CO2-26 BASE XS-0 [**2146-12-2**] 10:05PM freeCa-1.16 [**2146-12-2**] 09:54PM GLUCOSE-137* UREA N-6 CREAT-0.6 SODIUM-139 POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-22 ANION GAP-11 [**2146-12-2**] 09:54PM CALCIUM-7.8* PHOSPHATE-4.2 MAGNESIUM-1.7 [**2146-12-2**] 09:50PM WBC-9.5 RBC-3.18* HGB-10.0* HCT-28.1* MCV-89 MCH-31.5 MCHC-35.6* RDW-15.5 [**2146-12-2**] 09:50PM PLT COUNT-97* [**2146-12-2**] 09:50PM PT-13.3 PTT-30.6 INR(PT)-1.1 [**2146-12-2**] 08:42PM HGB-8.2* calcHCT-25 [**2146-12-2**] 04:46PM TYPE-ART PO2-150* PCO2-38 PH-7.35 TOTAL CO2-22 BASE XS--3 [**2146-12-2**] 04:46PM freeCa-1.11* [**2146-12-2**] 04:46PM LACTATE-1.4 [**2146-12-2**] 04:38PM WBC-8.3 RBC-2.72* HGB-8.2* HCT-24.1* MCV-89 MCH-30.1 MCHC-34.0 RDW-15.8* [**2146-12-2**] 04:38PM PLT COUNT-87*# [**2146-12-2**] 04:38PM PT-15.9* PTT-35.9* INR(PT)-1.4* [**2146-12-2**] 03:40PM TYPE-ART PO2-325* PCO2-45 PH-7.29* TOTAL CO2-23 BASE XS--4 [**2146-12-2**] 03:40PM GLUCOSE-165* LACTATE-2.5* [**2146-12-2**] 03:40PM freeCa-0.99* [**2146-12-2**] 03:30PM GLUCOSE-178* UREA N-7 CREAT-0.6 SODIUM-138 POTASSIUM-4.2 CHLORIDE-113* TOTAL CO2-18* ANION GAP-11 [**2146-12-2**] 03:30PM CALCIUM-6.2* PHOSPHATE-3.7 MAGNESIUM-1.6 [**2146-12-2**] 03:30PM WBC-11.8* RBC-3.26* HGB-10.5* HCT-30.0* MCV-92 MCH-32.1* MCHC-34.9 RDW-15.4 [**2146-12-2**] 03:30PM PLT COUNT-52* [**2146-12-2**] 03:30PM PT-18.1* PTT-42.3* INR(PT)-1.7* [**2146-12-2**] 02:08PM PO2-256* PCO2-43 PH-7.20* TOTAL CO2-18* BASE XS--10 COMMENTS-GREEN TOP [**2146-12-2**] 02:08PM GLUCOSE-204* LACTATE-5.1* NA+-133* K+-4.0 CL--111 [**2146-12-2**] 01:59PM UREA N-8 CREAT-0.5 [**2146-12-2**] 01:59PM estGFR-Using this [**2146-12-2**] 01:59PM AMYLASE-55 [**2146-12-2**] 01:59PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2146-12-2**] 01:59PM URINE HOURS-RANDOM [**2146-12-2**] 01:59PM URINE HOURS-RANDOM [**2146-12-2**] 01:59PM URINE GR HOLD-HOLD [**2146-12-2**] 01:59PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2146-12-2**] 01:59PM WBC-13.5* HCT-29.5* [**2146-12-2**] 01:59PM PLT SMR-LOW PLT COUNT-88* [**2146-12-2**] 01:59PM PT-18.6* PTT-43.6* INR(PT)-1.7* [**2146-12-2**] 01:59PM FIBRINOGE-105* [**2146-12-2**] 01:59PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.039* [**2146-12-2**] 01:59PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2146-12-2**] 01:59PM URINE RBC-[**3-1**]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 Brief Hospital Course: The patient is a 49 year old male who presented to [**Hospital1 18**] as a basic trauma via [**Location (un) **] following a high speed motor vehicle collision versus telephone pole. He was intubated and transferred from OSH with depressed skull fracture, SVT, and obvious right tib/fib fractures. . [**2146-12-2**] Patient to OR with ortho trauma team for the following: 1. Irrigation and debridement of open foot and ankle wound 2. Debridement of open fractures of the fibula, talus and distal tibia 3. Closed reduction of proximal tibia fracture 4. External fixation of the proximal tibia and ankle fractures. . [**2146-12-3**] Patient to OR with ortho trauma team for four compartment fasciotomy of right lower extremity. . [**2146-12-6**] Patient to OR with trauma for closure of fasciotomy wounds in right lower leg; adjustment of external fixator around the plateau fracture; debridement of open fracture to bone, and application of black sponge vacuum dressing to right dorsal foot wound. No complications during the procedures and pt tolerated it well. Transferred back to the TSICU post-operatively on ventilator support. . [**2146-12-9**] Patient to OR for tracheostomy with trauma team secondary to inability to wean from ventilator support for failure to clear secretions. There were no complications during the procedure and the patient tolerated the procedure well. Transferred back to the TSICU post-operatively on ventilator support. . [**2146-12-13**] Patient removed from ventilator support wean. Confusion continues. . [**2146-12-15**] Patient to OR for percutaneous endoscopic gastrostomy with trauma team secondary to inability to feed from delerium, disorientation. No complications and patient tolerated the procedure well. Pt extubated in the OR and transferred to PACU for mointoring. Ultimately transferred to floor CC6 for post-op care. . [**2146-12-15**] Patient to OR with ortho trauma team for the following: 1. Irrigation and debridement right foot soft tissue defect down to tendon level. 2. Irrigation debridement lateral wound down to the hardware. 3. Vacuum dressing application to right foot. 4. Vacuum dressing application to right leg wound. . [**2146-12-15**] Patient to OR with ortho trauma team for the following: 1. ORIF right bicondylar tibial plateau fracture. 2. Washout and debridement open fracture wound to bone 3. Application of VAC sponge. . Pt transferred to floor status on CC6A post-operatively with stable vital signs. . [**2146-12-16**] Nutrition consult completed and tube feeds begun twenty-four hours from placement of feeding tube. Feeds steadily advanced to goal with no residuals. Patient self-decannulates with no complications and sats > 90 percent; trach replaced with #8 Portex without complications. . [**2146-12-17**] Patient decannulated by trauma team and tolerates procedure well. . [**2146-12-22**] To OR with Ortho Trauma for removal of external fixation hardware and adjusting of right lower extremity screw alignment. [**2146-12-28**] doing well will be tx to plastic surgery for flap he is non-weight bearing on the rt leg at this time . Neuro-[**12-3**] Head CT demonstrated acute comminuted and depressed skull fracture with underlying 9.4x9.7mm hemmorhage. Pt received seizure prophylaxis with dilantin per neurosurgery for one week. Pt maintained with benzos to protect against withdrawal seconary to patient's known history of extensive alcoholism. Patient received pain control with IV narcotics and his withdrawal symptoms were treated with an ativan drip in the ICU. Overall neurologic status improved during the course of his ICU stay, and upon transfer to the floor the patient was mentating clearly with good orientation and insight. . CVS: Patient with stable, unremarkable cardiac exam during stay. However, he did require several transfusions of packed red cells during his TSICU stay secodary to bleeding from his right lower extremity fasciotomy. There were no transfusion reactions and patients hematocrit responded appropriately after each unit was given. . Resp: As noted above, the patient required significant ventilatory support during his unit stay with noted difficulty clearing his secretions ultimately requiring a tracheostomy. He tolerated this procedure very well and was moved from the ventilator on post-trach day 2, and decannulated on post-trach day 8. He also suffered from a significant presumed pneumonia while in the TSICU that required a bronchoscopy and antibiotic therapy. On a 10 day course of azithromycin he deffervesced and showed noted improvement is his respiratory staus. His respiratory exam is currently unremarkable. . Renal: Stable creatining and renal function throughout his stay with excellent urine output. . GI: Patient received prophylaxis with famotidine throughout stay. Patient was initially given enteral nutrition via a Dobhoff tube, however secondary to mental status he pulled the tube out. Eventually a PEG was placed on [**12-16**] and g-tube feeds were commenced on the following morning and continued for one week. On [**12-23**], after a swallow evaluation, tube feeds were stopped and the pt was begun on a regular diet with nectar thickened liquids, which he continued to tolerated without problem throughout the remainder of his hospitalization. Upon discharge he should continue this diet with supplemental ensures with each meal. General surgery was planning to remove the g-tube prior to discharge, but if this did not happen, the pt may follow up with Dr. [**Last Name (STitle) **] in 1 week at his office for g-tube removal. . ID: Patient with intermittent high grade fevers during his TSICU stay to nearly 104F. These fevers were of unknown origin on preliminary workup. Follow up contrast CT of the chest revealed multifocal bilateral ground-glass opacities with peribronchovascular and subpleural distribution. Pt was treated initially with bactrim for presumed PCP pneumonia, but subsequent BAL did not demonstrate active PCP. [**Name10 (NameIs) **], pt was begun on coverage with azithromycin for atypical PNA with defervescence and improvement in WBC count. Pt's respiratory status made steady progress on antibiotic course and was afebrile and stable at time of transfer from TSICU to floor CC6. During his stay on the floor, the pt was begun on ancef to cover skin flora, given his multiple open wounds, hardware and VAC dressings. On discharge, the pt remained afebrile on ancef, and he will be discharged on an indefinite course of po keflex. Medications on Admission: Zoloft Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 12. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed for pain. 14. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: 1. Left comminuted depressed squamosal temporal bone fracture 2. Right comminuted impacted proximal tibia fracture 3. Right fibular head fracture 4. Right comminuted distal tibia fracture 5. Right comminuted distal fibula fracture 6. Right dislocated talus fracture 7. Right cuboid fracture 8. 4th metatarsal fracture 9. Traumatic brain injury Discharge Condition: Stable, to rehab Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **], [**Hospital1 18**] Trauma Surgery, in [**12-28**] weeks after your discharge. Please call ([**Telephone/Fax (1) 22750**] to schedule an appointment. Follow up with Dr. [**First Name (STitle) **], [**Hospital1 18**] Plastic Surgery, in 2 weeks after your discharge. Call the plastic surgery office to arrange an appointment. [**Telephone/Fax (1) 5343**]. Follow up with Dr. [**Last Name (STitle) **], General Surgery, in 1 week for gastrostomy tube removal, or a follow up visit if the tube was removed before discharge. Name: [**Known lastname 12419**],[**Known firstname 33**] Unit No: [**Numeric Identifier 12420**] Admission Date: [**2146-12-2**] Discharge Date: [**2147-1-4**] Date of Birth: [**2097-5-28**] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1165**] Addendum: MSK: The day of discharge, the pt was ordered to have films of his LUE do to a complaint of inability to flex his arm at the elbow past 90 degrees. These films were not completed prior to discharge, but should be done prior to follow up with the orthopedic service, who will be the pt primary care team after discharge. Discharge Disposition: Extended Care Facility: [**Hospital6 4356**] - [**Location (un) 164**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1167**] MD [**MD Number(2) 1168**] Completed by:[**2147-1-4**]

[ "311", "E878.8", "825.25", "300.00", "E878.1", "427.31", "314.01", "427.89", "518.81", "251.2", "805.4", "996.69", "801.10", "824.0", "958.92", "486", "825.31", "879.8", "998.12", "E815.0", "823.02", "824.8", "801.30", "287.5", "824.3", "303.90", "458.9", "825.23", "263.9", "286.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.91", "78.47", "83.65", "31.1", "79.67", "78.67", "43.11", "78.17", "93.57", "77.67", "83.09", "83.39", "96.72", "33.24", "78.18", "79.06", "79.66", "96.04", "79.07", "79.36", "96.6" ]

icd9pcs

[ [ [] ] ]

16884, 17113

6325, 12861

337, 811

14470, 14489

2023, 2989

15579, 16861

1645, 1662

12918, 13986

14103, 14449

12887, 12895

14513, 15556

1677, 2004

274, 299

839, 1138

2998, 6302

1160, 1191

1207, 1629

48,999

137,007

6029

Discharge summary

report

Admission Date: [**2133-9-3**] Discharge Date: [**2133-9-5**] Date of Birth: [**2062-8-11**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 598**] Chief Complaint: elective cholecystectomy Major Surgical or Invasive Procedure: laparoscopic cholecystectomy History of Present Illness: The patient is a 71M with multiple medical conditions including chronic cholecystitis with a percutaneous cholecystostomy tube placed in [**2133-7-1**] following a acute cholecystitis. He was offered an interval cholecystectomy and was admitted to the ACS service following this elective operation. Past Medical History: Coronary artery disease -- s/p multiple PCI, last in [**Hospital1 18**] records from [**2124**] -- s/p MI in [**2130**] with stent placement Dilated Cardiomyopathy -- LVEF of 20-25% -- s/p PPM/ICD placement Hypertension Hyperlipidemia Hypothyroidism Depression ICH -- while on Coumadin Benign Prostatic Hypertrophy Bilateral Hydroceles Colonic polyps Hand osteomyelitis history Babesiosis history SCC -- left 4th finger and penis Appendectomy Gout Social History: He lives with his wife and has 3 sons. Smoked 1 PPD for several years in his 20s but none since. Drinks [**2-1**] glasses of wine on social occasions or when eating at restaurants, none at home. Drugs: None Family History: -Father -- died from throat cancer at age 63, heavy smoker and alcohol consumption - Mother -- congenital [**Last Name **] problem (unsure what), but lived into her 90s - Brother -- renal cancer, treated Physical Exam: See pre-op note and physical exam Pertinent Results: [**2133-9-3**] 09:30PM CK(CPK)-81 [**2133-9-3**] 09:30PM CK-MB-3 cTropnT-<0.01 [**2133-9-3**] 09:43AM TYPE-ART TEMP-35.5 RATES-/8 TIDAL VOL-764 O2-95 O2 FLOW-2.2 PO2-319* PCO2-42 PH-7.34* TOTAL CO2-24 BASE XS--2 AADO2-328 REQ O2-59 INTUBATED-INTUBATED VENT-CONTROLLED [**2133-9-3**] 09:30AM WBC-6.6 RBC-3.63* HGB-10.5* HCT-31.5* MCV-87 MCH-28.9 MCHC-33.4 RDW-15.1 [**2133-9-3**] 09:30AM PLT COUNT-197 Brief Hospital Course: The patient is a 71M with multiple medical conditions including chronic cholecystitis with a percutaneous cholecystostomy tube placed in [**2133-7-1**] following an episode of acute cholecystitis. He was admitted to the ACS service following an elective cholecystectomy. The patient underwent a laparoscopic cholecystectomy. Given his cardiac history, he underwent a TEE in the OR to assess his cardiac funtion. His blood pressure dropped and he was given epinephrine. The patient was then stable and the decision was made to proceed with the procedure. Following the operation, he was admitted to the ACS service. He had an uncomplicated hospital course and was discharged home with instructions to follow up in the [**Hospital 2536**] clinic. Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for dyspnea. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Three (3) Capsule, Ext Release 24 hr PO DAILY (Daily). 4. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 8. furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 11. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 16. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain for 10 days: Dispense 30. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: chronic cholecystitis s/p laparoscopic cholecystectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the Acute Care Surgery Service and underwent a laparoscopic cholecystectomy. Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * You may take a shower after 24 hours from your surgery have passed, but do not bathe or go swimming until instructed by your surgeon. * No strenuous activity until instructed by your surgeon. Followup Instructions: Please call the [**Hospital 2536**] clinic on Monday [**9-7**] at [**Telephone/Fax (1) 2359**] to schedule a follow up appointment in 2 weeks. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2133-9-8**]

[ "272.4", "V45.02", "425.4", "274.9", "575.12", "V45.82", "401.9", "244.9", "V12.72", "414.01" ]

icd9cm

[ [ [] ] ]

[ "51.23", "88.72" ]

icd9pcs

[ [ [] ] ]

4278, 4284

2109, 2855

326, 356

4382, 4382

1673, 2086

5631, 5910

1398, 1604

2878, 4255

4305, 4361

4532, 5608

1619, 1654

261, 288

384, 684

4397, 4508

707, 1157

1173, 1382