ChanBeDu/relevant_section_length · Datasets at Hugging Face

3,002

185,653

7148

Discharge summary

report

Admission Date: [**2138-11-13**] Discharge Date: [**2138-11-24**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: pelvic fracture Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 26585**] is a French Creole speaking [**Age over 90 **] M with recent pelvic fracture who developed aspiration pneumonia and now is admitted to the ICU with hypoxia. He was saturating well on the medical floor until 2 days ago when he had an aspiration event and became slightly hypoxic. This morning, his hypoxia progressed to the point that he needed high flow face mask to maintain sats of 96%. Since his chest x ray was unchanged, it was hypothesized that his new A-a gradient was due to a pulmonary embolism. A CTA cannot be obtained because of the patient's renal failure and a V/Q scan would not be useful since his baseline CXR shows infiltrates. He was hemodynamically stable at time of transfer. Past Medical History: diabetes II, hep B and hep C Social History: He has been a preacher for several years. He has been in the U.S. for 23 years and is a citizen. He lives with his wife. [**Name (NI) **] smoking, no drinking. Family History: nc Physical Exam: T 95.7 BP 172/102 HR 107 RR 20 O2 sat 96% Gen: thin, tired appearing and difficult to understand HEENT: dry MM, face mask in place Cor: tachy distant Pulm: crackles bilaterally at bases but poor inspiratory effort Abd: mildly distended, NT Ext: WWP, 3+ edematous Pertinent Results: [**2138-11-12**] 08:00PM PT-12.6 PTT-41.1* INR(PT)-1.1 [**2138-11-12**] 08:00PM PLT COUNT-329# [**2138-11-12**] 08:00PM NEUTS-73.4* LYMPHS-19.0 MONOS-4.7 EOS-1.8 BASOS-1.1 [**2138-11-12**] 08:00PM WBC-4.9 RBC-3.65* HGB-11.1*# HCT-32.7*# MCV-90 MCH-30.4 MCHC-33.9 RDW-14.3 [**2138-11-12**] 08:00PM CK-MB-5 proBNP-1599* [**2138-11-12**] 08:00PM cTropnT-0.18* [**2138-11-12**] 08:00PM ALT(SGPT)-33 AST(SGOT)-67* CK(CPK)-259* ALK PHOS-99 AMYLASE-122* TOT BILI-0.5 [**2138-11-12**] 08:00PM estGFR-Using this [**2138-11-12**] 08:00PM GLUCOSE-165* UREA N-41* CREAT-2.8*# SODIUM-136 POTASSIUM-6.6* CHLORIDE-107 TOTAL CO2-21* ANION GAP-15 [**2138-11-12**] 10:06PM K+-6.4* [**2138-11-12**] 10:15PM URINE RBC-[**2-23**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2138-11-12**] 10:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2138-11-12**] 10:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2138-11-13**] 12:22AM K+-4.9 [**2138-11-13**] 05:40AM PLT COUNT-286 [**2138-11-13**] 05:40AM HCV Ab-POSITIVE [**2138-11-13**] 05:40AM HBsAg-NEGATIVE HBs Ab-BORDERLINE HBc Ab-POSITIVE [**2138-11-13**] 05:40AM CK-MB-6 [**2138-11-13**] 05:40AM ALT(SGPT)-27 AST(SGOT)-47* CK(CPK)-876* [**2138-11-13**] 05:40AM GLUCOSE-116* UREA N-40* CREAT-2.8* SODIUM-142 POTASSIUM-4.6 CHLORIDE-111* TOTAL CO2-22 ANION GAP-14 [**2138-11-13**] 10:50AM PT-12.5 PTT-43.4* INR(PT)-1.1 [**2138-11-13**] 10:50AM PLT COUNT-241 [**2138-11-13**] 10:50AM WBC-4.5 RBC-2.95* HGB-9.0* HCT-26.0* MCV-88 MCH-30.6 MCHC-34.8 RDW-15.9* [**2138-11-13**] 10:50AM CK-MB-6 cTropnT-0.17* [**2138-11-13**] 03:48PM PLT COUNT-262 [**2138-11-13**] 03:48PM WBC-4.9 RBC-3.59* HGB-10.7* HCT-31.8* MCV-89 MCH-29.8 MCHC-33.7 RDW-14.4 [**2138-11-13**] 05:05PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2138-11-13**] 05:05PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.015 [**2138-11-13**] 08:42PM PLT COUNT-279 [**2138-11-13**] 08:42PM WBC-5.1 RBC-3.49* HGB-10.8* HCT-31.2* MCV-90 MCH-31.0 MCHC-34.7 RDW-14.1 . CT pelvis [**11-13**]: 7 x 4 cm right iliacus hematoma likely secondary to small nondisplaced right iliac bone fracture. 2.Superior and inferior right pubic rami fractures. 3. Ascites and soft tissue third spacing, a moderate left and small right pleural effusions. 4. Multiple hypodense renal lesions, likely cysts, the smallest too small to definitively characterize. . CXR [**11-21**]: A new consolidation is seen in the right lower lung having relatively sharp contours with elevation of right hemidiaphragm and downward displacement of the right hila, most likely representing new atelectasis. Underlying infectious process cannot be excluded based on this chest radiograph. The left retrocardiac atelectasis and left pleural effusion are unchanged. There is no evidence of failure or pneumothorax. . ECHO [**11-14**]: EF 70-75%. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. 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 mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Mr. [**Known lastname 26585**] is a [**Age over 90 **] year-old male admitted after a fall resulting in pelvic fracture with subsequent development of a multi-lobar pneumonia and fluid overload with bilateral pleural effusions and total body edema. . His pneumonia was treated with vancomycin, ceftriaxone and clindamycin given unclear source of pulmonary infiltrate. For volume overload, he received furosemide intravenously as needed and he diuresed appropriately. However, throughout his stay he required an increased amount of oxygen and was on 100% non-rebreather at the time of discharge. Culture data was pending at the time of discharge. After extensive discussion with the family and patient regarding prognosis, it was decided that he would go home with hospice. The patient wished this and the family was in agreement. . Medications on Admission: NKDA . Medications: unknown Discharge Medications: 1. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Transdermal Q72. Disp:*QS * Refills:*2* 2. Morphine Concentrate 20 mg/mL Solution Sig: 2-20 mg PO Qhour as needed for pain. Disp:*150 ml* Refills:*0* 3. Ativan 5mg/ml 0.25-2mg under tongue every 4-6 hours for anxiety, if necessary. (not to exceed 8mg/24 horus). DISPENSE: 30ml REFILLS: none Discharge Disposition: Home With Service Facility: [**Location (un) **] Discharge Diagnosis: hip fracture aspiration pneumonia hepatitis B hepatitis C renal failure diabetes hypertension Discharge Condition: Patient with poor prognosis overall, goals of care discussed, and family and patient wish to discontinue agressive care measures. Patient wants to go home. Discharge Instructions: Please continue oxygen until patient gets home. At that time he may continue with 6 liters by nasal canula. Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

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Discharge summary

report

Admission Date: [**2171-10-14**] Discharge Date: [**2171-10-24**] Date of Birth: [**2095-4-29**] Sex: F Service: Cardiothoracic Service CHIEF COMPLAINT: Ms [**Name13 (STitle) 51832**] is a postoperative admission at PAT prior to admission. Her chief complaint was coronary artery disease. HISTORY OF PRESENT ILLNESS: This is a 76 year old woman with known cardiovascular disease, status post transient ischemic attacks in [**2160**] treated with Coumadin and known cardiomyopathy documented by echocardiogram which demonstrated an ejection fraction of 35 to 40% with inferior posterior hypokinesis and mild mitral regurgitation. More recent echocardiogram suggested moderate to severe mitral regurgitation with a Myoview stress test demonstrating an ejection fraction of 46% with fixed inferolateral defects and baseline left bundle branch block. The patient does have dyspnea on exertion which for years only occurred while climbing stairs, but recently is occurring just walking shorter distances. Cardiac catheterization done at [**Hospital6 31672**] showed an ejection fraction of 50% with 70% left anterior descending occlusion, 70% diagonal disease, left circumflex with a total occlusion of 50%, right coronary artery with an left ventricular end diastolic pressure of 20. PAST MEDICAL HISTORY: Significant for status post total abdominal hysterectomy, status post breast biopsy, history of transient ischemic attacks and cerebrovascular accident, history of basilar artery stenosis, hypertension, hypercholesterolemia, peripheral vascular disease and history of silent myocardial infarctions. MEDICATIONS ON ADMISSION: Coumadin 5 mg q.d., Lisinopril 30 mg q.d., Coreg 12.5 mg b.i.d., Lipitor 10 mg on Monday, Wednesday and Friday, Folgard 2.2 mg q.d., Omega 3 500 mg t.i.d., Aspirin 81 mg q.d. and Vitamin C 1000 mg q.d. ALLERGIES: She states allergy to Sulfa which causes a rash. PHYSICAL EXAMINATION: Vital signs heartrate 60 with a sinus arrhythmia, blood pressure 137/72. General, well appearing woman in no acute distress. Skin, many keratoses, no rashes. Head, eyes, ears, nose and throat, mucous membranes moist, pupils equally round and reactive to light. Neck is supple with no masses. Chest, breathsounds clear bilaterally. Heart, sinus arrhythmia with systolic ejection murmur III/VI. Abdomen, flat, nondistended, nontender, positive bowel sounds, no hepatosplenomegaly, no [**Doctor Last Name 515**]. Extremities are warm, left cooler than right. No varicosities. Strength is equal bilaterally. Nonfocal neurological examination. Pulses, femoral 2+, bilaterally, dorsalis pedis 1 to 2+ on the right, faint to 1+ on the left, posterior tibial 1 to 2+ on the right and faint to 1+ on the left. Radial 2+ bilaterally. HOSPITAL COURSE: The patient was admitted to [**Hospital6 1760**] on [**10-14**], however, her surgery was cancelled on that date due to an INR which was 2.4 as well as a left lower lobe nodule on chest x-ray. She was to have INR rechecked and a chest computerized tomography scan done on the day of admission. Chest computerized tomography scan showed that there was no pulmonary nodule and the following laboratory data revealed coagulase 1.3, PT 13.2, PTT 30.6. The patient was then brought to the Operating Room on [**10-15**], at which time she underwent a mitral valve replacement and a coronary artery bypass graft times two. Please see the Operating Room report for full details. In summary the patient had a mitral valve replacement with a #27 Mosaic valve with coronary artery bypass graft times two with left internal mammary artery to the left anterior descending and saphenous vein graft to the right coronary artery. The patient tolerated the operation well. Her bypass time was 112 minutes with a crossclamp time of 98 minutes. She was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. She did well in the immediate postoperative period. Her anesthesia was reversed. She was weaned from the ventilator and successfully extubated on the night of her surgery. She was weaned from all intravenous medications. On postoperative day #1, she remained hemodynamically stable. She was noted to have a fair amount of drainage from her chest tubes and they were left in place. The patient was transferred to Far 2 for continuing postoperative care and cardiac rehabilitation. On postoperative day #2, the patient remained hemodynamically stable. Her chest tubes were discontinued as were her temporary pacing wires. She was started on heparin and Coumadin given her history of cerebrovascular accidents with bibasilar artery stenosis. Over the next several days the patient had an uneventful postoperative course with the exception of self-limiting bouts of atrial fibrillation. The patient was seen by the Electrophysiology Service, whose recommendation was to continue to beta block the patient and to not begin Amiodarone unless there was sustained atrial fibrillation. On postoperative day #8 it was decided that the patient was stable and ready to be transferred to rehabilitation on the following day. At that time the patient's physical examination was as follows - Vital signs, temperature 98.6, heartrate 69, sinus rhythm, blood pressure 113/61, respiratory rate 18, oxygen saturations 93% on room air. Weight preoperatively 68.1 kg, at discharge 64.4 kg. Laboratory data, PT 19, PTT 58.6, INR 2.4, potassium 5.0, BUN 16, creatinine 1.0, magnesium 2.3. Alert and oriented times three, moves all extremities, follows commands. Respiratory clear to auscultation bilaterally. Cardiac regular rate and rhythm with no murmur. Sternum was stable. Incision with Steri-Strips, open to air, clean and dry. Abdomen soft, nontender, nondistended, normoactive bowel sounds. Extremities are warm and well perfused with no edema. Right leg saphenous vein graft site with large ecchymotic area. Incision at the knee with Steri-Strips, open to air, clean and dry. DISCHARGE MEDICATIONS: Warfarin dose to maintain goal INR 2.0 to 2.5 Lasix 20 mg q.d. times ten days Potassium chloride 20 mEq q.d. times ten days Aspirin 81 mg q.d. Lipitor 10 mg on Monday, Wednesday and Friday Prilosec 40 mg q.d. Lisinopril 10 mg q.d. Metoprolol 50 mg b.i.d. CONDITION ON DISCHARGE: Good DISCHARGE DIAGNOSIS: 1. Coronary artery disease, status post coronary artery bypass grafting times two with left internal mammary artery to the left anterior descending and saphenous vein graft to the right coronary artery. 2. Mitral regurgitation status post mitral valve replacement with #27 Mosaic valve. 3. Status post total abdominal hysterectomy. 4. Status post breast biopsy. 5. History of transient ischemic attack and cerebrovascular accident. 6. History of basilar artery stenosis. 7. Hypertension 8. Hypercholesterolemia 9. Degenerative joint disease FOLLOW UP: The patient is to be discharged to [**Hospital1 **] CCU. She is to have follow up with Dr. [**Last Name (STitle) 51833**] in three to four weeks and follow up with Dr. [**Last Name (STitle) **] in four weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2171-10-23**] 15:51 T: [**2171-10-23**] 17:49 JOB#: [**Job Number 51834**]

[ "414.01", "443.9", "V58.61", "425.4", "272.0", "424.0", "401.9", "427.31", "412" ]

icd9cm

[ [ [] ] ]

[ "35.24", "36.11", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

6027, 6283

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175, 313

342, 1309

1332, 1632

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44,666

163,618

40136

Discharge summary

report

Admission Date: [**2184-9-15**] Discharge Date: [**2184-9-21**] Date of Birth: [**2120-3-12**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Left-sided weakness. Major Surgical or Invasive Procedure: Administration of intravenous tissue plasminogen activator. Placement of [**Last Name (un) **]-gastric tube but discontinued after passing the video-swallowing examination. History of Present Illness: Mr. [**Known lastname 88171**] is a 64 yo man with a history of HTN, HLD, DMII (recent diagnosis) who presnts today following a stroke. The patient states he was in his kitchen with his friend [**Name (NI) **] at 10:30 in the morning making coffee when he proceeded to spill it on the floor. His friend noticed that something wasn't right, had him sit on the floor for a few seconds. It was then noticed that the patient's left arm was "limp and floppy", his left face drooped and the patient appeared to be having a stroke. EMS was called and the patient was initially taken to [**Hospital **] hospital. Vitals on presentation were BP 190/110, EKG showed Afib with a rate of 87. Labs were all normal. He was evaluated by [**Hospital1 2025**] telestroke system and though details of his initial exam are not clear, the patient's friend and EMS state the patient wasinitially unable to move his left arm at all and had a forced right eye deviation. IVtPA was bolused at 12:15 and his friend noted improvement in symptoms within 15 minutes. The remaining dose was infused and due to space, the patient was referred to [**Hospital1 18**] for further care and ICU management post tPA. On neurologic review of systems, the patient denied any current deficits of weakness or sensory loss though he can report the history without problem. [**Name (NI) **] denies headache, loss of vision, blurred vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. No bowel or bladder incontinence or retention. On general review of systems, the patient denied recent fever or chills. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. Past Medical History: 1. Hypertension 2. Hyperlipidemia (last total cholesterol 164) 3. Type II DM 4. Chronic pain (DJD of the spine, s/p epidural injections last week). 5. s/p right rotator cuff surgery 6. s/p right meniscal repair 7. Atrial fibrillation noted during this admission - likely new diagnosis of paroxysmal atrial fibrillation. Social History: Lives alone. Works in construction. No smoking or drugs. Reports past heavy EtOH use but denies any hx of withdrawal seizures or DTs. Currently drinks 2~3 beers and 2~3 glasses of wine nightly. Family History: Father died of a stroke at age 82 Mother died of CHF Has sisters who are healthy Physical Exam: T 97.6 BP 156/114 HR 108 RR 18 95% on 2LO2% General: Awake, emotional, NAD. Head and Neck: no cranial abnormalities, no scleral icterus noted, mmm, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs clear to auscultation bilaterally Cardiac: regular rate and rhythm, normal s1/s2. No murmurs, rubs, or gallops appreciated. Abdomen: soft, non-tender, normoactive bowel sounds, no masses or organomegaly noted. Extremities: 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. 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. Did not have glasses to read well but could read some larger prints informally. Speech was dysarthric. He had good knowledge of current events. There was no evidence of apraxia but there was clear sensory neglect to the left and a visual preference to the right but he could be directed to attend visually to the left. Calculations intact. Registered [**1-21**] and recalled [**12-24**] at 5 minutes. Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. Visual fields full on bedside testing to finger counting. III, IV, VI: EOMI with limited leftward gaze but can cross the midline on smooth persuit. V: Facial sensation impaired to light touch on left VII: Left facial droop affecting lower face predominantely VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid bilaterally. XII: Tongue with slight right deviation. Motor: Normal bulk, decreased tone in left arm compared to slightly increased tone in legs. No pronator drift on right, arm with sensory ataxia and unable to clearly asess drift. No tremors noted. No asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 4 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Sensory: No sensation on the left leg, arm or face to light touch, pinprick, cold sensation. Extinction to double simultaneous stimuli. *****states he can feel you if he sees you administering stimuli to his left side, but does not acknowledge when looking away). Deep tendon reflexes: [**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach L 1 1 1 1 1 R 1 1 1 1 1 Plantar response was extensor bilaterally. Coordination: No intention tremor on right. Left arm unable to complete FNF testing Gait: deferred. NIHSS: NIH SS: 1a. Level of Consciousness: 0 1b. LOC questions: 0 1c. LOC commands: 0 2. Best gaze: 1 3. Visual: 0 4. Facial palsy: 2 5a. Motor arm, left: 1 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb ataxia: 1 8. Sensory: 2 9. Best language: 0 10. Dysarthria: 1 11. Extinction and inattention: 2 Pertinent Results: [**2184-9-19**] 07:20AM BLOOD WBC-5.9 RBC-5.11 Hgb-15.7 Hct-45.4 MCV-89 MCH-30.6 MCHC-34.4 RDW-13.6 Plt Ct-194 [**2184-9-20**] 09:15AM BLOOD PT-14.4* PTT-25.9 INR(PT)-1.2* [**2184-9-19**] 07:20AM BLOOD Glucose-93 UreaN-20 Creat-0.8 Na-140 K-4.0 Cl-106 HCO3-23 AnGap-15 [**2184-9-15**] 02:35PM BLOOD ALT-35 AST-29 LD(LDH)-182 CK(CPK)-78 AlkPhos-54 TotBili-0.5 [**2184-9-17**] 02:01PM BLOOD cTropnT-<0.01 [**2184-9-16**] 02:24AM BLOOD CK-MB-4 cTropnT-<0.01 [**2184-9-15**] 02:35PM BLOOD CK-MB-5 cTropnT-<0.01 [**2184-9-19**] 07:20AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.1 [**2184-9-15**] 02:35PM BLOOD Albumin-4.3 [**2184-9-15**] 03:40PM BLOOD %HbA1c-6.6* eAG-143* [**2184-9-16**] 02:24AM BLOOD Triglyc-235* HDL-65 CHOL/HD-3.3 LDLcalc-104 MRI of head: 1. Acute infarct in the right frontotemporal lobe with small focus of petechial hemorrhage. 2. Small microhemorrhage in the left temporal lobe, age indeterminate. 3. Extensive chronic small vessel ischemic changes and old lacunar infarcts. Echocardiogram: Mild symmetric left ventricular hypertrophy with low normal systolic function. No ASD or PFO identified EKG: Atrial fibrillation. Left ventricular hypertrophy with secondary repolarization abnormalities. Poor R wave progression. Consider prior anteroseptal myocardial infarction. No previous tracing available for comparison. Brief Hospital Course: Patient is a 64 year old RHM with hx of HTN, EM, hyperlipidemia who presented with acute L sided weakness and numbness found to have atrial fibrillation. He initially presented to an OSH and received IVtPA upon discussion with stroke telemedicine with [**Hospital1 2025**]. He then was transferred here for further care. He was initially admitted to the ICU. He had significant improvement of his L sided weakness with the IVtPA but MRI did showed acute stroke in the L MCA/inferior division territory. He stayed in the ICU for EtOH withdrawal symptoms including agitation but there was no evidence of seizures or DTs. He was transferred to the floor. He was also started on Coumadin for newly diagnosed Afib and given the stroke with IVtPA, it was decided to bridge with ASA 325mg daily until INR therapeutic. He had significant swallowing trouble hence he required NGT for meds and nutrition but he was started on a diet with restrictions on [**9-21**], the day of his discharge to acute rehab for inpatient physical, occupational and speech/swallowing therapy. He needs daily INR checks until INR 2~3 then his ASA can be decreased to 81mg daily in addition to Coumadin for his Afib. Additionally, given that his LDL was > 100, his Simvastatin was increased to 40mg daily. Medications on Admission: Metamucil 1 per day Calcium 1 per day Magnesium-zinc daily Percocet 10-325mg for pain at night PRN Celebrex 200mg daily Toprolol xl 100mg daily Omega-3 2pills daily ASA 81 mg daily simvastatin 20 metformin 500mg at night Discharge Medications: 1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety: Patient was not taking at home - please stop when not needed. . 2. Metamucil Powder Oral 3. calcium carbonate 500 mg (1,250 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID w/ meals. 4. insulin regular human 100 unit/mL Solution Sig: Per sliding scale Injection ASDIR (AS DIRECTED): Was on metformin 500 mg QHS at home. 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for stroke: Will continue at 325 until INR therapeutic. Please use enteric coated. Once INR therapeutic, his ASA dose can be reduced to 81mg once daily. 6. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 7. Omega-3 Fish Oil 1,000 (120-180) mg Capsule Sig: One (1) Capsule PO twice a day. 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for HL/stroke. 10. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 11. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every Friday). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Primary Stroke - ischemic Atrial fibrillation Secondary Alcohol use and withdrawal Hypertension Hyperlipidemia Diabetes, type II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came to the hospital after having a stroke. You were given intravenous TPA to reopen the blocked blood vessel - this was effective. Given this treatment, you stayed in the intensive care unit. You also demonstrated some physical signs that were attributed to alcohol withdrawal. You recovered well during your stay here, but still suffered from some left facial weakness and difficulty swallowing. For this, a tube was placed through your nose into your stomach. Given some left sided weakness and difficulty swallowing you will go to inpatient rehabilitation on discharge. Followup Instructions: Please attend the following appointments: 1. Please see Dr. [**Last Name (STitle) 88172**] on Monday [**10-4**] at 11:20 a.m. Dr. [**Last Name (STitle) 88172**] will also be following your oral anticoagulation with coumadin. 2. Please see your primary care doctor: Dr. [**Last Name (STitle) **] on [**Month (only) **] 3. Please also see the Neurologist that you saw here: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2184-10-20**] 3:00 Level 8 [**Hospital Ward Name 23**] Building, [**Hospital1 69**], [**Location (un) 86**] Completed by:[**2184-9-21**]

[ "427.31", "291.81", "342.90", "401.9", "272.4", "434.11", "250.00", "V49.87", "V45.88" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

10465, 10512

7455, 8739

345, 520

10686, 10686

6100, 7432

11471, 12152

2881, 2964

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10533, 10665

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2979, 3545

285, 307

548, 2307

4230, 6081

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2329, 2650

2666, 2865

29,854

191,176

53077

Discharge summary

report

Admission Date: [**2169-8-25**] Discharge Date: [**2169-9-2**] Date of Birth: [**2108-11-19**] Sex: M Service: MEDICINE Allergies: Heparin Sodium Attending:[**First Name3 (LF) 678**] Chief Complaint: Hyperglycemia, Hypotension Major Surgical or Invasive Procedure: Right subclavian line placed [**2169-8-25**] with no complications. History of Present Illness: Mr. [**Known lastname **] is a 60 year old male with history of Alzheimer's dementia, non-verbal at baseline, HTN, CAD s/p 3V CABG, who was sent to the E.D. for findings of upper extremity rigidity and elevated glucose with critically high finger sticks. Per discussion with the patient's wife, the patient has been increasingly lethargic over the last week, sleeping most of the day. Yesterday, the patient was noted by his wife to have increasing twitches throughout his body, upper and lower, although of note different in characteristic than when he seizes. The patient is reported to have headaches (although non-communicative) without other localizing symptoms. Patient not noted to have respiriatory distress or diarrhea. . ED Course: Vitals: 99.4 HR-96 BP-97/74 RR-20 O2: 100% In the E.D. the patient was placed on an insulin gtt for hyperglycemia. An ECG performed in the ED was revealing for Anterior ST depressions with TWI. Cardiology was consulted and performed a bedside echocardiogram. Per ED report, initial interpretation was concerning for wall motion abnormalities although this was re-interpreted as none on second look. Regardless, cardiology did not feel cardiac catheterization was warranted as the patient had already likely infarcted previously. Given Heparin allergy the patient was given ASA and Plavix loaded. During the ED course the patient became hypotensive with SBP to the 70s requiring fluid boluses, placement of a right subclavian line, and initiation of Dopamine, 20mcg on transfer. . On arrival to floor patient is awake and alert, noted to be mildly agitated, with occasional few words but no meaningful communication. Past Medical History: Presinilin mutation + Alzheimer's disease HTN MI s/p CABGx3 [**10-30**] IDDM Chronic renal insufficiency Social History: The patient was originally born in [**Male First Name (un) 1056**]. Previously worksed at [**Hospital3 **] in receiving, lives at home with wife and son. His wife feeds and clothes him. Walks from bed to bathroom only Tobacco: None ETOH: Previous use, quit 10 years ago Illicits: None Family History: Two sisters and one brother with dementia Physical Exam: Vitals: T-97.3 BP: 99/52 (20mcg/kg Dopa) HR:117 RR: 17 O2: 97% on 2L NC CVP: 2 . General: The patient is a chronically ill appearing male, appears older than stated age, appears to be mildly agitated, moving arms frequently, some fasciculations in lower extremities HEENT: NCAT, EOMI. Does not track to command OP: MM mildy dry appearing, dry blood and chronic ulceration over distal tongue Neck: Supple, JVP at base of neck Chest: Few transmitted upper airway sounds, no rales, rhonchi, or wheezes although posterior exam limited Cor: RRR, normal S1/S2. Soft II/VI early systolic murmur throughout precordium Abdomen: Soft, non-tender, non-distended. Normal bowel sounds Extremity: No C/C/E. DP 2+ bilaterally Access: RIght subclavian, left A-line, Foley Pertinent Results: [**2169-8-25**] 11:15AM PLT COUNT-122* [**2169-8-25**] 11:15AM WBC-8.4 RBC-5.46 HGB-10.5* HCT-34.2* MCV-63* MCH-19.3* MCHC-30.9* RDW-16.1* [**2169-8-25**] 11:15AM CALCIUM-9.6 PHOSPHATE-5.3* MAGNESIUM-3.9* [**2169-8-25**] 11:15AM CK-MB-7 cTropnT-0.41* [**2169-8-25**] 11:15AM CK(CPK)-575* [**2169-8-25**] 11:15AM GLUCOSE-869* UREA N-132* CREAT-4.5*# SODIUM-141 POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-30 ANION GAP-18 [**2169-8-25**] 11:23AM GLUCOSE-697* LACTATE-2.1* K+-4.8 [**2169-8-25**] 11:30AM PT-13.8* PTT-21.2* INR(PT)-1.2* [**2169-8-25**] 04:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2169-8-25**] 04:55PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.024 [**2169-8-25**] 05:09PM K+-3.2* [**2169-8-25**] 06:05PM TSH-0.62 [**2169-8-25**] 06:05PM ALBUMIN-3.9 [**2169-8-25**] 06:05PM cTropnT-0.44* [**2169-8-25**] 06:05PM LIPASE-41 [**2169-8-25**] 06:05PM ALT(SGPT)-22 AST(SGOT)-27 LD(LDH)-224 CK(CPK)-552* ALK PHOS-96 AMYLASE-79 TOT BILI-0.3 [**2169-8-25**] 09:21PM URINE HOURS-RANDOM UREA N-871 CREAT-140 SODIUM-36 [**2169-8-25**] 09:21PM CALCIUM-8.9 PHOSPHATE-3.1# MAGNESIUM-3.4* [**2169-8-25**] 09:21PM GLUCOSE-79 UREA N-114* CREAT-3.8* SODIUM-153* POTASSIUM-3.6 CHLORIDE-116* TOTAL CO2-23 ANION GAP-18 [**2169-8-25**] 10:20PM CALCIUM-8.3* PHOSPHATE-3.2 MAGNESIUM-3.2* [**2169-8-25**] 10:20PM GLUCOSE-172* UREA N-112* CREAT-3.7* SODIUM-148* POTASSIUM-3.7 CHLORIDE-114* TOTAL CO2-21* ANION GAP-17 [**2169-8-26**] 03:20AM BLOOD WBC-9.1 RBC-4.95 Hgb-9.4* Hct-29.4* MCV-59* MCH-19.0* MCHC-32.1 RDW-15.7* Plt Ct-100* [**2169-8-27**] 03:12AM BLOOD WBC-8.6 RBC-4.87 Hgb-9.4* Hct-29.1* MCV-60* MCH-19.3* MCHC-32.2 RDW-16.0* Plt Ct-102* [**2169-8-28**] 05:35AM BLOOD WBC-7.9 RBC-4.62 Hgb-8.9* Hct-27.5* MCV-60* MCH-19.2* MCHC-32.3 RDW-15.8* Plt Ct-84* [**2169-8-29**] 05:22AM BLOOD WBC-10.0 RBC-4.66 Hgb-8.9* Hct-27.6* MCV-59* MCH-19.0* MCHC-32.2 RDW-16.0* Plt Ct-90* [**2169-8-30**] 04:50AM BLOOD WBC-9.0 RBC-4.41* Hgb-8.5* Hct-26.0* MCV-59* MCH-19.2* MCHC-32.6 RDW-16.1* Plt Ct-101* [**2169-8-26**] 03:20AM BLOOD PT-13.1 PTT-21.2* INR(PT)-1.1 [**2169-8-26**] 03:20AM BLOOD Plt Ct-100* [**2169-8-27**] 03:12AM BLOOD PT-13.7* PTT-22.8 INR(PT)-1.2* [**2169-8-27**] 03:12AM BLOOD Plt Ct-102* [**2169-8-28**] 05:35AM BLOOD PT-13.4* PTT-22.2 INR(PT)-1.2* [**2169-8-28**] 05:35AM BLOOD Plt Ct-84* [**2169-8-29**] 05:22AM BLOOD PT-12.5 PTT-23.1 INR(PT)-1.1 [**2169-8-29**] 05:22AM BLOOD Plt Ct-90* [**2169-8-30**] 04:50AM BLOOD Plt Ct-101* [**2169-8-26**] 03:20AM BLOOD Glucose-248* UreaN-102* Creat-3.2* Na-148* K-3.3 Cl-114* HCO3-22 AnGap-15 [**2169-8-27**] 03:12AM BLOOD Glucose-151* UreaN-59* Creat-2.2* Na-151* K-4.0 Cl-116* HCO3-26 AnGap-13 [**2169-8-28**] 05:35AM BLOOD Glucose-183* UreaN-40* Creat-1.7* Na-144 K-3.9 Cl-110* HCO3-25 AnGap-13 [**2169-8-29**] 05:22AM BLOOD Glucose-135* UreaN-33* Creat-1.7* Na-142 K-4.0 Cl-109* HCO3-24 AnGap-13 [**2169-8-30**] 04:50AM BLOOD Glucose-224* UreaN-33* Creat-1.7* Na-140 K-4.4 Cl-106 HCO3-28 AnGap-10 [**2169-8-26**] 03:20AM BLOOD CK(CPK)-488* [**2169-8-26**] 03:20AM BLOOD CK-MB-11* MB Indx-2.3 cTropnT-0.24* [**2169-8-26**] 03:20AM BLOOD Calcium-8.3* Phos-3.1 Mg-3.2* Cholest-115 [**2169-8-27**] 03:12AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.9* [**2169-8-28**] 05:35AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.3 [**2169-8-29**] 05:22AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1 [**2169-8-26**] 03:20AM BLOOD Triglyc-201* HDL-23 CHOL/HD-5.0 LDLcalc-52 . [**2169-8-25**] ECG: Sinus rhythm Left atrial abnormality Consider left ventricular hypertrophy Anterolateral ST-T abnormalities - cannot exclude in part ischemia - clinical correlation is suggested. Since previous tracing of the same date, no significant change . [**2169-8-25**] CXR: No acute cardiopulmonary disease. . [**2169-8-25**] CT Head: Impression: 1. No hemorrhage, mass effect, or edema. 2. Moderate central atrophy. . [**2169-8-25**] ECHO: Conclusions: The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic, although the posterior wall appears to contract in a dyssynchronous fashion. There is no ventricular septal defect. Right ventricular chamber size is normal. Right ventricular systolic function appears depressed. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. LVEF > 75%, hyperdynamic. Brief Hospital Course: Hospital Day#1([**2169-8-25**]): Patient admitted to MICU for hypotension (SBP 70's) in the ER of sudden onset. Right subclavian line placed and dopamine drip started at 20 mcg/hr in ED. Patient likely presented with dehydration/hypovolemia secondary to non-ketotic hyperosmolar state and patient noted to be profoundly hyperglycemic with BG 869 and glycosuria. Hypotension secondary to cardiogenic shock also on the differential due to ?recent MI, but CVP found to be decreased. Low suspicion of sepsis due to lack of temperature and normal lactate. Patient was treated with aggressive fluid resuscitation and insulin ggt. Patient afebrile on presentation but had increased "twitching"/rigors and was pancultured. All Blood culture and urine culture results were subsequently negative. Home anti-hypertensives were held upon admission. Subsequent Hospital course by problem: #. Hyperglycemia - There was no anion gap on presentation, seemed more consistent with Hyperosmolar non-ketosis, likely in setting of recent possible NSTEMI and poor PO intake. Patient had been receiving home meds as prescribed per his wife. [**Name (NI) **] was placed on insulin drip on admission, which was taken off insulin ggt [**2169-8-29**]. He was loaded with lantus 25 U HS. [**Last Name (un) **] endocrinology fellow consulted for Managen of glucose levels which were relatively under control on the medical floor- 100's to 250's. Pt is currently on Humalog Sliding Scale and Lantus 35 units at bedtime. Sliding Scale has been adjusted on [**2169-8-31**] and [**2169-9-1**] [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations, patient was given sliding scale instructions on discharge. Blood glucose levels should continue to be monitored four times per day per sliding scale and insulin should be adjusted at Nursing home as needed. # Thrombocytopenia - Pt with thrombocytopenia during MICU course, nadir at 84, currently at 163. In the MICU, concern was for HIT given heparin allergy and possible heparin coated central line. Since transfer to the medical floor, the platelets are trending up, so HIT unlikely, possibly due to fluid load in the MICU. #. Hypotension - Patient unable to provide symptoms. The differential is most likely hypovolemia secondary to Non-ketotic hyperglycemia in setting of poor PO intake and insulin dependent diabetic. Consideration as well for cardiogenic etiology although CVP was not elevated. Sepsis was not a concern given fact that patient was afebrile and blood cultures were negative. Since transfer to the medical floor, Mr. [**Known lastname 17391**] blood pressures have been stable with SBP 130's to 140's and DBP 60's to 80's. We have adjusted his blood pressure medication regimen, Furosemide has been discontinued secondary to acute renal failure on presentation and Norvasc was decreased from 10mg daily to 5mg daily. Mr. [**Known lastname **] is to follow up with his PCP [**Last Name (NamePattern4) **] [**9-6**] for follow up on his blood pressure and review of his medications. #. Elevated [**Name (NI) 16835**] - Pt with elevated [**Name (NI) **] on admission, possibly secondary to NSTEMI prior to admission - not acute. However, pt also with acute renal failure on admission which distorts the picture. Elevated cardiac enzymes can also be increased during renal failure. However, ECG with ST depressions and T wave inversions which suggests a cardiac event. Cardiology consulted and decided against cardiac catheterization as NSTEMI was not considered acute, likely occurred prior to admission. Pt has been medically managed. Will continue with ASA, Lipitor, Avapro, Labetalol on discharge. #. ARF/CKD - Patient admitted with a Cr of 4.5, baseline around 2.0. On admission, patient thought to be hypovolemic. Pt was treated in the MICU and volume resuscitated. Upon transfer to the medical floor, Cr has stabilized to baseline - Cr 2.0 on [**2169-9-1**]. # Sacral Decubitus Ulcer - Pt noted to have Stage II sacral decubitus ulcer on transfer from MICU. As patient was only in the ICU for a few days, it is unlikely that this ulcer began in the hospital. He is being treated with DuoDerm patches q3days. Last change today, [**2169-7-3**]. Wound care to continue at nursing home. #. Seizure Disorder - Patient with history of seizure disorder. No seizures have been noted while in the hospital. Pt sometimes has jerking movements while being examined but seems volitional in nature, pt is responsive and smiling with these movements. Pt to continue with outpatient Depakote. #. Alzheimer's - continue Memantine, Vitamin E. Medications on Admission: Aranesp 40mcg every other week Memantine 10mg/5ml twice daily Depakote sprinkles 250mg qAM, 500mg qPM Avapro 75mg daily HCTZ 25mg PO daily Labetolol 150mg [**Hospital1 **] Furosemide 40mg daily Norvasc 10mg daily Flomax 0.4mg daily Lipitor 10mg daily ASA 325mg daily Novolog 5u AC meals Lantus 5u in the evening Calcitriol 0.25mcg daily MVI daily Vitamin E 400u daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid (). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Lipitor 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule, Sprinkle PO QAM (once a day (in the morning)). 8. Divalproex 125 mg Capsule, Sprinkle Sig: Four (4) Capsule, Sprinkle PO QHS (once a day (at bedtime)). 9. Labetalol 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): Please hold for SBP < 100, HR < 60. 10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please hold for SBP < 100. 11. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day: Hold for SBP < 100. 12. Avapro 75 mg Tablet Sig: One (1) Tablet PO once a day: Hold for SBP < 100. Tablet(s) 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous sliding scale: Please follow attached sliding scale instructions. 16. Insulin Glargine 100 unit/mL Solution Sig: One (1) 35u Subcutaneous at bedtime. 17. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 18. Duoderm patch Wound Care: Pt with Stage II sacral decubitus ulcer. Treat with Duoderm patch q3days. Last change [**2169-9-2**]. Discharge Disposition: Extended Care Facility: [**Hospital6 4657**] - [**Location 1268**] Discharge Diagnosis: Primary: Hyperosmolar Non-Ketosis Non-ST elevation Myocardial Infarction . Secondary: Coronary Artery Disease - s/p MI, CABGx3 [**10-30**] Alzheimer's Diabetes Mellitus Type 2 Chronic Kidney Disease Anemia of Chronic Disease Hypertension Hyperlipidemia Seizure disorder Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital for a diabetic emergency. Your glucose levels were dangerously high above 800 on admission. This is thought to have been caused by a heart attack which ocurred prior to your visit to the emergency room. You were seen by cardiology who recommended medical management for your event. You also had an episode of low blood pressure while in the emergency room , which is thought to be due to dehydration. You were sent to the Medical intensive care unit for rehydration and management of your blood pressure. Your pressure and fluid balance stabilized while in the intensive care unit and you were transferred to the medical floor. We have discontinued your furosemide and decreased your Norvasc from 10mg daily to 5mg daily. Otherwise, You are to continue with your regular doses of your remaining blood pressure medication (hydrochlorothiazide, labetolol, avapro). You have been seen by the endocrinologists at [**Last Name (un) **] for management of your blood glucose levels. You are to take 35units of Lantus at night. You have also been placed on an Insulin sliding scale, please follow the attached directions. You were also noted to have a Stage II sacral decubitus ulcer while in the hospital. This occurs from prolonged bedrest. We have treated this with duoderm patches. Please continue with duoderm patches, which you will change every 3 days. You should not remain in bed for prolonged periods of time, if you are in bed please be sure to change positions to lie on your left and right side of the body. You should also sit in a chair during the day and walk with assistance. If you experience chest pain, palpitations, jaw pain, arm pain, shortness of breath, nausea, vomiting, fainting, dizziness or any other concerning symptom then please call your doctor or report to the nearest emergency room. Please continue with your remaining outpatient medications unless otherwise stated above. Please attend your follow up appointments listed below. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2169-9-6**] 4:20 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2169-9-21**] 2:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2169-10-3**] 9:30 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]

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49661

Discharge summary

report

Admission Date: [**2124-11-5**] Discharge Date: [**2124-11-17**] Date of Birth: [**2078-6-20**] Sex: F Service: MEDICINE Allergies: Codeine / Erythromycin Base / Sulfa (Sulfonamides) / Prednisone / Percocet / Tetracycline / Bactrim / Ampicillin / Amoxicillin / Albuterol / Ipratropium / Heparin Agents Attending:[**First Name3 (LF) 1055**] Chief Complaint: Abdominal pain/nausea/vomiting Major Surgical or Invasive Procedure: ERCP History of Present Illness: Ms. [**Known lastname **] is a 45 year old woman with a complicated medical history including aortic root replacement for acortic ectasis in [**2123-1-23**]. She has had multiple hospitalizations since that time for wound debridement and superficial sternal infections. Her course was complicated by a motor vehicle accident, [**12-4**], [**2123**], as an unrestrained driver with airbag deployment, head-on into a truck at approximately 50-60 mph. The patient sustained facial and nasal fractures, bruises to chest and knees. She was evaluated at [**Hospital6 5016**] and was also found to have a T12-L1 compression spine fracture. She was admitted to the CT service at [**Hospital1 18**] on [**2123-12-19**] for a sternal hematoma and was found to have a fluid collection anterior to the manubrium, with an enlarged pseudoaneurysm measuring 3.3 x 5.6. On [**12-22**], the patient was brought to the Operating Room at which time she underwent an aortic root replacement and coronary artery bypass grafting times one with SVG-->RCA. She returned to the OR on [**2123-12-25**] and underwent a clean-out of her chest and primary closure of her chest. She was discharged on [**2124-1-4**] with a back brace for her spinal fracture. She was discharged on Vancomycin 1 g b.i.d., stop date of [**1-30**], Rifampin 300 mg q.8 hours, to be continued indefinately, Gentamicin 100 mg q.8 hours, stop date of [**1-8**]. Following completion of Gentamicin course, the patient was to start on Levofloxacin 500 mg q.d., and this is to continue indefinitely. Patient presented to an outside hospital on [**2124-11-4**] with 11 hours of chest pain which was epigastric in character and associated with nausea and bilious emesis and SOB with exertion. It occurred suddenly while she was at work. She works as a nurse at a nursing home in [**Hospital1 487**]. The pain began in the epigastric area and then spread to her back, shoulders and down her legs. Last BM was day prior to admission and pt was passing gas. She reported that her temperature at work was 101. In the ED at [**Hospital 28941**] she was given vancomycin 1 gm and Levaquin 500 IV. She also got compazine, zofran and morphine. T 100.4 BP 157/70 HR 96 RR 24 O2 98% RA. Given her history of aortic root replacement she was transfered to the CSRU at [**Hospital1 18**] for further evaluation. She underwent a CT scan which showed no pathology of the aortic root and no evidence of sternal osteomyelitis. She was noted to have markedly elevated bilirubin, amylase and lipase. Her rifampin was held due to concern for hepatitis. She was continued on vancomycin and levaquin. On further history she reports that she has been off rifampin for the past 3-4 weeks as it causes nausea and vomiting. She restarted it 4 days ago and has had increasing nausea and epigastric pain since, but on the day of admission the pain was far worse in nature than prior. The pain was different from the pain she had with her aortic aneurysm. When the patient first started rifampin in [**11-28**] she did not tolerate it due to N/V and also developed mildly elevated transaminases, therefore the dose was decreased from 800 to 600 and the patient tolerated the medication better. She has been taking acetominophen and tylenol but cannot quantify how much. Past Medical History: 1. Aortic ectasia status post aortic root replacement in [**Month (only) 958**] [**2122**] with re-do in [**2123-12-22**] and one vessel CABG with SVG-->RCA. 2. Sternal wound debridement in [**2123-6-25**]; further sternal wound debridement in [**2123-9-25**]. 3. Zenker's diverticulum. 4. Gastroesophageal reflux disease. 5. Hypertension. 6. Nephrolithiasis with renal surgery [**2094**]. 7. Depression. 8. Anxiety. 9. Cholecystectomy [**2108**]. 10. Appendectomy [**2083**]. 11. Total abdominal hysterectomy [**2092**]. 12. Exploratory laparotomy [**2115**] for SBO. 13. Lysis of adhesions. 14. Ovarian cyst [**2105**] and [**2107**] Social History: Lives in [**Location 7661**] with her family of four children and boyfriend of many years. Smoked [**11-26**] PPD for 20 years but has quit. Rare Alcohol use. Denies blood transfusion, IVDU, tatoos. Denies any recreational drug use. Family History: non-contributory Physical Exam: VS- Tm 98.6 Tc 98.4 HR 57-84 76 BP 133/63 118-169/50-82 RR 19 17-26 O2 sat: 96-98% 1L I/O: 2610/330 GEN: Ill appearing, woman, lying in bed in some distress. NGT in place. Breathing comfortably on 1 liter oxygen. HEENT: PERRL, EOMI, sclera icteric. MMM. Scant petechiae on posterior pharynx, no erythema, edema or exudate. Neck: No LAD. Lungs: CTA bilaterally. CV: Regular, no murmurs, rubs or gallops appreciated. Abd: Soft, non distended, active bowel sounds in all four quadrants. Moderate tenderness in the epigastric area. No rebound and no guarding. Liver edge palpable 2 cm below the costal margin. Spleen non palpable. Ext: No edema, 2+ DP pulses bilaterally. Neuro: Alert and oriented x 3. Pertinent Results: At OSH: WBC 8.4 Hct 41.5 plt 215 Poly 56% lymph 28% mono 9.5% eos 5.0% Na 138 K 3.3 Cl104, HCO3 26, BUN 23 Creat 1.0. glucose 90 UA: large blood, + nitrites, sm LE, [**4-3**] RBC, 20-50 RBC casts, 0-2 WBC, many urate cyrstals, sm bilirubin. PH 5.0 SG 1.030 Pr 100. Total bilirubin 3.4 direct 1.5. AP 93 AST 84 ALT 18 Albumin 3.5 TP 6.4 amylase 50 LDH 622 CK 76 TnI < 0.04. D dimer > 40 MICRO: [**2123-2-18**]: blood MRSA 1/2 bottles [**2124-2-19**]: swab MRSA [**2123-5-6**]: swab MRSA [**2124-7-9**]: swab MRSA [**2123-9-20**]: blood: MRSA 2/4 bottles [**2123-9-21**]: abscess MRSA [**2123-9-22**]: swab MRSA [**2123-12-22**]: swab MRSA [**2124-11-5**] 03:35AM BLOOD WBC-11.4* RBC-4.73 Hgb-13.5 Hct-37.6 MCV-80* MCH-28.4 MCHC-35.8* RDW-14.0 Plt Ct-97*# [**2124-11-5**] 03:35AM BLOOD Neuts-78* Bands-14* Lymphs-4* Monos-1* Eos-0 Baso-1 Atyps-1* Metas-1* Myelos-0 [**2124-11-14**] 06:16AM BLOOD WBC-7.1 RBC-3.42* Hgb-9.6* Hct-27.7* MCV-81* MCH-28.1 MCHC-34.7 RDW-13.5 Plt Ct-305 [**2124-11-5**] 03:35AM BLOOD PT-15.8* PTT-32.0 INR(PT)-1.6 [**2124-11-5**] 03:35AM BLOOD Glucose-144* UreaN-44* Creat-1.8* Na-139 K-4.3 Cl-103 HCO3-24 AnGap-16 [**2124-11-13**] 05:00AM BLOOD Glucose-142* UreaN-74* Creat-8.6* Na-140 K-3.9 Cl-101 HCO3-25 AnGap-18 [**2124-11-5**] 03:35AM BLOOD ALT-164* AST-483* LD(LDH)-2137* CK(CPK)-146* AlkPhos-205* Amylase-342* TotBili-11.9* DirBili-6.5* IndBili-5.4 [**2124-11-5**] 01:56PM BLOOD ALT-127* AST-261* LD(LDH)-1648* AlkPhos-171* Amylase-157* TotBili-2.9* [**2124-11-6**] 03:04AM BLOOD ALT-82* AST-89* AlkPhos-122* Amylase-53 TotBili-0.9 [**2124-11-14**] 06:16AM BLOOD ALT-12 AST-7 LD(LDH)-251* AlkPhos-88 Amylase-15 TotBili-0.3 [**2124-11-5**] 03:35AM BLOOD Lipase-1328* [**2124-11-14**] 06:16AM BLOOD Lipase-14 [**2124-11-5**] 03:35AM BLOOD Albumin-4.1 Calcium-9.9 Phos-3.2# Mg-2.0 UricAcd-7.7* [**2124-11-14**] 06:16AM BLOOD VitB12-361 Folate-13.1 Ferritn-238* TRF-PND ---- HEPARIN DEPENDENT ANTIBODIES POSITIVE COMMENT: POSITIVE FOR HEPARIN PF4 ANTIBODY BY [**Doctor First Name **] REPORTED TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],RN [**2124-11-8**] 2PM ---- [**2124-11-5**] 12:42PM URINE Color-Brown Appear-Cloudy Sp [**Last Name (un) **]-1.020 [**2124-11-5**] 12:42PM URINE Blood-LG Nitrite-POS Protein->300 Glucose-TR Ketone-TR Bilirub-SM Urobiln-1 pH-6.5 Leuks-SM [**2124-11-5**] 12:42PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0-2 [**2124-11-9**] 10:00AM URINE Eos-NEGATIVE [**2124-11-10**] 12:17PM URINE Hours-RANDOM Creat-19 Na-98 TotProt-43 Prot/Cr-2.3* Albumin-23.9 Alb/Cre-1257.9* ---- Brief Hospital Course: A/P: 46 year old woman with a history of aortic root replacement x 2 complicated by MRSA bacteremia and chest wound presents now with acute pancreatitis, obstructive cholangitis and acute renal failure. 1) Pancreatitis and obstructive cholangitis: She initially had transminitis and enzymatic evidence of pancreatitis. Patient is s/p cholecystectomy and therefore one etiology was a retained gallstone. Also, possible that rifampin may be causing symptoms, as she has had similar repsonse of abd pain/V/N to this medication in past. This was not restarted. Also had RUQ U/S, Abd/pelvis CT, and renal U/S which were all WNL. Finally, she had an ERCP which was nL and showed no evidence of a stone. The etiology of her symptoms was never fully determined, but rifampin and possible gallstones that passed before ERCP are on list. She needs to stay on chronic ppx for her sternal MRSA osteo. Spoke with her outpt ID doctor and decided on levofloxacin based on her large allergy list. Her enzymes trended down quickly while in SICU, and were normal when we picked her up. Her abd pain/N/V had basically resolved as well. However, she began to c/o GERD, and then had more of her symptoms on the floor. Wondering if reaction to levofloxacin, as she has N/V to many other antibiotics. Continued her on PPI throughout and treated with Anzemet standing and prn compazine. 2) Acute renal failure: Although liver and pancreatic enzymes improved, her creatinine continued to rise indicitive of worsening renal failure. Seen by renal and felt was c/w ATN, not AIN from rifampin ingestion. However, ? of RBC casts at OSH which would point to more of a glomerulonephritis. Not seen here. She was never oliguric, but did have fairly significant creatinine elevation. Etiology was felt to be reponse to CT contrast along with prerenal state. Initially treated with Lasix as she was symptomatically volume overloaded. After she was euvolemic, cr continued to climb. Lasix stopped. She then began an apparent post-ATN diuresis, putting out 3-4 liters/day. Half of this amount was replaced as IVFs each day. Her creat peaked at 8.6 and then began to trend down. 4) Heme: Initial labs showed a Hct drop. Other studies were c/w hemolysis(high indirect bili, LDH). Can be seen with rifampin, but also several other drugs she was on(levo, lasix). Unclear which may have caused this. Continued to have a slow Hct drop while here. No evidence of bleeding. Fe studies c/w anemia of chronic disease. 5)HITT:She had a fast drop in her platelets, so heparin was stopped and PF4 antibody test was sent and positive. She was not immediately staretd on anticoag in SICU, but when we picked her up 5 days later, argatroban was initiated. She was then transitioned to warfarin. She will need to stay in this for [**12-28**] months as she is hypercoagulable for this amount of time after acute HITT episode. She showed no evidence of thrombosis. 6)ID:Pt needs chronic ppx for MRSA sternal infection/aortic root graft ppx. Rifampin may be acute cause of her GI symptoms +/- pancreatitis, so will not give this again. Pt has Bactrim allergy, so started Levo, renally dosed. Talked with her outpt ID doctor about this. If levoflox causing N/V, may need to stop it in future. She improved while in the hospital, and she was discharged on coumadin 4 mg qhs. She has close f/u with her PCP for lab work and can have her dose adjusted as appropriate. Medications on Admission: Rifampin 600 po daily Prevacid 30 Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 4. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 5. Compazine 10 mg Tablet Sig: One (1) Tablet PO every [**5-2**] hours. Disp:*30 Tablet(s)* Refills:*2* 6. Prevacid 30 mg Tablet,Lingual Delayed Release Sig: One (1) Tablet,Lingual Delayed Release PO once a day. Disp:*30 Tablet,Lingual Delayed Release(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: ATN, likely result of contrast nephropathy Heparin induced thrombocytopenia GERD Chronic MRSA sternal infection Discharge Condition: Stable. She had some residual nausea. Discharge Instructions: Please call your doctor or return to the ED if you experience chest pain, shortness of breath, increased abdominal pain, nausea, or vomiting that you can't control with medications. Also call if you have fevers, chills, or night sweats. -Take all of your medications as prescribed. Followup Instructions: Please call your primary care doctor to be seen on this Monday to have bloodwork including a CBC, Chem 7 and INR. Call Dr. [**Last Name (STitle) 952**] at ([**Telephone/Fax (1) 1504**] to make an appointment for [**12-29**] weeks from now. Call Dr. [**Last Name (STitle) 103855**] from the department of infectious diseases for an appoinment in the next month regarding the Levofloxacin for your sternal infection.

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icd9cm

[ [ [] ] ]

[ "38.93", "51.10" ]

icd9pcs

[ [ [] ] ]

12292, 12298

8085, 11524

462, 468

12454, 12493

5470, 8062

12824, 13244

4712, 4730

11609, 12269

12319, 12433

11550, 11586

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4745, 5451

392, 424

496, 3787

3809, 4446

4462, 4696

64,270

187,496

13414

Discharge summary

report

Admission Date: [**2195-8-15**] Discharge Date: [**2195-8-19**] Date of Birth: [**2175-4-1**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 4760**] Chief Complaint: fever, rigidity Major Surgical or Invasive Procedure: none History of Present Illness: This is a 20 year-old male with a history of recent initiation of antipsychotic medications who presents with increasing paranoia, fevers and stiffness. Patient had stopped smoking pot 1 month ago. He became increasingly agitated and paranoid; he was seen at [**Hospital1 18**] ED 2 weeks ago and evaluated by psychiatry. He was seen as an outpatient and started on seroquel. . In the ED, VS: T 100.8 BP 143/45 HR 103 SO2 100%RA. He was given 2mg IV ativan and 3L IV NS which improved his rigidity and paranoia. Toxicology was negative. Lactate was elevated to 2.5 and CK 100. Blood cultures were taken. Psychiatry was consulted and felt patient's presentation was consistent with 'paranoid catatonia'. Toxicology was contact[**Name (NI) **] and recommended treatment with benzos, avoidance of antipsychotics and EKG q6h. . ROS: The patient denies any fevers, chills, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: asthma eczema anxiety Social History: Denies alcohol, drug/IV drug use other than MJ. Lives in [**Location 686**] with mother,father, and 3 older siblings (2 sisters, 1 brother). Family History: brother with schizophrenia Physical Exam: Vitals: T: 99.8 BP: 134/79 HR: 112 RR: O2Sat: 100% RA GEN: Well-appearing, thin young man in NAD HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no cervical lymphadenopathy, trachea midline COR: RRR, 3/6 systolic murmur heard throughout the precordium radiating to the carotids, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Symmetrical increased tone in both lower extremities; increased tone R>L in upper extremities. Reflexes equal b/l, gait not assessed. SKIN: Dry skin throughout with eczema patches over b/l shins and arms. Pertinent Results: [**2195-8-17**] 04:00AM BLOOD WBC-11.9* RBC-4.38* Hgb-12.3* Hct-36.8* MCV-84 MCH-28.0 MCHC-33.4 RDW-12.4 Plt Ct-311 [**2195-8-16**] 04:14AM BLOOD WBC-13.1* RBC-4.90 Hgb-13.3* Hct-42.1 MCV-86 MCH-27.1 MCHC-31.5 RDW-12.4 Plt Ct-363 [**2195-8-15**] 08:17PM BLOOD WBC-12.6* RBC-4.20* Hgb-11.5* Hct-35.3* MCV-84 MCH-27.4 MCHC-32.6 RDW-12.4 Plt Ct-327 [**2195-8-15**] 12:10PM BLOOD WBC-15.7* RBC-4.85 Hgb-13.1* Hct-40.5 MCV-83 MCH-27.0 MCHC-32.3 RDW-12.8 Plt Ct-448* [**2195-8-17**] 04:00AM BLOOD Plt Ct-311 [**2195-8-17**] 04:00AM BLOOD PT-12.7 PTT-28.6 INR(PT)-1.1 [**2195-8-16**] 04:14AM BLOOD Plt Ct-363 [**2195-8-16**] 04:14AM BLOOD PT-12.9 PTT-27.3 INR(PT)-1.1 [**2195-8-17**] 04:00AM BLOOD Glucose-109* UreaN-8 Creat-0.7 Na-139 K-3.6 Cl-106 HCO3-25 AnGap-12 [**2195-8-16**] 04:14AM BLOOD Glucose-79 UreaN-9 Creat-0.7 Na-142 K-4.1 Cl-107 HCO3-23 AnGap-16 [**2195-8-15**] 12:10PM BLOOD Glucose-191* UreaN-10 Creat-0.9 Na-140 K-3.5 Cl-102 HCO3-25 AnGap-17 [**2195-8-17**] 04:00AM BLOOD ALT-18 AST-18 AlkPhos-57 TotBili-0.1 [**2195-8-17**] 04:00AM BLOOD Albumin-3.9 Calcium-9.2 Phos-4.3 Mg-1.8 [**2195-8-15**] 08:17PM BLOOD calTIBC-250* Ferritn-68 TRF-192* [**2195-8-15**] 12:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2195-8-15**] 01:53PM BLOOD Lactate-2.5* [**8-15**] CXR: The hemidiaphragms are in normal position. The structure and transparency of the lung parenchyma is unremarkable. There is no evidence of focal parenchymal opacities suggestive of pneumonia. Normal size of the cardiac silhouette, normal hilar and mediastinal contours. No pleural effusions, no pneumothorax. [**8-15**]: CT head negative Brief Hospital Course: This is a 20 yo M with a recent diagnosis of psychotic disorder, presenting with tachycardia and low grade fevers, felt to be due to NMS vs. malignant catatonia. Eventually it was felt the pt has acute psychosis and malignant catatonia. # Fever, rigitidy: Patient with presentation concerning for NMS- fever, rigidity, tachycardia, elevated BP, and mental status changes, namely catatonia/mutism and paranoia. Malignant catatonia, a psychiatric diagnosis, also presents in this manner. Psychiatry felt that the seroquel at 100 mg daily was unlikely to induce NMS. His TSH was normal. Utox and serum tox negative. Patient remained afebrile. Culture data was negative (urine and blood cultures negative at time of discharge). White count trended down. He was started on ativan 4 mg every 6 hours standing, and this was tapered down to 1.5 mg every 6 hours standing. His rigidity resolved as did his fever. . # Paranoia/malignant catatonia: This could have been triggered by family predisposition and marijuana use. His seroquel was discontinued given initial concern for NMS. He was started on standing ativan and abilify was titrated to 5 mg at night. He was followed by psychiatry, and due to acute psychosis with the pt claiming he was hearing voices tell him to go home, he was kept under section 12 with 1:1 sitter. . # Sinus tachycardia: The patients heart rate would rise up to 170 with anxiety, and at times the pt claimed he was hearing voices. His heart rate would quickly come down to the 100s-110s with reassurance. He also had improvement of his heart rate with his ativan. Again, his sinus tachycardia is felt to be due to anxiety and psychosis. He has no evidence of infection. His orthostatic vital signs were negative. . # Dizziness/ataxia: The patient had complaints of dizziness and ataxia. This is felt to be likely due to his ativan. Attempt was made to decrease his ativan to 1 mg every 6 hours from 3 mg every 6 hours, but this caused increased anxiety and more tachycardia. Due to apathy and sleepiness on the ativan, it was difficult to have the patient comply with neurologic testing. Head CT on admission was negative for any acute process. His ataxia was resolved by [**8-19**] after his ativan had been tapered to 1.5 mg every 6 hours. He was able to ambulate without difficulty back and forth down the hallway, and he was not orthostatic by vital signs. It is felt the ativan is likely causing his dizziness, and titrating this down as much as possible would help his symptoms. . # Asthma: He was written for albuterol inhaler . #Eczema: Pt was written for betamethasone. . # Comm: [**Name (NI) 11460**] (sister) [**Telephone/Fax (1) 40703**] (home), [**Telephone/Fax (1) 40704**] (cell) Medications on Admission: Seroquel 100 mg HS Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 3. Betamethasone, Augmented 0.05 % Gel Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 5. Betamethasone Valerate 0.1 % Cream Sig: One (1) Appl Topical QD () as needed for to arms and legs. 6. Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Lorazepam 1 mg Tablet Sig: 1.5 Tablets PO QID (4 times a day). Discharge Disposition: Extended Care Discharge Diagnosis: Primary: Malignant Catatonia Supraventricular tachycardia Fever Discharge Condition: stable, ambulating down the halls without difficulty, not orthostatic Discharge Instructions: You were admitted with a fast heart rate, fevers, and muscle rigitidy. This was felt to be due to malignant catatonia (a psychiatric disorder). Your symptoms improved with ativan. . Please call your doctor or go to the ER if you experience chest pain, shortness of breath, fever, fainting, suicidal thoughts, or any other concerning symptoms. Followup Instructions: Please follow up with your primary care doctor within 2 weeks of discharge.

[ "493.90", "E939.3", "293.89", "305.23", "427.89", "692.9", "V58.69", "781.3", "288.60", "298.9", "780.60" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7655, 7670

4239, 6963

283, 289

7778, 7850

2565, 4216

8241, 8320

1707, 1735

7032, 7632

7691, 7757

6989, 7009

7874, 8218

1750, 2546

228, 245

317, 1486

1508, 1531

1548, 1691

48,006

149,717

14307

Discharge summary

report

Admission Date: [**2193-9-3**] Discharge Date: [**2193-9-10**] Date of Birth: [**2106-3-7**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Cephalosporins Attending:[**First Name3 (LF) 6075**] Chief Complaint: left sided weakness found to have right thalamic bleed, transferred from [**Hospital3 **] Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. [**Known lastname 42461**] is an 87 y.o. Polish speaking right handed woman, with a past medical history of 2 distinct strokes (left MCA 7y. ago and right PCA 2 y. ago), afib currently on coumadin, hypertension and fibromyalgia, who presented to [**Hospital1 42462**] this morning because of difficulty moving her left side, left gaze paralysis and worsening dysarthria. She was in her usual state of health last night when she went to bed at 10:00 pm. She lives with her daugher and her dauther's husband. At around 7am, when her daughter went to check on her, she found her in bed unable to stand up and not moving her left side, with her eyes deviated to the right. She was alert and talking to her daughter, but with more dysarthria. She was taken to [**Hospital1 **] hospital, where her SBP was found to be 239. INR was 3.3, and head CT showed acute right thalamic hemorrhage, with no midline shift, but blood present in the aqueduct. She received 10mg of vitamin K IV, 2 doses of 20mg Labetalol IV, 1 unit of FFP, 500mg of IV Keppra, and was transferred to us for further management. She denies headaches, nausea or vomiting. At baseline, her blood pressure ranges in the 120's over 80's. At her baseline, she has right sided weakness secondary to her left MCA stroke in addition to expressive aphasia. She has intact comprehension and mental status except for not knowing what date it is. She does speak in full sentences, but has some paraphasic erros. In our ED, she was started on Nicardipine drip to maintain SBP<150, received factor IX. Head CT was reordered. 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: -afib on coumadin, last INR checked 1 month ago was 2.5 -Hypertension, well controlled per family report. -Question of CHF, unknown last echo and EF. -fibromyalgia Social History: Lives with her daughter and daughter's husband. Family History: noncontributory Physical Exam: Physical Exam on Admission: Vitals: T: 97.2 P: 68 R: 16 BP: 13-160/70's while in the ED SaO2: 98% 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: irregular rate. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to name and place, not to date (this is baseline). Talking to her daughter in Polish, answering questions appropriately, sighltly more disarthric than baseline but per daughter, does not have her dentures, Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Able to follow some midline and appendicular commands. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1.5mm and minimally reactive. VFF to confrontation on the right only. III, IV, VI:eyes deviated to the right, with left gaze paresis. V: Facial sensation intact to light touch. VII: left orbicularis oculi weakness, smile is 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 deviated to the right. Motor Increased tone in right upper and lower extremities, with strength ranging from 4 to 4+/5 on the right side, distal better than proximal, but I was unable to test single muscle groups as she did not follow all my commands. She can raise her left arm at least against gravity, did not follow my commands to activate biceps/triceps/wrist extensors or flexors, but is spontaneously moving these muscle groups at least against gravity. She has a weak grip of [**3-25**]. She raises her left lower extremity against gravity, distally her strength is [**4-25**] in dorsiflexion and plantar flexsion. -Sensory: No deficits to light touch, but unable to test for DSS. -DTRs: [**Name2 (NI) **] throughout, with 2 beats of knee clonus on the right, no ankle clonus on right but tight heel cord. [**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach L 3 3 3 3 1 R 3 3 3 3 1 Toes downgoing bilaterally. -Coordination: No dysmetria upon reaching for objects. Physical Exam on Discharge: Pertinent Results: Labs on Admission: [**2193-9-3**] 10:50AM WBC-8.1 RBC-4.57 HGB-13.6 HCT-42.6 MCV-93 MCH-29.8 MCHC-32.1 RDW-14.3 [**2193-9-3**] 10:50AM NEUTS-64.0 LYMPHS-30.0 MONOS-4.5 EOS-0.9 BASOS-0.6 [**2193-9-3**] 10:50AM PT-21.0* PTT-33.8 INR(PT)-2.0* [**2193-9-3**] 10:50AM CALCIUM-8.5 PHOSPHATE-3.7 MAGNESIUM-2.2 [**2193-9-3**] 10:50AM GLUCOSE-191* UREA N-22* CREAT-0.9 SODIUM-136 POTASSIUM-8.8* CHLORIDE-100 TOTAL CO2-27 ANION GAP-18 [**2193-9-3**] 11:05AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2193-9-3**] 11:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM [**2193-9-3**] 11:05AM URINE RBC-2 WBC-25* BACTERIA-FEW YEAST-NONE EPI-3 [**2193-9-3**] 08:58PM PT-14.0* PTT-26.2 INR(PT)-1.3* Imaging: CT head [**2193-9-3**] FINDINGS: Again seen are old infarcts in the left parietal and right cerebellar regions. The previously seen right thalamic hemorrhage has increased in size and now has extension into the ventricular system. Blood is seen within the lateral ventricles, the third ventricle, in the aqueduct. There is also slight increase in the size of the ventricles. The basal cisterns appear patent and there is preservation of [**Doctor Last Name 352**]-white differentiation. No bony abnormalities are identified. The visualized paranasal sinuses, mastoid air cells and middle ear cavities are clear. The globes are unremarkable. CT head [**2193-9-5**] Stable appearance of right thalamic hemorrhage with extension into the ventricular system. Brief Hospital Course: Mrs. [**Known lastname 42461**] is an 87 y.o. Polish speaking right handed woman, with a past medical history of 2 ischemic strokes (left MCA 7yrs ago and right PCA 2 yrs ago), afib on coumadin, question of CHF, hypertension and fibromyalgia who presented with left sided weakness , found to have an acute right thalamic hemorrhage in the context of elevated BP (SBP 239) and INR of 3.3. The patient admitted to Neuro ICU Repeat INR s/p vit K and 1u of ffps was 2 so received factor IX in ED. Her SBP in the ED ranged between 130-160s and she was started on Nicardipine. Her new deficits consist of left gaze paresis, left orbicularis oculi weakness, new left sided weakness. Repeat CT on [**9-3**] afternoon showed extension of hemorrhage but no evidence of midline shift. Clinically, pt was more lethargic on arrival to the ICU compared to in the morning in the ED. She was monitored in the neuro ICU and required a nicardipine drip to maintain goal SBP<160. This was d/c'ed on morning of [**9-4**]. That afternoon, she went into afib with RVR and required a diltiazem drip. Neuro wise, she became a bit less lethargic and was transferred to the floor. Patient had made it very clear that she did not want any surgical procedures and not even an NG tube in prior conversations with the daughter. [**Name (NI) **] failed speech and swallow. Of note, prednisone was held in the setting of a bleed. On admission, patient was DNI/DNR, does not wish to have neurosurgical procedure such as drains/shunts/bolts. Had discussion with daughter on [**9-4**] and told her that she would not return to her baseline of being able to walk with a walker and would most likely need a nursing home with 24 hour care. [**Doctor First Name **] feels that her mother would not want to be in a nursing home. She had told her many times that "when it is her time to go" to let her go. So after being in hospital till [**2193-9-10**] as no changes happened in his clinical status, she is discharged home with hospice care, Medications on Admission: Coumadin 2.5mg daily (of note, did not take dose last night) Diltiazem 240mg daily Metoprolol XL 200mg daily Digoxin 0.125mg daily Prednisone 10mg daily (for the fibromyalgia) Discharge Disposition: Home With Service Facility: Home with Hospice Discharge Diagnosis: Right thalamic hemorrhage Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Neuro exam: open her eyes when calling her name,not following commands, Eyes deviated to right, pupils 2mm reactive to light. spastic tone in upper ext, plantar reflex up bilaterally. Discharge Instructions: Dear Ms. [**Known lastname 42461**], You initially went to [**Hospital3 **] because you were weak on the left side of your body. A CAT scan of your head showed that you had bleeding in your brain, so you were transferred to [**Hospital1 1535**] for further management. Of note, your blood was quite thin so we gave you medications and blood products to reverse the effects of coumadin. You were admitted to the neurologic intensive care unit for blood pressure monitoring. 2 days later, you were transferred to the general neurology floor. You said that you did not want any procedures or surgical interventions and we respected your wishes. You were not able to swallow safely, but you did not want a feeding tube in your nose or stomach per your previous discussions with your daughter. [**Name (NI) **], we allowed you to eat for taste knowing the risk of coughing food into your lungs and having a pneumonia. We discharged you to a hospice facility where you could be made comfortable at the end of life. It was a pleasure taking care of you. Followup Instructions: none Completed by:[**2193-9-10**]

[ "599.0", "401.9", "438.89", "729.89", "438.11", "428.0", "729.1", "V49.86", "427.31", "431" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8970, 9018

6733, 8743

379, 385

9088, 9088

5151, 5156

10488, 10524

2638, 2655

9039, 9067

8769, 8947

9408, 10465

3654, 5103

2670, 2684

5132, 5132

249, 341

413, 2368

5171, 6710

9103, 9384

2390, 2556

2572, 2622

16,049

118,280

17280

Discharge summary

report

Admission Date: [**2118-4-26**] Discharge Date: [**2118-5-6**] Date of Birth: [**2068-7-18**] Sex: F Service: #58 HISTORY OF PRESENT ILLNESS: The patient is a 49 year-old woman diagnosed with metastatic renal cell cancer with spinal and pelvic mets on [**2118-3-27**]. The patient had a bony destruction of the left pedicle of L3 as well as posterior elements on the left side of L3 with impingement on the L3 nerve root without evidence of cord compression. The patient is preoped for lumbar embolization, renal embolization followed by left radical nephrectomy and removal of the L3 vertebra and L2-L4 spinal fusion. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. MEDICATIONS: 1. Oxycontin SR. 2. Percocet. 3. Colace. 4. Ambien. PHYSICAL EXAMINATION: In general, the patient was awake, alert and oriented times three, pleasant, cachectic looking female. Temperature 100. Blood pressure 120/62. Heart rate 117. Respiratory rate 18. Sat 98%. Pupils are equal, round and reactive to light. Mucous membranes are moist. Neck was supple. Pulmonary clear bilaterally. Cardiac tachy S1 and S2 within normal limits. Abdomen soft, nontender, nondistended. Positive bowel sounds. Extremities no edema. Back there was no swelling in the lumbar area. Neurologically the patient was awake, alert and oriented times three. Cranial nerves II through XII were intact, mildly symmetric. She had no drift. Her strength was 5 out of 5 in all muscle groups. Her sensation was intact to light touch. She was hyperreflexic throughout with clonus of the left lower extremity. PREOPERATIVE LABORATORIES: Sodium was 137, K 4.9, chloride 99, CO2 29, BUN 15, creatinine .8, glucose 154. HOSPITAL COURSE: The patient was preoped for a embolization of her lumbar spine area, which was done on [**2118-4-28**] without complications. The patient was monitored in the Intensive Care Unit postoperatively. The patient then underwent an embolization of her right kidney on [**2118-4-28**] without complications. She was again monitored in the Intensive Care Unit and then preoped for the Operating Room for left nephrectomy and L3 vertebrectomy with L2 to L4 fusion. She had this on [**2118-4-29**]. She tolerated the procedure well. There were no intraoperative complications. She was again monitored in the Intensive Care Unit. Postoperatively she was fitted for a TLSO brace. She remained on flat bed rest. She was moving both lower extremities with good strength. Her dressings were clean, dry and intact. She had a chest tube in place, which was draining serosanguinous fluid. She also had a JP drain in place. JP drain was removed on [**2118-5-2**]. The patient's brace was brought in on [**2118-5-2**] and the patient was out of bed on [**2118-5-2**]. Chest tube was removed on [**2118-5-3**] and she was out of bed in her brace. Her strength remained 5 out of 5 in all muscle groups. She was awake, alert and oriented times three and afebrile. She was transferred to the floor on [**2118-5-3**] and continued to do well and continued to be followed by physical therapy and occupational therapy and was found to be safely discharged to home. She was discharged to home on [**2118-5-6**] in stable condition with follow up with Dr. [**Last Name (STitle) 1327**] on Tuesday the 17th at 10:40 a.m. for staple removal. She will follow up with Dr. [**Last Name (STitle) 9125**] on [**5-23**] and with the oncology people on [**5-18**]. CONDITION ON DISCHARGE: Stable. She was afebrile. Her dressing was clean, dry and intact. MEDICATIONS ON DISCHARGE: 1. Percocet one to two tabs po q 4 hours prn. 2. Nystatin 5 cc q.i.d. prn. 3. Lasix 20 mg po q.d. times one day and then discontinued. 4. Hydrocodone sustained release 30 mg po q.a.m. 5. Hydrocodone 40 mg one tab at bedtime. 6. Calcium carbonate 500 mg t.i.d. 7. Phosphorus one packet b.i.d. for three days. 8. Zolpidem tartrate 5 mg at h.s. prn. 9. Lorazepam .5 mg q 4 to 6 hours prn. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2118-5-6**] 11:48 T: [**2118-5-6**] 12:13 JOB#: [**Job Number 48401**]

[ "E878.8", "189.0", "198.7", "198.5", "512.1", "E849.7" ]

icd9cm

[ [ [] ] ]

[ "99.29", "55.51", "84.51", "40.3", "81.06", "78.49" ]

icd9pcs

[ [ [] ] ]

3609, 4269

1744, 3489

698, 775

798, 1726

164, 644

667, 674

3514, 3583

22,446

173,059

4624

Discharge summary

report

Admission Date: [**2126-10-10**] Discharge Date: [**2126-10-17**] Date of Birth: [**2076-11-10**] Sex: F Service: ORTHOPEDICS HISTORY OF PRESENT ILLNESS: The patient is a 49 year-old female with a history of open reduction and internal fixation of right acetabular fracture on [**2126-6-6**] secondary to a motor vehicle accident. She was admitted on [**2126-7-12**] for intravenous therapy for cellulitis versus possible joint infection. The patient was readmitted on [**2126-7-25**] and underwent removal of hardware and loose bodies. She was also diagnosed with avascular necrosis of the right femoral head. The patient was treated with six weeks of intravenous antibiotics. On [**2126-10-10**] the patient was admitted for right total hip arthroplasty. PAST MEDICAL HISTORY: As above, plus depression, morbid obesity, hypertension. ALLERGIES: No known drug allergies. MEDICATIONS: Oxycodone prn, Clonazepam, Acetaminophen, Bisacodyl suppository, ______ prn, Effexor, Fluoxetine, Bextra, Buspirone, Senna, Docusate sodium, Neurontin. FAMILY HISTORY: Diabetes mellitus, Alzheimer's disease. SOCIAL HISTORY: The patient lives with her sister in [**Name (NI) **]. She is single and has no children. The patient denies any history of alcohol, smoking or drug use. PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.5. Pulse 100. Respiratory rate 12. Blood pressure 114/45. O2 sat 95% on room air. In general, the patient is a morbidly obese white female, alert and oriented. Eyes, extraocular movements intact. Pupils are equal, round, and reactive to light and accommodation. Neck no JVD. Chest clear to auscultation bilaterally. Heart regular rate and rhythm. Abdomen soft, nontender, obese, positive bowel sounds. Extremities scar over the right lateral thigh well healed. Severe onychomycosis of the toes noted. Distal pulses 2+, dorsalis pedis bilaterally. The patient is moving extremities well. Normal sensation to light touch in both feet. LABORATORY DATA ON ADMISSION: White blood cell count 6.7, hemoglobin 10.6, hematocrit 31.4, platelet count 302. HOSPITAL COURSE: The patient underwent total hip arthroplasty on hospital day number two [**2126-10-11**]. The procedure was done by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**]. There were no complications during the surgery, however, the patient lost 5 liters of blood and received 5 units of packed red blood cells in the Operating Room. The patient tolerated the procedure well and was transferred to the Medical Surgical Floor. The patient required several transfusions of packed red blood cells and on the discharge her hematocrit was 28. After surgery the patient had transient confusion related to effects of anesthesia and _________ and analgesics. Within two days her mental status improved. Erythema around the scar was noted. This did not look like cellulitis. However, because of previous history of infected hardware in the hip it was decided to start the patient on intravenous antibiotics. She was started on Cephazolin 2 grams every eight hours and needed to continue this for two weeks. For this purpose the patient received a PICC line in the right forearm. The patient has been treated for possible allergic to reaction to the tape with Benadryl. Right now the erythema is limited to the area covered by tape and does not seem to be expanding. The patient was restarted on Lovenox for deep venous thrombosis prophylaxis. She will need to continue for a total of six weeks. At the time of this dictation the patient already received one week of Lovenox. The patient was several episodes of loose stools. A sample was sent to the laboratory for C-difficile toxin SA, which was found negative. The patient continued to be depressed during this admission and spent a long time talking to her psychiatrist on the phone. The patient was screened and accepted by a rehabilitation facility. She will be discharged on [**2126-10-17**]. The patient will need to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] on [**Location (un) 86**] Orthopedic Group at phone number [**Telephone/Fax (1) 4301**] in two weeks. Please leave her staples intact until the date of appointment. DISCHARGE DIAGNOSES: 1. Status post right total hip arthroplasty on [**2126-10-11**]. 2. Hypertension. 3. Depression. MEDICATIONS ON DISCHARGE: Quinapril 20 mg po q day, Docusate sodium 100 mg po b.i.d., Gabapentin 600 mg po at h.s., Buspirone 10 mg po t.i.d., Lovenox 30 mg subQ q 12 hours times five weeks, Cephazolin 2 grams intravenous q.d. times two weeks, Fluoxetine sodium 100 mg po q day, _______________ XR 125 mg po q day, Oxycodone 5 mg po one to two tablets q 4 to 6 hours prn pain, Clonazapam 1 mg po q 8 hours prn. Touch down weight bearing on the right leg with thorough hip precautions. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 19623**] MEDQUIST36 D: [**2126-10-17**] 09:32 T: [**2126-10-17**] 10:02 JOB#: [**Job Number 19624**]

[ "250.00", "E878.1", "401.9", "278.01", "996.67" ]

icd9cm

[ [ [] ] ]

[ "38.93", "81.51" ]

icd9pcs

[ [ [] ] ]

1087, 1128

4291, 4392

4419, 5140

2133, 4270

176, 784

2032, 2115

807, 1070

1145, 1323

13,634

170,168

22307

Discharge summary

report

Admission Date: [**2144-10-27**] Discharge Date: [**2144-11-1**] Date of Birth: [**2089-8-24**] Sex: M Service: CSU Mr. [**Known lastname 58107**] is a direct admission to the operating room. He was seen in preadmission testing prior to being admitted to [**Hospital Ward Name 26168**] [**First Name (Titles) **] [**Last Name (Titles) **] for aortic surgery. CHIEF COMPLAINT: The patient was relatively asymptomatic with the exception of occasional palpitations. HISTORY OF PRESENT ILLNESS: A 55-year-old man, with a history of a murmur since childhood. An echo done 15 years ago showed no aortic dilatation. He has not had one since that time. A recent echo in [**2144-8-16**] showed moderate LV enlargement with an EF of 55 percent, bicuspid aortic valve with a dilated root and ascending aorta to 5.8 cm at the level of the valve, no AS, trace AI, trace MR, 1 plus TR. He was then referred for cardiac catheterization. Cath done on [**9-29**] showed normal coronaries with a dilated root and ascending aorta and an EF of 55 percent. PAST MEDICAL HISTORY: Hypertension. Arrhythmias. Isolated PVCs. Tension migraine headaches. Environmental allergies. Shingles. Chronic sinusitis. Hemorrhoids. BPH. Low back pain. Tonsillectomy. Appendectomy. ALLERGIES: He states no known drug allergies. MEDICATIONS PRIOR TO ADMISSION: 1. Atenolol 25 mg once daily. 2. Ferrous sulfate 325 [**Hospital1 **]. 3. Xanax prn. 4. Singulair 10 once daily. 5. Zyrtec 10 once daily. 6. Paxil 30 once daily. 7. Altace 5 once daily. FAMILY HISTORY: Father died at age 64 from an MI. Mother had labile hypertension. SOCIAL HISTORY: The patient is married, lives with his wife. [**Name (NI) **] has one adult daughter. [**Name (NI) 1403**] as a biomedical engineer. Denies tobacco. Alcohol - one drink per week. Denies recreational drug use. The patient had a chest CT in [**2144-9-16**] that showed an ascending aortic dilatation to a maximum of 5.2 cm from level of the aortic root to the level of the brachiocephalic arteries. PHYSICAL EXAMINATION: VITAL SIGNS: Heart rate 64, blood pressure 110/68, respiratory rate 18, height 6 feet 1 inch, weight 220. GENERAL: Well-appearing 55-year-old man in no acute distress. SKIN: No lesions. HEENT: Pupils equally round and reactive to light. Extraocular movements intact. Normal buccal mucosa, nonicteric. Neck is supple with no JVD and no bruits. Chest is clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm, S1, S2, with a I/VI systolic ejection murmur. Abdomen is soft, nontender, nondistended with hypoactive bowel sounds, and hepatosplenomegaly, or CVA tenderness. Extremities are warm and well-perfused with no clubbing, cyanosis or edema. No varicosities. NEURO: Cranial nerves II through XII grossly intact. Nonfocal exam. Pulses are 2 plus throughout. Carotids with no bruits. LAB DATA: White count 9, hematocrit 39, platelets 245, PTT 24, INR 1.1, sodium 142, potassium 4.1, chloride 106, CO2 26, BUN 14, creatinine 0.9, glucose 107. HOSPITAL COURSE: As stated previously, the patient was a direct admission to the operating room on [**10-27**] where he underwent a Bentall with number 29 homograft. His bypass time was 168 minutes. His crossclamp time was 139 minutes. He tolerated the operation well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient was A-paced at 91 beats per minute with a mean arterial pressure of 72. He had nitroglycerin at 0.3 mcg/kg/min, and propofol at 20 mcg/kg/min. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated. He remained hemodynamically stable throughout the operative day. On postoperative day 1, the patient continued to be hemodynamically stable. His central lines were discontinued, and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. On postoperative day 2, the patient continued to be hemodynamically stable. His chest tubes, as well as his Foley catheters were removed. His activity level was advanced with the assistance of the nursing staff, as well as the physical therapy staff. On postoperative day 3, his temporary pacing wires were removed. He was begun on beta blockade, and his activity level was further advanced. On postoperative day 4, it was decided that the patient was stable and ready to be discharged home. At the time of this dictation, the patient's physical exam, temperature 98.3, heart rate 56/sinus brady, blood pressure 98/58, respiratory rate 18, weight 107.1, preoperatively 100. Hematocrit 26.7, sodium 141, potassium 4.7, chloride 104, CO2 32, BUN 13, creatinine 0.8, glucose 123, mag 2.1. PHYSICAL EXAM: Alert and oriented x 3. Moves all extremities. Nonfocal exam. PULMONARY: Clear to auscultation bilaterally. CARDIAC: Regular rate and rhythm, S1, S2, with no murmur. Sternum is stable. Incision with Steri-Strips, open to a air, clean and dry. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well-perfused with no edema. CONDITION AT DISCHARGE: Good. He is to be discharged to home with visiting nurses. DISCHARGE DIAGNOSES: Status post Bentall with a number 29 homograft. Migraines. Shingles. Sinusitis. Hemorrhoids. Benign prostatic hypertrophy. Low back pain. Tonsillectomy. Appendectomy. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg once daily. 2. Lasix 20 mg [**Hospital1 **] x 7 days. 3. Colace 100 mg [**Hospital1 **]. 4. Zantac 150 mg [**Hospital1 **]. 5. Paxil 30 mg once daily. 6. Singulair 10 mg once daily. 7. Ferrous sulfate 325 once daily. 8. Ascorbic acid 500 [**Hospital1 **]. 9. Lopressor 25 [**Hospital1 **]. 10.Potassium chloride 20 mEq once daily x 7 days. 11.Percocet 5/325, 1 tablet q 4-6 hours prn for pain. FO[**Last Name (STitle) 996**]P: The patient is to have follow-up with Dr. [**Last Name (Prefixes) 411**] in 4 weeks, and follow-up with Dr. [**Last Name (STitle) 58108**] in [**2-18**] weeks, and follow-up with Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 17399**] also in [**2-18**] weeks. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2144-11-2**] 17:35:14 T: [**2144-11-3**] 10:27:22 Job#: [**Job Number 34731**]

[ "395.9", "746.4", "441.2", "427.31", "E878.2", "997.1" ]

icd9cm

[ [ [] ] ]

[ "35.21", "38.45", "99.02", "36.99", "39.61", "88.72" ]

icd9pcs

[ [ [] ] ]

1574, 1642

5339, 5515

5538, 6524

3086, 4836

4852, 5241

1369, 1557

2084, 3068

5256, 5317

400, 488

517, 1068

1091, 1337

1659, 2061

15,968

109,092

21239+57231

Discharge summary

report+addendum

Admission Date: [**2133-8-5**] Discharge Date: [**2133-8-11**] Date of Birth: [**2068-7-17**] Sex: F Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5644**] Chief Complaint: cuts to ankles Major Surgical or Invasive Procedure: none History of Present Illness: This 70 year old female with multiple medical issues presented to the ED with cuts to her legs. There is a question of self-inflicted wounds vs. assault. At the time of EMS arrival her door was locked from the inside requiring EMS to force entry. The patient was found down, responsive, confused, with no signs of trauma except for the bilateral ankle lacerations, she was found with large amount of blood on the floor. No active bleeding at the time of admission. She had week pulses in the ED initially 40/p then up to 80s with IVF. She was intubated secondary to nausea/vomiting for airway protection. She recieved 4 units PRBC and 6 liters IVF, 1 liter LR. She was given charcoal for presumed toxic ingestion. She was admitted to the T/SICU intubated on PPF and Dopamine. In the T/SICU she stabilized. She was weaned off all drips and extubated the following AM. She was then transferred to the floor. Past Medical History: 1. HTN 2. hypercholesterolemia 3. CHF 4. Osteoporosis s/p vertebral fractures 5. Depression 6. asthma 7. s/p vaginal CA 8. Herniated disk 9. hx. EtOh abuse 10. s/p MI '[**24**] 11. s/pBilateral leg clots '[**28**] 12, s/p small bowel and stomach resection 13. s/p AAA repair 14. s/p vascular surgery on legs 15. s/p CCK Social History: remote history of EtOH, 1ppd smoker for 50 years, lives alone Family History: non-contributory Physical Exam: Temp 97.9 BP 74 Pulse 135/59 Resp 13 O2 sat 97% on RA Gen - Alert, no acute distress HEENT - PERRL, bilateral cataracts, extraocular motions intact, anicteric, mucous membranes moist Neck - right IJ line, no cervical lymphadenopathy Chest - Clear to auscultation bilaterally CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, nontender, nondistended, with normoactive bowel sounds Back - No costovertebral angle tendernes Extr - Bilateral ankle lacerations, dressings clean dry and intact, No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3, cranial nerves [**3-12**] intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact Skin - No rash Pertinent Results: [**2133-8-5**] 06:55PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2133-8-5**] 06:40PM WBC-9.5 RBC-3.15* HGB-11.2* HCT-32.2* MCV-102* MCH-35.5* MCHC-34.8 RDW-14.5 [**2133-8-5**] 10:49PM GLUCOSE-162* LACTATE-3.3* NA+-142 K+-4.1 CL--115* Brief Hospital Course: Please see addendum for additional hospital course. 1. Ankle lacerations - She was evaluated by ortho who advised that she received a tetanus shot and that the wounds not be closed when she first arrived. On the third day of hospitalization they advised to have the trauma team suture the wounds. 2. Increased LFTS - After she was transferred out of the MICU her LFTs were elevated. These appeared to be due to shock liver due to her severe fluid loss from bleeding. When rechecked later they had normalized. 3. CV - Upon tranfer to the floor she was noted to have crackles throughout her lungs and be SOB. She had been given a lot of fluid the prior day. It was felt that she was in mild CHF and she was given 20mg Lasix IV with good effect. 4. Pulmonary - She was noted to be SOB upon transfer to the floor. We restarted all of her home asthma medications and inhalers with good effect. 5. Psychiatry - The psychiatry team evaluated her while she was in the MICU and again on the floor. They initially felt that it was most likely these wounds were due to assault and not self inflicted. However, upon obtaining the police report and with careful patient questioning, it appeared that the wounds were in fact self-inflicted. She will be admitted to a psychiatric facility. 6. Her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], was contact[**Name (NI) **] and all of her out-patient medications were restarted. Medications on Admission: Meclizine prn Ezetimibe 10 Rofecoxib 25 Theophylline SR 300 TID Cardiazem CD 360 Fluoxetine 20 Lasix 40 Atenolol 25 [**Hospital1 **] Advair Albuterol Xanax prn Protonix 40 Trazadone 150 MVI Synthroid 25 Discharge Medications: see addendum Discharge Disposition: Extended Care Facility: [**Hospital1 1680**] HRI Discharge Diagnosis: see addendum Discharge Condition: see addendum Name: [**Known lastname 10540**],[**Known firstname **] Unit No: [**Numeric Identifier 10541**] Admission Date: [**2133-8-5**] Discharge Date: [**2133-8-11**] Date of Birth: [**2068-7-17**] Sex: F Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2339**] Chief Complaint: ankle lacerations Major Surgical or Invasive Procedure: Intubated for Airway protection. Given 6 Units of PRBCs. Past Medical History: 1. HTN 2. hypercholesterolemia 3. CHF 4. Osteoporosis s/p vertebral fractures 5. Depression 6. asthma 7. s/p vaginal CA 8. Herniated disk 9. hx. EtOh abuse 10. s/p MI '[**24**] 11. s/pBilateral leg clots '[**28**] 12, s/p small bowel and stomach resection 13. s/p AAA repair 14. s/p vascular surgery on legs 15. s/p CCK Brief Hospital Course: 1. Ankle Lacerations. Pt continued to do well with minimal discomfort of her wounds. Will continue dressing changes. Will need f/u with out-pt trauma clinic next week for closure. 2. Psychiatry. Based on the police report obtained describing nature of lacerations, primary team and psychiatry team were concerned that pt's wounds were self-inflicted. Pt and Psych agreed to in-patient psych evaluation. During hospital stay pt denied suicidal ideation. Discharge Disposition: Extended Care Facility: [**Hospital1 3288**] HRI Discharge Diagnosis: 1. b/l ankel lacerations, presumed self-inflicted, r/o suicide attempt. 2. hypotension, hemorrhage resolved 3. CHF-stable 4. Astma/COPD-stable Discharge Condition: Unstable secondary to psych evaluation. Discharge Instructions: Will be discharged to in-patient psych unit. Patient is medically cleared. Followup Instructions: 1. Patient will go to in-patient psych unit. [**Unit Number **]. Please call PCP for [**Name Initial (PRE) **]/u once discharged from psych unit. [**Unit Number **]. Please f/u in out-patient trauma clinic for closure of ankle lacerations in one week. Call [**Telephone/Fax (1) 10542**] for appointment. [**Month (only) 412**] page in-patient trauma team for other questions regarding ankle lacerations. [**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**] MD [**MD Number(1) 628**] Completed by:[**2133-8-11**]

[ "891.0", "570", "428.0", "518.82", "958.4", "E956", "285.1", "493.20", "303.90" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6054, 6105

5572, 6031

5132, 5191

6292, 6333

2504, 2786

6457, 7020

1731, 1749

4527, 4541

6126, 6271

4300, 4504

6357, 6434

1764, 2485

5075, 5094

358, 1277

5213, 5549

1651, 1715

63,213

146,594

33058

Discharge summary

report

Admission Date: [**2185-7-30**] Discharge Date: [**2185-8-26**] Date of Birth: [**2101-7-12**] Sex: F Service: MEDICINE Allergies: Egg Attending:[**First Name3 (LF) 2145**] Chief Complaint: OSH transfer for cholangitis Major Surgical or Invasive Procedure: #ERCP w/ Stent Removal and Replacement #Placement of percutaneous billiary drain to clear abcess History of Present Illness: 84yo female with multiple medical problems including coronary artery disease s/p CABG, Type 2 Diabetes Mellitus, chronic diastolic heart failure, and peripheral vascular disease was transferred from an OSH for further evaluation of abdominal pain. She was admitted to [**Hospital1 18**] from 7/25-29/09 to the surgical service for evaluation of abdominal pain. At that time, she underwent an ERCP which demonstrated the following: "filling defect that appeared like a stone at the distal CBD, 2cm distal CBD narrowing and post obstructive dilation and measured 15mm in diameter. Also there was intrahepatic dilation of the biliary tree." Sphincterotomy was not performed as patient was on plavix at the time. Follow-up CTA Abdomen was obtained which revealed "porta hepatis lymphadenopathy and suggestion of lower CBD soft tissue at the site of filling defect on ERCP raises possibility of cholangiocarcinoma." Cytology specimens were negative for malignancy and CEA was 3.1 (not elevated). She was then discharged with plans to repeat the ERCP and EUS in [**2-2**] weeks after cardiology evaluation and consideration of stopping aspirin and plavix prior to repeat procedure. In fact, she was scheduled to have a stress test performed on [**2185-8-1**] in anticipation of a likely repeat GI procedure; however, she presented to an OSH on [**2185-7-28**] with RUQ pain radiating to her substernal chest. She was admitted to for rule-out MI. Her hospital course was complicated by a temperature to 100.5 and CXR demonstrating dilated pulmonary vasculature. She was started on unasyn and gentamicin for treatment of presumed cholangitis and was diuresed with IV lasix. Upon arrival to [**Hospital1 18**], she reports feeling generally well and without abdominal pain. Review of systems: (+) Per HPI. abdominal pain as described above; low-grade temperature (-) Denies pain, chills, night sweats, weight loss, headache, sinus tenderness, rhinorrhea, congestion, cough, shortness of breath, chest pain or tightness, palpitations, nausea, vomiting, constipation, change in bladder habits, dysuria, arthralgias, or myalgias. Past Medical History: 1. Coronary Artery Disease - s/p CABG x 3 in [**2168**] at [**Hospital1 112**]: LIMA to LAD, SVG to PDA, SVG to OM - stent palced in [**1-9**] 2. Chronic Diastolic Congestive Heart Failure - [**6-6**] - EF 70% 3. Peripheral Vascular Disease - s/p bilateral CEA 4. Hyperlipidemia 5. AAA (unchanged since the [**2165**]'s) 6. Type 2 Diabetes Mellitus - Uncontrolled 7. GERD 8. Hiatal hernia 9. Osteoarthritis 10. Melanoma s/p resection 11. Spinal stenosis 12. Anxiety / depression s/p ECT therapy 13. h/o Tobacco Abuse Social History: Home: lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]; very supportive and involved family Occupation: homemaker EtOH: Denies Drugs: Denies Tobacco: prior tobacco use - smoked < 1ppd x 35 years, quit 14 years ago Family History: Mother - died of PE at age 82 Father - died at age 77 from complications of a stroke Brother - died at age 67 with an MI Physical Exam: Vitals: T: 101.3 BP: 110/70 P: 100 R: 22 O2: 94-96% on 3L NC General: Rigoring initially, now more comfortable, initially slightly confused, then fully oriented HEENT: Sclera anicteric, MM slightly dry, oropharynx clear Neck: supple, right internal jugular line in place, slight ozzing from line. Lungs: Rales greater on left base over lower [**12-4**], and right side over base, moving good air CV: Borderline tachycardic, regular rate and rhythm, [**1-7**] HSM at the LLSB and apex Abdomen: soft, non-distended, bowel sounds present, tender to palpation in RUQ, no rebound tenderness or guarding, no organomegaly. No guarding or rebound tenderness, no focal or reproducible tenderness. GU: foley in place Ext: warm, well perfused, slightly damp, trace bilateral non pitting pedal edema bilaterally Neuro: Awake, alert, conversing appropriately Pertinent Results: OSH LABS: [**2185-7-28**] WBC 11 / Hct 41.8 / Plt 214 N 75 / L 16 / M 7 / E 1 / B 0 . [**2185-7-30**] WBC 17.6 / Hct 40.8 / Plt 221 N 72 / Bands 13 / Mono 5 / Lymphs 10 Na 136 / K 3.3 / Cl 101 / CO2 25 / BUN 12 / Cr 1.3 TB 4.9 / DB 2.9 / AST 182 / ALT 143 TP 6.6 / Alb 3 / Alk Phos 373 BNP 840 UA - pH 6, 1.019, clear, 30 protein, 300 glucose, negative for ketones, negative blood, small bili, neg nitrite, large leuk est, 4 RBCs, 9 WBCs, few bacteria Urine Osm 558 / Urine Na 94 . [**Hospital1 18**] Results: [**2185-8-8**] WBC 13.5 / Hct 34.3 / Plt 326 N 75.7 / L 16.4 / M 5.2/ Eos 2.6/ Baso 0.1 PT 12.5 / PTT 32.8 / INR 1.1 Glc 89 / BUN 8 / Cr 0.9 / Na 139 / K 4.1 / CL 105 / HCO3 25 ALT 15 / AST 18 / CK 17 / AP 211 / T Bili 0.5 CK-MB 3 / Trop 0.05 Ca 8.1 / Phos 3.2 / Mg 2.3 . OSH MICROBIOLOGY: [**2185-8-7**]: Urine Cx NG [**2185-8-6**]: URINE CULTURE (Final [**2185-8-8**]): YEAST. 10,000-100,000 ORGANISMS/ML.. [**2185-7-30**]: Blood Cx pending [**8-5**], [**8-6**]: C. Diff x2 NG . IMAGING: [**2185-7-28**] CXR (OSH) - questionable nodule identified overlying the heart and possibly in the left lower lobe. It is visible on a chest radiograph from [**12-9**] and has not changed. No active disease seen elsewhere . [**2185-7-29**] Abdominal US (OSH) - choledocholithiasis and cholelithiasis. There is gallbladder sludge present and there is borderline mural thickening. There is choledocholithiasis noted and pneumobili. By report, the patient has undergone recent biliary stenting which would account for the pneumobili. No definite intrahepatic biliary dilatation is seen . [**2185-7-30**] Portable CXR (OSH) - left ventricular dilatation. Post-surgical changes in left hemithorax. Lungs are well expanded. Oval nodular density at the left base behind the heart. remainder of the lungs are clear. . [**2185-8-1**]: ERCP: Scout view demonstrates a plastic biliary stent in the right upper quadrant. Subsequent images demonstrate cannulation of the common bile duct with irregularity in the region of the stent, and stable common bile duct and intrahepatic ductal dilatation. No definite filling defects are seen. Stent removal and replacement is noted. Please refer to the operative note for further details. . [**2185-8-3**]: Abd U/S: 1. Gallbladder sludge. No evidence of acute cholecystitis. 2. Pneumobilia, presumably related to recent ERCP procedure. . [**2185-8-3**] CXR Decrease in lung volumes with superimposed mild-to-moderate volume overload. Repeat radiography following appropriate diuresis recommended to assess for underlying infection. . [**2185-8-4**]: CXR: In comparison with study of [**2185-8-3**], there is persistent enlargement of the cardiac silhouette _____ the patient following CABG procedure. There is a breakage of the upper portion of the two most superior sutures, as on the study of [**2185-8-3**]. Evidence of increased pulmonary venous pressure persists with bibasilar atelectasis, especially in the retrocardiac region. Dense calcification is seen in the region of the mitral valve. Right IJ catheter tip again extends to the lower portion of the SVC. . [**2185-8-5**] CXR: Improved pulmonary edema and lower lobe atelectasis. Stable mild cardiomegaly. Rounded calcification projected over the mitral valve,on review of a prior CT confirms this calcification is in/attached to the mitral valve, Correlation with echo is recommended. . [**8-6**] CT Abd: 1. Contained gallbladder perforation into the right lobe of the liver. Cholelithiasis. 2. Atrophy of the interpolar left kidney. Atherosclerotic changes of the left renal artery, not well assessed on this non-angiographic study. 3. Fibroid uterus. . [**8-10**] GB DRAINAGE,INTRO PERC TRANHEP BIL US: 1. Successful CT and ultrasound-guided placement of percutaneous cholecystostomy catheter. Approximately 130 cc of purulent material was aspirated, with subsequent decrease in size of both the gallbladder and the adjacent hepatic abscess. Samples were sent for culture and Gram stain. 2. Small right lateral abdominal wall hematoma. Monitoring of hematocrit is recommended to assess for hematoma expansion in this patient on Aspirin and Plavix. This was discussed with Dr. [**Last Name (STitle) 4312**] at approximately 3:30PM by Dr. [**Last Name (STitle) **]. . [**8-12**] CXR: Bibasilar atelectasis related to low lung volumes. No overt evidence for pneumonic consolidation or edema. . [**8-15**] CT Abd: 1. Drainage catheter at the perihepatic abscess next to the largely decompressed gallbladder. 2. New 2 x 5-cm collection at the lower edge of the liver. [**Month (only) 116**] be due to the bile leak with subcapsular collection formation, or another point of perforation of the gallbladder. Abscess cannot be excluded. 3. Further noted increased stranding surrounding decompressed gallbladder. . CARDIAC IMAGING: Echo [**2185-6-27**] ([**Hospital1 18**])- EF > 55%; dilated left atrium; mild symmetric LVH; moderate aortic stenosis with [**Location (un) 109**] 1-1.2cm; 2+ MR; 2+ TR; severe pulmonary artery systolic hypertension . PATHOLOGY: [**2185-8-1**]: Stent (common bile duct): NEGATIVE FOR MALIGNANT CELLS. Bile pigment and few degenerated epithelial cells. . EKG [**2185-8-22**]: Atrial fibrillation, average ventricular rate 131. Intraventricular conduction delay with QRS duration of 98 milliseconds. There are marked ST segment depressions in leads I, II, aVL and leads V2-V6. Compared to the previous tracing of [**2185-8-21**] these changes are similar but somewhat more prominent. Brief Hospital Course: [**Hospital Unit Name 153**] Course: Mrs. [**Known lastname 76866**] is an 84 year old female who was admitted to [**Hospital Unit Name 153**] post ERCP on the [**2185-8-1**], presenting with fever, rigors, and tachycardia. #Cholangitis: Her post-ERCP fevers, rigors, and tachycardia were most likely related to the cholangiogram with subsequent transient sepsis. OSH blood culture grew E. Coli sensitive to cefazolin, ampicillin, and piperacillin. She was started on zosyn to cover her bacteremia. Due to her continuing spiking fevers and abnormal urine analysis consistent with possible infection, ciprofloxacin and vancomycin were started as empiric coverage, however they were then discontinued after negative culture data for 24-48 hours. She continued to spike fevers, at which vancomycin was added back to her regimen. Her subsequent blood/urine cultures remained without growth. Through her ICU course, she has RUQ pain, which was felt to be due to a musculoskeletal, pleuritic, or cholestatic source. A right upper quadrant ultrasound demonstrated no evidence of cholecystitis and she had remained afebile with a decreasing leukocytosis. Her pain was controlled with PRN percocet. Throughout her course, her MAP has been maintained above 65 with Levophed and small fluid boluses. She was weaned off of the levophed. Upon discharge from the ICU to the floor, PICC line was placed for continuation of zosyn and her a-line. She was transferred to floor [**8-5**] after being off pressors for 24 hr. She was subsequently readmitted to the [**Hospital Unit Name 153**] on [**8-6**] for fever, tachycardia, hypotension. On the morning of [**2185-8-6**], she developed fever 102, systolic blood pressure in the high 80's, and rigors. Repeat cultures were obtained and she was re-started on ciprofloxacin, flagyl, and vancomycin. An ABG 7.44/26/61 demonstrated, with lactate 5.9. She was transfered to the [**Hospital Unit Name 153**] for further management and given small fluid boluses. After she was stabalized, she underwent a CT abdomen showed perforated loculated gallbladder, loculated in the right liver lobe. Surgery was consulted who recommended percutaneous drainage by IR. IR was consulted for procedure to be done. At that time, however, after extensive discussion with patient and her daughter [**Name (NI) **] (her HCP), the patient elected not to pursue IR drainage, and wished her code status to be DNR/DNI, with conservative management only. For her antibiotic regimen, she was started back on vancomycin, zosyn, and flagyl. After C. Difficile x2 came back negative, flagyl was discontinued. On the morning of [**2185-8-8**], she experienced an episode of chest heaviness that radiated to both arms that resolved within a minute after SL nitroglycerin administration. She stated she has experienced this type of pain before, but was less in severity in comparison to her regular anginal pain. EKG [**Location (un) 1131**] showed T-wave inversions/ST depressions in leads V2-V5. ASA dose was increased to 325, SL nitro PRN, MSIR 7.5mg PRN, O2 NC, metoprolol 25mg, repeat CEs, and EKGs were ordered. Troponin after event was 0.05. Subsequent EKGs showed no further change. The palliative care and infectious disease teams were involved in her care. Several family meetings and meetings with the patient took place to discuss potential options going forward, regarding getting the patient home on antibiotics and discussion of surgery. There still remains a question of underlying malignancy given the stenosis initially seen on her first ERCP in [**2185-6-1**], at which time biopsy was not pursued as she remained on plavix. The patient continued to do well in the [**Hospital Unit Name 153**], and was transitioned to flagyl and ceftriaxone on the recommendations of the infectious disease team. Over the weekend of [**9-12**], patient decided she wished to re-consider the surgical option for management of her contained perforation. She was transferred to the floor on [**2185-8-14**] for further management and ongoing discussion with surgical and infectious disease teams about next steps. Social work and palliative care also will continue to be involved. An insulin sliding scale was maintained for her DMII. For her CAD, antihypertensives were held. ASA and plavix were continued. For her hyperlipidemia, zetia was continued while simvastatin was added back after her LFTs came down within normal limits. For depression/dementia, her celexa, remeron and abilify were continued while holding her ativan. For prophylaxis, SC heparin and ranitidine were implimented due to the interaction between PPI and plavix. She is DNR/DNI and is hemodynamically stable upon transfer back to floor status. FLOOR COURSE #Cholangitis- Prior to arrival on floor, pt had CT-guided percutaneous drain was placed on [**8-10**] to drain a localized gallbladder fluid collection, and was stabilized on IV ceftriaxone and IV flagyl. However, pt's abscesses were multiple and loculated, requiring additional drain placement and/or repositioning for cure. However, given that first drain placement had caused her significant abdominal pain and could not guarantee cure, pt felt that additional drain placement was not in line with her wishes. On floor, patient was evaluated by surgery, though given her significant CAD history, pt was deemed not a surgical candidate. She was again evaluated by IR for placement of second drain, however pt declined. Care was focused on comfort and symptom control. Pt plans to go home with hospice, and efforts were made to adjust her in-hospital care to what she would receive at home. Pt's family felt strongly regarding continuing antibiotics to avoid the discomfort of septicemia. Patient's antibiotics can be continued for 3-4 weeks as long as there are no complications from therapy or PICC line. If there is difficulty continuing iv ceftriaxone, pt's family is open to considering changing ceftriaxone to cefpidoxime po. She will continue flagyl po at home. Physician following pt's care . #A-fib w/ RVR: On floor, pt went into atrial fibrillation w/ RVR (130s), though pt was asymptomatic. Given pt's age, h/o biatrial enlargement on echo, significant h/o CAD, heart failure, and ongoing infection, she has many risk factors for atrial fibrillation. Her heart rate was controlled w/ diltiazem, which was titrated up to 90mg PO QID, and metoprolol 12.5mg PO TID. When decision was made for hospice, pt and family preferred to be off telemetry and treat heart rate symptomatically only. Patient developed anginal pain with faster heart rates, which was treated with SLNG and PO morphine to good effect. . #Hyperlipidemia-Once decision was made for hospice care, efforts made to minimize medication regimen. Zetia and simvastatin were discontinued. . #Diabetes Mellitus-Once decision was made for hospice care, efforts made to minimize medication regimen, and ISS was discontinued. . #Anxiety / Depression- Stable. Home medications (celexa, remeron and abilify) except ativan were continued. Initially, ativan was avoided given propensity to cause delirium in elderly. However, pt takes standing ativan at home and pt strongly requested ativan for anxiety. Pt tolerated ativan well. . #Pain-Palliative care was consulted and recommended a regimen of basal MS-Contin with concentrated morphine sulfate solution as needed for breakthrough pain. Pt was discharged with home hospice. Her adult children have been very involved in her care and will continue to care for her at home with the additional help of private duty nursing. Medications on Admission: HOME MEDICATIONS: 1. Glipizide 5mg PO daily 2. Plavix 75mg PO daily 3. Lasix 40mg PO daily 4. Toprol XL 25mg PO daily 5. Cozaar 50mg PO daily 6. Aspirin 81mg PO daily 7. Abilify 2mg PO daily 8. Celexa 20mg PO daily 9. Ativan .5mg PO bid 10. Glipizide 10mg PO qhs 11. Imdur 30mg PO qhs 12. Zetia 10mg Po qhs 13. Zocor 80mg PO qhs 14. Remeron 45mg PO qhs prn 15. Colace 16. Senna 17. SLNG prn TRANSFER MEDICATIONS: 1.Ativan .5mg PO bid 2.Losartan 50mg PO daily 3.Toprol XL 25mg PO daily 4.Remeron 45mg PO qhs 5.Simvastatin 80mg PO qhs 6.Heparin SC tid 7.Novolog insulin sliding scale 8.Imdur 30mg PO daily 9.Oxycodone 5mg PO q4-6h prn pain 10.Abilify 2.5mg PO daily 11.Aspirin 81mg PO daily 12.Citalopram 20mg PO qhs 13.Plavix 75mg PO daily 14.Ezetimibe 10mg PO daily 15.Furosemide 20mg IV bid 16.Glipizide 5mg PO daily / 10mg PO q pm 17.Unasyn 3g IV q12h 19.Gentamicin 120mg IV q daily Discharge Medications: 1. Aripiprazole 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Disp:*90 Tablet(s)* Refills:*0* 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Clopidogrel 75 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). Disp:*30 Tablet(s)* Refills:*0* 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:*1 vial* Refills:*0* 9. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for itchy. Disp:*1 vial* Refills:*0* 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 13. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). Disp:*90 Tablet Sustained Release(s)* Refills:*0* 14. DILT-XR 240 mg Capsule,Degradable Cnt Release Sig: One (1) Capsule,Degradable Cnt Release PO once a day. Disp:*30 Capsule,Degradable Cnt Release(s)* Refills:*0* 15. DILT-XR 120 mg Capsule,Degradable Cnt Release Sig: One (1) Capsule,Degradable Cnt Release PO once a day. Disp:*30 Capsule,Degradable Cnt Release(s)* Refills:*0* 16. Morphine Concentrate 20 mg/mL Solution Sig: 10-20 mg PO q1h as needed for pain/dyspnea. Disp:*20 ml* Refills:*0* 17. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours). Disp:*14 doses* Refills:*1* 18. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 10 days. Disp:*42 doses* Refills:*0* 19. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Disp:*14 ML(s)* Refills:*0* 20. Lorazepam 2 mg/mL Concentrate Sig: 0.5 mg PO three times a day. Disp:*10 ml* Refills:*0* 21. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0* 22. Hospice Care Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: #Cholangitis #Sepsis #Atrial Fibrillation w/ RVR Secondary: #Coronary Artery Disease #Type 2 Diabetes Mellitus #Chronic Diastolic Congestive Heart Failure #Peripheral Vascular Disease #Anxiety Discharge Condition: Gaurded Discharge Instructions: You were admitted for fevers and abdominal pain and were found to have infected bile stent. You underwent a procedure to remove and replace the stent, but despite this procedure, you ended up with E.Coli bacteria in your blood, causing you to have very low blood pressure, high fevers, and fast heart rate. You were given antibiotics and stabilized briefly, however your gallbladder wall ruptured and created a localized abscess. During this time, you blood pressure again dropped very low due to overwhelming infection. Because your blood pressure was so low, you sustained a minor heart attack. Again, you were stabilized, and you were given intravenous antibiotics and a drain was placed under CT-guidance to drain the abscess. However, the abscess was complex and would require multiple drain placements to clear, which you chose to decline given that it as not in line with your goals of care. Surgery was consulted, however your case was deemed not amenable to surgical intervention. You and your family decided in favor of returning home with hospice. Followup Instructions: None [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

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Discharge summary

report+addendum

Admission Date: [**2170-9-15**] Discharge Date: [**2170-9-28**] Date of Birth: [**2129-1-19**] Sex: M Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 898**] Chief Complaint: transferred from OSH per his request with hypoxia and respiratory distress Major Surgical or Invasive Procedure: Intubation on [**2170-9-15**], L radial arterial line placement on [**2170-9-16**]. Lumbar puncture on [**2170-9-20**] negative for white cells, blood, bacteria, excessive protein or glucose, and Cryptococcus History of Present Illness: HPI: Mr. [**Known lastname **] has longstanding HIV/AIDS, diagnosed as HIV positive in [**2166-10-25**] w/ CD4 count of 2, VL 338,000 copies/mL, s/p presentation with a cryptococcal meningitis. Briefly on zidovudine + protease inhibitors (4 months) but halted due to myalgias, fever; re-started in [**1-27**] following admission for severe diarrhea and abdominal pain. He is + for a history of PCP pneumonia in [**2168-8-24**] and [**2169-9-25**]. Approx. 2 weeks prior to admission in [**Hospital1 18**] ED, he presented to OSH w/ 2 week hx of fevers and chills, occasionally productive cough, worsening dyspnea on exertion about a week prior. His temperature was 103 F and he was in evident respiratory distress, sat??????ing 70-80% on RA which rose to 95% on a non-rebreather. Cultured for AFB, PCP silver stain, [**Hospital1 1065**] infection, Cryptococcus, viral load, CD4, histoplasmosis, CMV viral load. Empiric Rx w/ CTX, levofloxacin. Reticulonodular infiltrates and CT c/w PCP, [**Name10 (NameIs) 11024**] switched to Bactrim, and Zosyn/Cipro. Did not tolerate 100% non-rebreather or BiPap well. He developed a sinus bradycardia in the setting of hypothermia and baseline relatively low HR, no treatment undertaken. Given stress dose steroids for hypothermia, bradycardia. Transferred to [**Hospital1 18**] per patient request, as he receives longitudinal ID care here. His ROS + for anorexia/weight loss (62 per patient over last several years, 15-25 in last year alone), soaking night sweats. Denies nuchal rigidity, photophobia, h/a, n/v/d, chest pain, rashes. Past Medical History: HIV/AIDS, last CD4 of 25,Vl<50 [**4-29**]. On retrovirals in [**2166**] ([**Month (only) **]-[**Month (only) **] but d/c'd [**12-27**] AEs; restarted [**1-27**]) HCV coinfection Hx PCP [**Name Initial (PRE) 11091**] [**8-27**] and [**9-28**] Hx Herpetic keratits Hx CMV retinitis (questionable as IgG negative) Hx MSSA joint infection Hx cryptococcal meningitis [**10-25**] s/p VP shunt Hx left lower lobe pneumonia in [**2166-4-25**] Possible osteomyelitis in [**2158**] for which he had a laminectomy C. diff colitis [**11-29**] IVDA Legally-blind s/p meningitis and traumatic R eye injury (corneal tear) on a job Social History: Former EtoH hx and IVDA, fmr smoker has not smoked in 1 month. Homeless, living with friends, has worked laying tile. He was married in [**2158**], but since [**2164**] has been divorced. He knows his ex-wife was HIV negative then. He has no children. Close relationship with aunt [**First Name5 (NamePattern1) **] [**Name (NI) 60023**]). Family History: father d. homicide at 31. mother d. at age 59 in [**2165**] with history of obesity, DVT and bronchitis. One brother who is healthy. Physical Exam: PE: Tmax 98.5 Tc 96.8 Pulse 47-61 BP 110/60 RR 7-15 Sat 93-96% on 4L Gen: Pleasant and alert, but tachypneic, appearing fatigued and out of breath, chronically ill HEENT: His R cornea is opacified and there is evident scarring from a prior corneal scratch, L pupil PERRL, no icterus. MM dry w/ no apparent thrush, oropharynx clear, poor dentition. Neck/nodes: Trachea midline. No [**Doctor First Name **]. Neck supple. No detectable goiter or thyroid enlargement. No JVD. Cardio: RRR, normal S1/S2, no m/r/g. Pulm: Bibasilar rales w/ attenuated rales on auscultation of upper lungs, pronounced expiratory wheezes bilaterally. GI: Bowel S/ND but his belly is painful to moderate palpation generally and esp. in RLQ, apparently baseline, perhaps drug reaction. No guarding/rebound tenderness, no HSM or palpable masses, + bowel sounds 4Q. GU: No CVA tenderness. Skin/joints: No rashes or open sores. No joint pain on active or passive movement. 2+ dorsalis pedis pulses. No c/c/e. Neuro: No numbness or tingling. Psych: Pleasant and appropriate. Pertinent Results: [**2170-9-15**] 10:02PM TYPE-ART TEMP-36.5 O2-100 PO2-47* PCO2-32* PH-7.48* TOTAL CO2-25 BASE XS-0 AADO2-644 REQ O2-100 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA [**2170-9-15**] 10:25PM WBC-10.1# RBC-4.38* HGB-13.3* HCT-38.8* MCV-88# MCH-30.3 MCHC-34.2 RDW-13.0 [**2170-9-15**] 10:25PM PLT COUNT-287 [**2170-9-15**] 10:25PM PT-16.6* PTT-32.2 INR(PT)-1.9 [**2170-9-15**] 10:25PM NEUTS-91* BANDS-4 LYMPHS-3* MONOS-1* EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2170-9-15**] 10:25PM GLUCOSE-102 UREA N-17 CREAT-0.7 SODIUM-137 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-23 ANION GAP-14 [**2170-9-15**] 10:25PM LIPASE-76* [**2170-9-15**] 10:25PM LD(LDH)-1069* ALK PHOS-182* AMYLASE-62 TOT BILI-0.5 [**2170-9-15**] 10:25PM ALBUMIN-2.3* CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-2.1 [**2170-9-15**] 10:25PM WBC-10.1# RBC-4.38* HGB-13.3* HCT-38.8* MCV-88# MCH-30.3 MCHC-34.2 RDW-13.0 CHEST (PA & LAT) [**2170-9-23**] 5:50 PM CHEST, SINGLE AP VIEW. The lower left chest wall and costophrenic angle are excluded from the film. Allowing for this, there is patchy opacity in the left mid and lower zones and faint opacity at the right base. The overall distribution is similar to that on [**2170-9-17**], but there is suggestion of slight interval clearing in the left mid zone and right base. No new areas of infiltrate are identified. No right pleural effusion is seen. A right subclavian PICC line is present, tip over distal SVC. CT HEAD W/O CONTRAST [**2170-9-20**] 3:06 PM IMPRESSION: No significant change from prior study of [**2170-3-31**]. No evidence of acute intracranial hemorrhage, mass effect, or hydrocephalus. No evidence of impending herniation. CT ABDOMEN W/CONTRAST [**2170-9-16**] 10:02 PM IMPRESSION: 1. Diffuse pulmonary airspace opacity at the visualized portions of the lung bases. The findings could be consistent with atypical infection such as PCP, [**Name10 (NameIs) 1065**] or bacterial pneumonia. 2. No evidence of bowel obstruction or perforation. No evidence of acute appendicitis. 3. Fluid filled colon could indicate colitis. Clinical correlation is recommended. 4. Small amount of ascites, a nonspecific finding in the setting of a ventriculoperitoneal drainage catheter. CHEST (PORTABLE AP) [**2170-9-15**] 10:16 PM IMPRESSION: Diffuse bilateral pulmonary opacities affecting the left lung to a greater degree than the right. The bilateral distribution raises the possibility of PCP; however, considering the asymmetry, other opportunistic infections as well as multorganism infection are also possible. Brief Hospital Course: Hospital course # PCP/pulmonary, cryptococcus, hepatic issues: On [**9-15**] in [**Hospital Unit Name 153**] he did not tolerate bipap, O2 sats dropped into 70s and he was intubated under sedation. On [**9-16**] given L radial arterial line. CXR and CT both indicated diffuse bibasilar pulmonary airspace opacities suggestive of PCP [**Name Initial (PRE) 60024**]. Empirically placed on ceftaz, levofloxacin, vancomycin, fluconazole. Later received bronchoalveolar lavage that elicited thin watery secretions and was positive for PCP, [**Name10 (NameIs) 5963**] for other pneumonia pathogens. BCx negative for growth. HIV viral load 85,700 copies/ml, CD4 count of 2. On [**9-17**] some rapid improvement in lung consolidation suggestive of perhaps overlying pulmonary edema process before, in addition to PCP. [**Last Name (NamePattern4) **] [**9-18**] BAL results showed PCP and his antibiotics (including fluconazole) halted. Bactrim, prednisone given for PCP, [**Name10 (NameIs) **] for [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]. Extubated, placed on O2 mask, initially non-rebreather. On [**9-19**] his [**Month/Year (2) **] d/c'ed due to apparent transaminitis that may also have been exacerbated by fluconazole, switched to Ambisome for + cryptococcal BCx. CMV serologies negative and transferred to floor as otherwise stable. On [**9-20**] CT and LP showed no signs of meningitis, no leukocytes or cryptococcus in CSF. [**9-22**]: Trial to wean off O2 failed as became quite dyspneic w/o nasal cannula. [**9-23**]: Lungs sound very clear though he desats to 85% on 2L during ambulation. CXR ordered. His Ambisome d/c'ed and switched back to fluconazole w/ improving LFT's. Per ID consult he must not begin HAART again until PCP brought firmly under control to avoid immune reconstitution syndrome, will discuss at scheduled appointment w/ Dr. [**First Name (STitle) 20069**] on [**10-17**]. Still persistent question about his hyponatremia, possibly due to hypotonic saline used in Bactrim IV. [**9-24**]: Hyponatremic to 128 but stable. Plan to change IV bactrim to PO for 21 day course with equivalent duration of tapered prednisone and needs PCP prophylaxis with bactrim DS QD from thereafter. Plan to DC to rehab on [**9-25**] or [**9-26**]. [**9-25**]: AVSS, sat'ing >90% on RA at rest though desats w/ fatigue on modest exertion. Discharge plans and rehab discussed. His [**Doctor First Name **] [**Doctor First Name 1065**] cultures from [**9-21**] still negative though can take up to 2 weeks for these to grow, recommend f/u if positive. Recommend f/u, discussion of possible PEG-Ifn, ribavirin treatment for HCV. [**9-26**]: AVSS in morning, he is sat'ing 95% on room air and 98% on 1L NC, ready for discharge to rehab. #Ophtho issues [**9-21**]: Due to vision loss and prior history of herpetic keratitis and CMV retinitis, called ophtho consult. Found no acute infectious process, no HSV or CMV, just suspicion of irritation from prior trauma, given erythromycin gel 3 days for xerophthalmos and post-procedure eye irritation. #Opiate addiction: Maintained on methadone throughout hospitalization. #PT: PT consult on [**9-21**], recommend discharge to rehab. Medications on Admission: Home med [**Month/Year (2) 11024**] prior to admission not picked up per his ID physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 20069**]. [**First Name (STitle) **] includes boosted atazanvir, truvada, Bactrim [**First Name (STitle) **], fluconazole [**First Name (STitle) **]. He apparently refused [**First Name (STitle) **] [**First Name (STitle) **] for MAC. On methadone, oxycodone. Upon transfer to [**Hospital1 18**], his meds included Bactrim 400 iv tid Zosyn 4.5 g iv tid Cipro 400 mg iv bid Protonix 40 mg PO Q24H Fluconazole 44 mg qd Hydrocort 100 mg iv tid Methadone 30 qam, 20 qnoon, 20 qpm Percocet 1-2 tabs po q4-6 hrs prn Atrovent, albuterol nebs Tylenol PRN MVI Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Naloxone 1 mg/mL Syringe Sig: One (1) Injection [**Hospital1 **] (2 times a day) as needed for constipation. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed. 6. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble PO at bedtime. 10. Methadone 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble PO qam. 12. Methadone 5 mg Tablet Sig: One (1) Tablet PO qam. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Pneumocystis carinii pneumonia in the setting of HIV with minimal CD4 count, along with positive Cryptococcal blood cultures but no meningitis Discharge Condition: Fair; still dyspneic with desaturation on mild exertion but lungs are improved with minimal rales/crackles/wheezes. He is able to maintain >90% saturation on room air at rest. Discharge Instructions: On the day of discharge, you are on day 11 of a *21-day course* of your Bactrim for your PCP [**Name Initial (PRE) 1064**]. Thus, including your day of discharge, please take your Bactrim at the prescribed dose (double strength, 2 tablets PO tid) for a total of 11 days, from [**2170-9-27**] through [**2170-10-7**]. After this 11-day period, you will be maintained on daily Bactrim prophylaxis for PCP. [**Name10 (NameIs) **] dose is 1 double-strength Bactrim tab PO DAILY, beginning on [**2170-10-8**]. Please continue to take this Bactrim dose every day unless the [**Date Range 11024**] is changed by a physician. You will also be on a prednisone taper for your PCP following discharge that will finish at the same time as your treatment dose Bactrim. Please take 20 mg prednisone PO DAILY for 11 more days ([**2170-9-27**] through [**2170-10-7**]). At this time, you may then discontinue the prednisone. You will also be on long-term fluconazole prophylaxis, 200 mg PO DAILY. As with the Bactrim, please continue to take your fluconazole unless your treatment [**Month/Day/Year 11024**] is changed by a physician. Re-start HAART only when course of PCP treatment complete, and blood cultures negative for Cryptococcus and after discussing with your infectious disease doctor. You will be seeing Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 20069**] on [**2170-10-17**] for your HAART. Please notify staff at the rehabilitation hospital that you are legally blind and may require assistance and supervision while consuming foods and beverages. It is essential for you to maintain adequate nutrition, and if you cannot eat a full normal diet please supplement with Boost. Please make sure to make the appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 20069**] on [**2170-10-17**] at 9:00. At this appointment, your anti-retroviral [**Date Range 11024**] will be re-started. When you return home, please contact a physician immediately if you feel suddenly short of breath worse than your baseline, if you have a new severe cough, if you have a severe new headache especially if this occurs with a stiff neck and a desire to avoid light, or if you have sudden onset of chest pain, severe vomiting, or severe and persistent diarrhea, especially if bloody. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **] MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2170-10-17**] 9:00 Name: [**Known lastname 1516**],[**Known firstname 126**] Unit No: [**Numeric Identifier 10995**] Admission Date: [**2170-9-15**] Discharge Date: [**2170-9-28**] Date of Birth: [**2129-1-19**] Sex: M Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 391**] Addendum: The patient missed his appointment with his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10996**] on [**2170-9-28**] on the day of discharge. Thus, he was unable to receive his scheduled methadone dose. Therefore, I called Dr.[**Name (NI) 10997**] office and confirmed the dose of methadone that the patient normally receives and the patient was given a 3 day supply to last him until his appointment with his primary care physician on [**Name9 (PRE) 228**]. Discharge Disposition: Home With Service Facility: [**Hospital 136**] Homecare [**Name6 (MD) 116**] [**Name8 (MD) 117**] MD [**MD Number(1) 392**] Completed by:[**2170-9-28**]

[ "304.00", "136.3", "117.5", "042", "518.81", "790.7", "276.1" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.6", "03.31", "96.04", "33.24", "38.91" ]

icd9pcs

[ [ [] ] ]

15752, 15936

6990, 10217

341, 552

12227, 12406

4414, 6967

14758, 15729

3179, 3314

10970, 11959

12061, 12206

10243, 10947

12430, 14735

3329, 4395

227, 303

580, 2167

2189, 2806

2822, 3163

5,581

138,990

51163

Discharge summary

report

Admission Date: [**2165-11-28**] Discharge Date: [**2165-12-5**] Date of Birth: [**2122-7-11**] Sex: M Service: Gold Surgery ADMISSION DIAGNOSIS: Bile duct stricture. HISTORY OF PRESENT ILLNESS: Patient is a 43-year-old gentleman with a two month history of abdominal pain and jaundice, who was subsequently investigated and accounted for by a biliary stricture. A CTA has also shown a dilated pancreatic duct and a hypodense mass at the lower head/uncinate of the pancreas. Calcifications were also present in this area and there was some concern for a malignancy. The patient was being admitted for a planned Whipple resection of the pancreatic head. As of note, patient also has a history of ankylosing spondylitis and has had difficult intubations in the past. For this reason, Dr. [**Last Name (STitle) **] from Anesthesiology was asked to evaluate him before the surgery in lieu of management of his airway. PAST MEDICAL HISTORY: 1. Ankylosing spondylitis. 2. Status post bilateral hip replacements in [**2162**] and [**2163**]. 3. Status post hernia repair. 4. Peptic ulcer disease in past. MEDICATION: Morphine sulfate. ALLERGIES: 1. Codeine which gives hives. 2. Percocet. 3. Demerol. PHYSICAL EXAMINATION: At the time of presentation, patient's vital signs: Patient was afebrile and vital signs were stable. Patient was in no acute distress and was alert and oriented times three. Patient had a regular, rate, and rhythm. Clear to auscultation bilaterally. Abdomen is soft, nondistended, nontender. CT scan showed a hypodense mass with calcifications and dilated pancreatic duct with cut-off. These findings were consistent with a pancreatic mass and possible cystadenoma. HOSPITAL COURSE: Patient was taken to the OR on [**2165-11-28**] for a planned Whipple resection of the pancreatic head. This procedure was not performed due to the inability to dissect the pancreas safely from the arterial supply. Instead a choledochojejunostomy and open cholecystectomy was performed. Patient tolerated that procedure well and there were no immediate postoperative complications. Patient was initially managed in the SICU and on postoperative day one, the patient was successfully extubated. Since there were no other events, the patient was transferred to the floor later that evening. On postoperative day two, the patient had persistent pain control issues, and the patient was placed on Dilaudid PCA. On postoperative day three, the nasogastric tube and Foley were discontinued. Due to the persistent pain issues, a Pain consult was requested and they recommended continuing the Dilaudid PCA along with the addition of Toradol. On postoperative day four, the patient was started on sips. On postoperative day five, the patient was complaining of a cough, and a sputum culture and chest x-ray were sent, which were both negative. By postoperative day six, the patient was tolerating a general diet. Patient was also switched to p.o. pain medications, and was successfully controlled on OxyContin 20 mg 3x a day, and Dilaudid 4 mg every four hours. Due to some complaints of abdominal pain, the wounds were explored, were examined, and a 2 cm area of the right incisional wound was opened, and pus was subsequently expressed. The wound was then packed with wet-to-dry dressings and the patient subsequently felt some improvement in his pain. The patient remained afebrile during his hospital course. On postoperative day seven, patient was tolerating a regular diet and no further pus could be expressed from his wound. Patient felt to be ready for discharge with home services for daily wound care. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: Status post choledochojejunostomy and cholecystectomy. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. q.d. 2. Clonidine patch 0.1 mg transdermal q Friday. 3. Oxycodone 20 mg tablets sustained release one tablet p.o. q.8h. 4. Dilaudid 2 mg tablets 1-2 tablets p.o. q.4h. prn for pain. 5. Colace 100 mg capsules one capsule p.o. b.i.d. DISCHARGE INSTRUCTIONS: Patient is to be discharged home with VNA services. FOLLOW-UP INSTRUCTIONS: Patient is to followup with Dr. [**Last Name (STitle) **] within one week. Patient is also to followup with Dr. [**Last Name (STitle) 497**] on [**2165-12-20**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) **] Dictated By:[**Name8 (MD) 3430**] MEDQUIST36 D: [**2165-12-5**] 08:37 T: [**2165-12-5**] 08:38 JOB#: [**Job Number 106194**]

[ "289.3", "V43.64", "577.9", "577.1", "576.2", "575.11" ]

icd9cm

[ [ [] ] ]

[ "51.22", "51.36", "40.29" ]

icd9pcs

[ [ [] ] ]

3684, 3693

3715, 3771

3794, 4050

1743, 3662

4075, 4128

1250, 1725

168, 190

219, 943

4153, 4572

965, 1227

20,900

162,433

12787

Discharge summary

report

Admission Date: [**2124-7-8**] Discharge Date: [**2124-7-17**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: Mrs. [**Known lastname 39425**] is an 88 yo woman with a PMH of dementia, DM2, CKD (baseline Cr 2.0), HTN, chronic subdural hematoma, recent GI bleed and recent admission with ?sepsis/bradycardic arrest/hypotension complicated by spinal cord infarct who presented to the ED from nursing home with respiratory distress. . Per the nursing home, she was in her USOH until approximately 6 a.m. on the morning of admission, when she acutely desaturated to 74%. With suctioning, chest PT and "breathing treatments," her sats improved to 92%. She then again became hypoxemic (to the 70s), and she was placed on a NRB, at which point mental staus changes became worrisome to the staff. She received 60 of furosemide IV, and EMS was called. . The pt was intubated for hypoxemic respiratory failure in transit to [**Hospital1 18**]. In the ED, initial VSs were temp of 101.0 HR 68, BP 80/59, RR 16, 100% vented. She was started on norepinephrine for hypotension and given vancomycin and ceftazadime. Past Medical History: 1. Dementia 2. NIDDM 3. Renal insufficiency (bl Cr 1.7) 4. Vitamin D deficiency 5. HTN 6. UGI bleed with admission [**Date range (1) 39419**] tx with 5Units PRBC, EGD with epi and cautery. 7. Iron deficiency anemia 8. CAD s/p NSTEMI recent admission [**Date range (2) 39426**] 9. Lower extremitity paraplegia s/p spinal artery infarct last admission [**2124-6-18**] -[**2124-7-1**] Social History: Lived at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] recently, unknown tobacco or EtOH history. Family History: NC Physical Exam: Vitals: T: 97 BP: 134/75 (off pressors) P: 74 R: 22 SaO2: 100% Vent: AC 400 x 18, 50% 5 peep, 22bpm General: Chronically ill appearing, non-responsive HEENT: NCAT, Surgical pupils, no scleral icterus, MMM, intubated, no lesions noted in OP Neck: supple, no significant JVP (4cm) Pulmonary: Lungs transmitted upper airway sounds Cardiac: RR, nl S1 S2, II/IV SEM at USB, rubs or gallops appreciated Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or organomegaly noted, g tube in place Extremities: 2+ edema/anasarca UE>LE, 2+ radial, 1+ DP pulses b/l Skin: no rashes or lesions noted. Neurologic: intubated, not sedated, moves head and arms bilaterally spontaneously, no movement in LE, toes mute. Pertinent Results: ADMISSION LABS --------------- ([**2124-7-8**]) 08:00AM WBC-19.5* RBC-3.36* Hgb-9.6* Hct-30.1* MCV-90 MCH-28.4 MCHC-31.7 RDW-17.3* Plt Ct-466* Neuts-85* Bands-6* Lymphs-6* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Hypochr-1+ Anisocy-1+ Poiklo-2+ Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ Stipple-OCCASIONAL [**Name (NI) **] [**Last Name (STitle) 31525**] [**Name (STitle) **]16.3* PTT-51.1* INR(PT)-1.5* Plt Smr-HIGH Plt Ct-466* Glucose-173* UreaN-115* Creat-2.8* Na-135 K-4.6 Cl-92* HCO3-32 AnGap-16 CK(CPK)-111 CK-MB-4 cTropnT-0.51* Calcium-8.7 Phos-6.7*# Mg-2.3 04:02PM BLOOD Cortsol-36.6* 04:05PM BLOOD Cortsol-47.9* 06:00PM BLOOD Cortsol-60.2* . 08:28AM BLOOD Type-ART Temp-38.3 Rates-/14 Tidal V-450 FiO2-100 pO2-263* pCO2-64* pH-7.31* calTCO2-34* Base XS-3 AADO2-403 REQ O2-69 INTUBATED . 01:10PM BLOOD Type-ART Rates-18/22 Tidal V-400 PEEP-5 FiO2-50 pO2-82* pCO2-49* pH-7.45 calTCO2-35* Base XS-8 -ASSIST/CON Intubat-INTUBATED . 01:10PM BLOOD Lactate-1.0 Na-132* K-3.9 Cl-92* . 10:27PM BLOOD Type-ART Temp-37.0 pO2-145* pCO2-45 pH-7.44 calTCO2-32* Base XS-6 . . STUDIES ---------- ([**2124-7-8**]) HEAD CT IMPRESSION: 1. No hemorrhage or mass effect. 2. Brain and medial temporal atrophy. . ([**2124-7-8**]) CHEST X-RAY IMPRESSION: Consolidation in the left lower lobe with small left-sided pleural effusion. Probable consolidation in the right lower lobe. . . ([**2124-7-8**]) ECG Normal sinus rhythm. T wave inversions in leads V1-V6 suggest possible anterior ischemia. Late R wave transition. Left axis deviation. Probable left anterior fascicular block. Cannot exclude prior inferior myocardial infarction. Compared to the prior tracing of [**2124-6-18**] no diagnostic change. . . ([**2124-7-10**]) CHEST X-RAY Moderate cardiomegaly, unchanged since [**7-8**], substantially improved since [**6-28**]. Worsening left lower lobe consolidation could be pneumonia or atelectasis. Lungs otherwise generally clear. Heavy mitral annulus calcification noted may be contributing to mitral regurgitation. ET tube and left subclavian line in standard placements. Tubing coiled over the stomach, cannot be localized with certainty on this single view. No pneumothorax or appreciable pleural effusion. . ([**2124-7-10**]) ECG Atrial fibrillation with rapid ventricular response Borderline left axis deviation - is nonspecific Left ventricular hypertrophy Delayed R wave progression - may be due to left ventricular hypertrophy Diffuse nonspecific ST-T wave changes Since previous tracing of [**2124-7-8**], atrial fibrillation now present, and further ST-T wave changes seen . ([**2124-7-11**]) TRANS-ESOPHAGEAL ECHO IMPRESSION: No definitive evidence of vegetations. However, there are filamentous strands on the aortic valve leaflets which are likely normal variant, but endocarditis cannot be entirely excluded. . [**2124-7-13**] 02:35PM BLOOD Ret Aut-1.1* . [**2124-7-13**] 02:35PM BLOOD ALT-30 AST-24 LD(LDH)-174 AlkPhos-82 TotBili-0.3 . [**2124-7-13**] 02:35PM BLOOD calTIBC-147* Hapto-164 Ferritn-854* TRF-113* . DISCHARGE LABS: Brief Hospital Course: Briefly this is an 88 year old woman with multiple medical issues (dementia, DM, CHF, CKD, spinal cord infarction with BLE hemiplegia) who presented with hypoxic respiratory failure, and hypotension, found to have MRSA in sputum and BAL, coagulase negative staph in blood and from PICC line and VRE in blood from art line. . 1.Respiratory failure: Pt admitted for hypoxemic respiratory failure, intubated in field. See to have b/l pulmonary consolidations on CXR. Sputum, BAL cultures grew BRSA. Pt on vancomycin initially, switched to PO linezolid on [**7-13**]. Pt extubated in [**7-12**]. On d/c did not have oxygen requirement. . 2. Sepsis: Pt was admitted with PICC line in place. Blood cultures from [**7-8**] grew coagulase negative staph, her PICC was d/c'd on [**7-10**], the cath tip also grew CNS. Surveillance cultures the following day ([**7-11**]) grew VRE from a-line. Vancomycin d/c'd and pt started on IV linezolid on [**7-13**] to cover MRSA PNA as well as CNS and VRE bacteremia. ID was consulted and recommended plan to continue linezolid PO on discharge for a total of 2 week course. Will check weekly CBCs to monitor for pancytopenia. Last day of linezolid [**2124-7-27**]. . 3. CKD: History of CKD and elevated creatinine on presentation. During admission however, creatinine improved and is now below previously recorded values. New baseline cr = 1.7. Pt started on ACE-I prior to d/c. . 4. DM2: Adequate blood glucose control on insulin sliding scale. . 5. Anemia/h/o GIB: Pt's hematocrit was in high 20s for hospital stay. Anemia panel negative for hemolysis or iron deficiency. No signs of acute bleed. Anemia likely due to phlebotomy superimposed on anemia of chronic disease. Pt did not require transfusion during this stay. On day of discharge Hct = 28.4. . 6. C. diff: Patient was c. diff + on last admission, and her antibiotic course was completed on [**2124-7-10**]. No signs of ongoing infection. Pt continued on flagyl during this admission for prophylaxis during treatment with antibiotics for her PNA and bacteremia. C diff toxin has been negative x 2 during this admission. Pt to continue flagyl for one week after the completion of linezolid course. Last day of flagyl [**2124-8-3**]. . 7. CAD/HTN: Pt had NSTEMI on last admission. Had episode of afib with RVR in unit, responded to labetalol. Maintained on labetalol with parameters, ASA and statin. On tele during admission with no further events on floor. Pt was hypertensive on regimen of labetalol, lasix and nifedipine. Started on HCTZ. Prior to d/c pt's labetolol was increased to her admission dose of 300mg [**Hospital1 **]. Lasix chaged to PO at 100mg PO daily. Nifedipine changed to XL 120 mg PO daily. Pt started on low dose ACE-I in setting of HTN with CHF and recent NSTEMI on last admission. [**Month (only) 116**] titrate up as tolerated. . 8. Decubitus Ulcer: Wound care nursing involved during admission. Pt had state [**1-29**] decubitous coccyx ulcer and state 1 ulcer on left heel. Dressing changed daily. No signs of infection in either wound. Pt has had foley catheter in place in an effort to aid with coccyx ulcer healing. . 9. Spinal cord infarct: occured on last admission believed to be due to hypotension during her brady arrest. Pt seen by neuro at this time. No further intervention recommended Pt has been normotensive to hypertensive since transfer to the floor on this admission. . 10. Chronic Subdural Hematomas: During neuro evaluation, head CT was obtained showing interval resolution of subdural hemorrhage. . 11.Mental Status: Per history, patient has a significant baseline dementia. On transfer to the floor pt had returned to her baseline, significantly improved from prior admission. She would open her eyes spontaneously, follow commands, answer questions appropriately in [**12-28**] word sentences, albeit with some significant stuttering. Head CT this admission showed atrophy but no intracranial mass, acute bleed or midline shift. . 12. FEN/Lytes: Patient was maintained on tube feeds, which she tolerated well throughout admission. . 13. Prophylaxis: During admission, heparin SC TID was used for DVT prophylaxis and PPI IV was given due to history of GI bleed. . 14. Communication: Contact person was daughter, [**Name (NI) 1743**] [**Name (NI) **], [**Telephone/Fax (1) 39422**] (H), [**Telephone/Fax (1) 39423**] (C) and grandson, [**Name (NI) 4882**], [**Telephone/Fax (1) 39424**] . 15. Code status: Ms [**Known lastname 39425**] remained FULL CODE during admission, confirmed with family. . On day of discharge pt was afebrile with VSS. Sating 100% on 2L NC. Pt's white count had trended down from high of 25 to 7. Pt to be discharged to acute rehabilitation facility on continued antibiotics. Pt will need to have CBC checked while on linezolid. Medications on Admission: Atorvastatin 20 mg daily Aspirin 81 mg daily Acetaminophen prn pain Nifedipine 30 mg q8hrs Esomeprazole Labetalol 300 mg [**Hospital1 **] Metronidazole 500 mg [**Hospital1 **] Insulin Glargine 4 units [**Hospital1 **] Furosemide 100 mg IV daily Heparin (goal PTT 40-60) Insulin sliding scale Discharge Medications: 1. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. Zinc Sulfate 220 (50) mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY (Daily). 3. Calcium Acetate 667 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 5. Insulin Glargine 100 unit/mL Cartridge [**Hospital1 **]: One (1) 10 Subcutaneous at bedtime. 6. Insulin Regular Human 100 unit/mL Cartridge [**Hospital1 **]: One (1) please see sliding scale Injection QAC: Please see attached sliding scale. 7. Ascorbic Acid 90 mg/mL Drops [**Hospital1 **]: One (1) PO BID (2 times a day). 8. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 10. Linezolid 600 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day for 12 days: Take twice a day until [**7-27**], pt will need CBC checked on [**7-24**] to check for potential side effect of pancytopenia. . 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 12. Metronidazole 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3 times a day) for 19 days: Take for 7 days after linezolid completed. 13. Hydrochlorothiazide 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day: Please give 1/2 hour before lasix. 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 15. Labetalol 200 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO BID (2 times a day): Hold for SBP <100, HR <55. 16. Furosemide 40 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY (Daily). 17. Nifedipine 60 mg Tablet Sustained Release [**Last Name (STitle) **]: Two (2) Tablet Sustained Release PO DAILY (Daily): Hold for SBP <100. 18. Lisinopril 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily): Hold for SBP <100. [**Month (only) 116**] titrated up as BP allows. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: PRIMARY: 1. MRSA PNEUMONIA 2. RESPIRATORY FAILURE 3. BACTEREMIA 4. ACUTE ON CHRONIC RENAL FAILURE SECONDARY: 1. DIABETES MELLITUS 2. HYPERTENSION 3. PARAPLEGIA Discharge Condition: Stable, extubated, maintaining adequate oxygenation with saturation 100% on 2L NC Discharge Instructions: You were admitted to the hospital in respiratory failure requiring intubation. You were found to have a pneumonia and an infection in your blood. You were treated with antibiotics that will be continued on discharge. You need to get blood drawn every week while on the antibiotic linezolid because of the potential side effect of pancytopenia (low blood counts). Take the antibiotic flagyl for one week after the course of linezolid is completed. Please take all medications as prescribed. Please follow up with your primary care physician within [**Name Initial (PRE) **] week of discharge. Call your doctor or return to the emergency room if you experience fevers, hypothermia, low blood pressure, change in mental status or respiratory distress or for any other concerning symptoms. Followup Instructions: You will follow up with the staff Radius Physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 2405**].

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icd9cm

[ [ [] ] ]

[ "96.71", "96.6" ]

icd9pcs

[ [ [] ] ]

13089, 13144

5719, 9281

282, 307

13348, 13432

2639, 5678

14272, 14392

1891, 1895

10885, 13066

13165, 13327

10568, 10862

13456, 14249

5696, 5696

1910, 2620

222, 244

335, 1328

9296, 10542

1350, 1735

1751, 1875

40,457

140,705

39824

Discharge summary

report

Admission Date: [**2129-1-6**] Discharge Date: [**2129-1-24**] Date of Birth: [**2073-10-23**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2129-1-6**] Pump-assisted, beating-heart coronary artery bypass grafting x3 -- left internal mammary artery to left anterior descending artery and saphenous vein sequential grafting to posterior descending artery and posterior left ventricular branch History of Present Illness: 55 year old Cantonese speaking male with a history of Cardiomyopathy EF 10-15%, Hypertension, and pulmonary artery hypertension who has been experiencing chest pain for the past year. He complains of chest discomfort for the past year that occurs with rapid exertion. He denies chest discomfort at rest; he denies shortness of breath and leg swelling. He was referred for cardiac catheterization on [**12-16**] which revealed multiple coronary artery disease. Past Medical History: Coronary artery disease Dilated Cardiomyopathy (EF 10-15%) Hypertension Hyperlipidemia Pulmonary Artery hypertension Mitral Regurgitation TIA per patient ([**2123**]) Social History: Race:Asian, speaks Cantonese and a small amount of English Last Dental Exam:pt states a long time ago Lives with:girlfriend Occupation:[**Name2 (NI) **] in a Chinese restaurant Tobacco:quit one year ago history of 10 cigarettes/day x39 years ETOH:denies Family History: one younger sister with diabetes and a chest pain syndrome Physical Exam: Pulse:90 Resp:20 O2 sat: 20 B/P Right:172/110 Left: 176/104 Height: 5'6" Weight:173 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:+2 Left:+2 DP Right: +2 Left:+2 PT [**Name (NI) 167**]: +2 Left:+2 Radial Right:+2 Left:+2 Carotid Bruit Right: none Left:none Pertinent Results: [**2129-1-6**] Echo: PRE-BYPASS: The left atrium is moderately dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. No thrombus/mass is seen in the body of the left atrium. No mass or thrombus is seen in the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed, with akinetic inferior wall and apex(LVEF= 20 %). The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. There is no pericardial effusion. POST-CPB: 1. Improved [**Hospital1 **]-ventricular systiolic function with persistent wall m otion abnmormalities (EF =30%) (Background epinephrine infusion) 2. No change in valve structuer and function. [**2129-1-10**] Head CT: There is no evidence of acute intracranial pathology. Mucosal thickening is noted in the sphenoid and left maxillary sinus, focal defect is noted on the left lamina papyracea, of uncertain chronicity. Punctate calcifications are visualized in the vertebral arteries and both carotid siphons. [**2129-1-18**] Echo: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. LV systolic function appears depressed. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is dilated with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. Significant pulmonic regurgitation is seen. There is no pericardial effusion. [**2129-1-22**] CXR: Severe cardiomegaly is stable postoperatively and comparable to the preoperative appearance. There is no appreciable atelectasis and no pleural effusion or pulmonary edema. Prominent nipple shadow should not be mistaken for lung nodules. No pneumothorax. Right PIC line ends in the region of the superior cavoatrial junction. Brief Hospital Course: This 55-year-old patient with ischemic cardiomyopathy who presented with exertional symptoms and was investigated and found to have a very low ejection fraction of 10%-15%. The coronary angiogram showed significant disease in the left anterior descending artery, the right coronary artery, and the distal circumflex artery. A perfusion scan demonstrated reversible ischemic areas. He was admitted for elective coronary artery bypass grafting. In view of the low ejection fraction, the plan was to proceed with pump-assisted, beating-heart coronary artery bypass grafting. He was brought to the operating room on [**2129-1-6**] where the he underwent pump-assisted, beating-heart coronary artery bypass grafting x3 with left internal mammary artery to left anterior descending artery and saphenous vein sequential grafting to posterior descending artery and posterior left ventricular branch. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. On POD 2 he was walking to the bathroom and became unresponsive upon return to the chair. He was found to be in PEA and code blue was called. Compressions were initiated and he was coded with a return of blood pressure and spontaneous rhythm after epinephrine and atropine. He was intubated for airway protection and transferred to the CVICU. He remained hemodynamically stable on no inotropic support but was slow to wake. Head CT was done [**1-11**] which was negative for any acute event. On [**1-12**] he was consistently following commands and was extubated without incident. He was hypertensive after extubation and medications were titrated up for goal SBP <130. Coreg and Ace-I were initiated with low EF. He had a swallow evaluation which he passed for regular diet with thin liquids. He did have some confusion and agitation which improved with Haldol. Chest tubes and pacing wires were discontinued without complication. On [**1-17**] he was transferred again to the step down unit. Echocardiogram was done to reassess EF which showed LVEF of 30%. EP evaluated patient on [**1-19**] for his PEA arrest and recommendations for follow-up in future. They recommended an outpatient AICD evaluation in 1 month. The patient was evaluated by the physical and occupational therapy services for assistance with strength and mobility. By the time of discharge on POD 18 the patient was ambulating with assistance (with a left drift), the wound was healing well and pain was controlled with Tylenol. The patient was discharged to [**Hospital3 **] in [**Location (un) 86**] in good condition with appropriate follow up instructions. Medications on Admission: AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth daily ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth daily FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth daily LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth daily NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s) sub lingually 1 tablet under the tongue. as needed for when you get chest pain. Take sitting down POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 10 mEq Capsule, Sustained Release - 1 Capsule(s) by mouth daily PRAVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth daily Medications - OTC ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily Discharge Medications: 1. isosorbide mononitrate 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. amlodipine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 9. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-26**] Puffs Inhalation Q6H (every 6 hours) as needed for wheezes. Disp:*qs * Refills:*0* 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. Disp:*30 Tablet(s)* Refills:*0* 11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Disp:*qs * Refills:*2* 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary artery bypass graft x 3 postop cardiac arrest Past medical history: Dilated Cardiomyopathy (EF 10-15%) Hypertension Hyperlipidemia Pulmonary Artery hypertension Mitral Regurgitation TIA per patient ([**2123**]) Discharge Condition: Alert and oriented x2 nonfocal Ambulating with assistance (left drift) Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. No Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**First Name (STitle) **] on [**2-7**] at 2:00pm Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**] on [**2-3**] at 8:20am Please call to schedule appointments with your Primary Care Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**3-29**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2129-1-24**]

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icd9cm

[ [ [] ] ]

[ "99.60", "96.72", "89.64", "36.12", "36.15", "39.61", "96.04" ]

icd9pcs

[ [ [] ] ]

10352, 10422

4904, 7940

320, 575

10714, 10942

2258, 3508

11865, 12507

1542, 1602

8743, 10329

10443, 10526

7966, 8720

10966, 11842

1617, 2239

270, 282

603, 1065

3517, 4881

10548, 10693

1271, 1526

52,530

137,412

40950

Discharge summary

report

Admission Date: [**2147-3-21**] Discharge Date: [**2147-3-26**] Date of Birth: [**2066-8-8**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7281**] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: Colonoscopy Mesenteric Angiography PICC placement and removal History of Present Illness: This is an 80 year old male with Past medical history of Diabetes type 2 complicated by nephropathy s/p living related donor kidney transplant in [**2137**] with subsequent baseline Cr of 2, CAD s/p stents to LAD and Left circumflex, diastolic CHF with EF=65%, Peripheral Vascular Disease, hypertension, pulmonary hypertension (45 to 55 mm Hg based on TTE in [**8-/2146**]), OSA on CPAP, history of C diff, chronic gastritis, and history of lower GI bleed 5 years ago s/p colonoscopy and successful clipping in NY presenting from his [**Hospital1 1501**] with multiple episodes of Bright red blood per rectum consistent with a repeat lower GI bleed. In the ED he filled a bed pan with bright red blood. Otherwise, he was asymptomatic and never became tachycardic or hypotensive. His daughter, [**Name (NI) **], who is a GI physician in [**Name9 (PRE) 9012**] initially preferred to perform a colonoscopy first and would not consent to CTA with potential embolization as she was concerned about the IV dye load for his kidneys. However, she did agree to pursue this after speaking with the GI team over the phone in the ED. He received IVFs with bicarb and normal saline for pre-hydration in the ED. He was also given 2 units of pRBCs for a Hct of 23.6 from a recent baseline of 29. Access was obtained with a 16 gauge peripheral in the Left upper extremity and he already had a PICC line in place in his Right upper extremity from a previous admission. Transplant surgery, GI, and IR were consulted in the ED and the patient had a CTA prior to arrival to the ICU which was significant for a cecal blush. Initial VS: 98.9, 68, 129/40, 18, 98% RA. Vital signs prior to transfer: HR=70s and BP=110s systolic . On arrival to the MICU, the patient appeared comfortable and had no acute complaints. Past Medical History: Past Medical History: - hypertension - CAD s/p stents to LAD and LCx - PAD - dCHF with preserved LVEF 65% - pulmonary HTN (45 to 55 mm Hg based on TTE in [**8-/2146**]) - lung nodules - OSA on CPAP - Type II diabetes mellitus - CKD s/p living-related donor kidney transplant [**2137**] from son in [**Name (NI) 7581**] NY - DVT s/p IVC filter, related to transplant - rhodococcus infection [**2144**] w/ lung biopsy - frequent UTIs - h/o C diff. - GI Bleed - chronic gastritis Past Surgical History: [**2146-12-28**] - RLE angio & proximal PT stent [**2146-11-25**] - Right 4th and 5th ray amputations [**2146-11-23**] - Right common femoral artery endarterectomy with patch angioplasty [**2137**] - living-related donor kidney transplant IVC filter Social History: Former 20-pack-year smoking history. Denies alcohol or drug use. Born in [**Country 2045**] but immigrated to United States in [**2103**]. He completed law school in [**Country 2045**] but worked as a cab driver in the United States. His wife died over a year ago. Previously lived alone in [**Hospital3 **] facility, currently in [**Hospital1 1501**]/Rehab. He has nine children. Family is involved in his care, daughter [**Name (NI) **] is HCP. Family History: No family history of kidney disease or CAD/PAD. Brother: heavy smoker, died of lung cancer in his 70s Niece: died of lung cancer in her 50s Physical Exam: Admission physical exam: Vitals: T: 98.7, BP: 162/40, P: 74, R: 21, O2: 99% RA Gen: Elderly Haitian Creole male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP benign. Neck: Supple. JVP not elevated. No cervical lymphadenopathy. CV: RRR with normal S1, S2. Harsh systolic murmur at RUSB/LUSB. Chest: Respiration unlabored, no accessory muscle use. CTAB without crackles, wheezes or rhonchi. Abd: Normal bowel sounds. Soft, NT, ND. Minimal tenderness over transplant in RLQ. Ext: LE edema 1+ bilaterally. Right foot with 4th and 5th toe amputation. Tenderness over right medial/anterior thigh. Skin: Dry scaly skin on lower extremities. Neuro: Motor strength and sensory grossly equal and intact bilaterally . Discharge physical exam: Vitals: 97.1, 99.7, 139/75, (134-145/46-84), 62 (58-86), 20, 100RA Gen: Elderly Haitian Creole male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP benign. Neck: Supple. JVP not elevated. No cervical lymphadenopathy. CV: RRR with normal S1, S2. Harsh systolic murmur at RUSB/LUSB. Chest: Respiration unlabored, no accessory muscle use. CTAB without crackles, wheezes or rhonchi. Abd: Normal bowel sounds. Soft, NT, ND. Minimal tenderness over transplant in RLQ. Ext: LE edema 1+ bilaterally. Right foot with 4th and 5th toe amputation. Tenderness over right medial/anterior thigh. Pertinent Results: Admission labs: =============== [**2147-3-21**] HGB-7.8* calcHCT-23 [**2147-3-21**] GLUCOSE-249* UREA N-52* CREAT-1.6* SODIUM-134 POTASSIUM-5.4* CHLORIDE-101 TOTAL CO2-25 ANION GAP-13 [**2147-3-21**] cTropnT-0.06* [**2147-3-21**] WBC-6.7 RBC-2.67* HGB-7.3* HCT-23.6* MCV-89 MCH-27.5 MCHC-31.0 RDW-17.5* PLT COUNT-249 [**2147-3-21**] NEUTS-83.6* LYMPHS-9.9* MONOS-5.3 EOS-1.0 BASOS-0.2 [**2147-3-21**] PT-12.2 PTT-27.5 INR(PT)-1.1 . Discharge labs: =============== [**2147-3-26**] BLOOD Hct-29.1* [**2147-3-26**] BLOOD Creat-1.3* Na-138 K-4.6 Cl-106. Imaging: ======== [**3-21**] CTA abdomen: ----------------- IMPRESSION: 1. Contrast extravasation in the cecum, representing active GI bleed. 2. Small bilateral pleural effusions. 3. Cholelithiasis without cholecystitis. . [**3-22**] Mesenteric Angiography: FINDINGS: 1. Conventional vascular anatomy, with extensive atherosclerotic plaque within the SMA, aorta, and iliac arteries. Left iliac stent was noted and patent. 2. Initial right colic and SMA angiography demonstrated very delayed appearance of a tiny focus of contrast extravasation within the ileocecal area, likely corresponding CTA findings. 3. Sequential selective catheterization of initially two potential third/fourth order branches within the right colic artery that might have supplied this area, followed by additional selection of two potential sources within the ileocolic artery did not demonstrate any further extravasation. After this tiny focus was seen on initial angiography, no it could not be re-demonstrated on the remaining portion of our study (over approximately 2-3 hours). No further extravasation was identified, suggesting that the source of bleeding had stopped. As a specific source branch could not be determined, no embolization was performed. IMPRESSION: 1. Tiny focus of contrast extravasation initially seen within the cecum, which stopped on subsequent angiography. 2. The source branch could not be determined as bleeding had stopped, and no embolization was performed. . [**3-23**] Tagged red cell scan: IMPRESSION: 1. No evidence of active bleeding during the time of study. 2. Transplanted right pelvic kidney. . [**2147-3-24**] Colonoscopy: Impression: -Polyps in the whole colon -Diverticulosis of the transverse colon and sigmoid colon -Grade 1 internal hemorrhoids -Angioectasia in the cecum (endoclip) -Macerated, friable in the rectum compatible with injury from recent flexiseal -Otherwise normal colonoscopy to cecum -Recommendations: Serial hcts to ensure stability. Repeat colonoscopy to remove polpys and assess rectum in the next 3 months. Recommend this be done with an adult colonoscope. Brief Hospital Course: This is an 80 year old male with past medical history of DM2 complicated by nephropathy s/p living related donor kidney transplant in [**2137**] with subsequent baseline Cr of 2, CAD s/p stents to LAD and Left circumflex, diastolic CHF with EF=65%, PVD, hypertension, pulmonary hypertension (45 to 55 mm Hg based on TTE in [**8-/2146**]), OSA on CPAP, history of C diff, chronic gastritis, and history of lower GI bleed 5 years ago s/p colonoscopy and successful clipping in NY presenting from his [**Hospital1 1501**] with multiple episodes of bright red blood per rectum consistent with a repeat lower GI bleed. He was found to have bleeding angioectasia in the cecum which was clipped. He received during his stay total of 5 u Packed RBC. He was never hemodynamically unstable. Hct was stable around 29-30 after transfusion. Discharged back to [**Hospital1 1501**] in stable condition. . #. Lower GI bleed: Patient with Hct drop to 23.6 from recent baseline of 29. On admission, he required total of 5 u pRBC. After transfusion, his Hct remained stable around 29-30. During his stay he had several studies to localize the bleed. CTA showed cecal blush on admission, but IR was not able to embolize the bleeding vessel as it spasmed during the procedure. A tagged red cell scan was negative for active bleeding the following day. His home Plavix and ASA were held on admission. After stable Hct and no further bright red blood per rectum episodes, he was prepped for a colonoscopy which showed polyps in the whole colon diverticulosis of the transverse colon and sigmoid colon, Grade 1 internal hemorrhoids, and Angioectasia in the cecum (endoclip). He remained hemodynamically stable. Aspirin and plavix were restarted. He will require repeat colonoscopy in 3 months to remove the polyps. It needs to be discussed with GI when to stop ASA, plavix or both prior to the next colonoscopy. For anti-hypertensive management, please see below. . # CKI s/p renal transplant: The patient was admitted with a creatinine of 1.6 below his recent baseline of 2. He was hydrated and given bicarb in the ED prior to CTA and IR embolization. His Cr remained below his recent baseline of 2 on discharge (1.0-1.3). . # CAD History: Patient was without chest pain, SOB, or other anginal equivalents on admission. Initially aspirin and plavix were held. After colonoscopy and clipping of angioectasia in addition to stable hematocrit, his home aspirin 18 mg daily was restarted. Upon discharge, plavix was restarted as well. Statin was continued as below. Labetalol was initially held given GI Bleed though was not hemodynamically unstable. Labetalol was restarted upon discharge back to his home regimen. . # Hypertension: Patient's home labetalol and hydralazine were held on admission given his massive lower GI bleed. Home labetalol was restarted after maintaining hemodynamic stability and Hct level s/p colonoscopy and angioectasia clipping. Hydralazine was discontinued on discharge. . # Chronic Diastolic CHF: Home furosemide was held on admission given active GI bleed. This was restarted on discharge along with labetalol (held on admission as well) as explained below. . # Depression: We continued home antidepressant regimen of citalopram and mitazapine. Home bupropion was held during his stay given history of coronary artery disease and hypertension. . # Vascular Surgery / Amputation: Patient is s/p right foot 4th and 5th ray amputations and right CEA endarterectomy with patch angioplasty during his recent admission from [**2146-11-18**] to [**2146-11-30**]. We continued Tylenol as needed for pain control and opiates as needed as he is on home Dilaudid PO PRN as long as his BP tolerated. . # Hyperlipidemia: We continued home simvastatin 40 mg PO DAILY. . # Diabetes Mellitus Type 2: Currently well controlled, but complicated by peripheral neuropathy and nephropathy. The patient was continued on home Lantus and humalog sliding scale. . # OSA: We continued home CPAP. . # Glaucoma: The patient was continued on his chronic glaucoma medications. . # BPH: We continued Tamsulosin 0.4 mg PO QHS. . # GERD: Patient was maintained on his home omeprazole and famotidine. . # Chronic nasal congestion: The patient was continued on Flonase nasal spray, glycopyrrolate, and fexofenadine. . TRANSITIONAL ISSUES: # Communication: Patient, HCP/daughter [**Name (NI) **], other daughter [**Name (NI) **] (gastroenterologist) [**Telephone/Fax (1) 89371**]. . # Code: Full Code confirmed with HCP [**Doctor First Name **] . # Repeat colonoscopy to remove polpys and assess rectum in the next 3 months (discharged back on home regimen of aspirin and plavix. Please discuss with GI when to stop these prior to the next colonoscopy) Medications on Admission: -Mirtazapine 15mg PO HS -Wellbutrin 37.5mg at noon -Citalopram 20mg daily -Dilaudid 2mg PO q4 PRN pain -Tylenol 500mg q6 PRN pain -Albuterol nebs q4 PRN -Spiriva daily -Fluticasone NS daily -ASA 81mg daily -Plavix 75mg daily -Simvastatin 40mg daily -Humalog SS -Lantus 32 units QAM -Calcitriol 0.25mcg on MWF -Brimonidine 0.15% OU [**Hospital1 **] -Dorzolamide/timlolol 1 drop OU [**Hospital1 **] -Xalatan 0.005% 1 drop OU HS -Fexofenadine 180mg daily -Famotidine 40mg daily -Omeprazole 20mg daily -Gabapentin 100mg QAM, 200mg HS -Glycopyrrolate 0.5mg daily -Hydralazine 100mg TID -Labetalol 300mg [**Hospital1 **] -Lasix 40mg daily -Multivitamins with minerals -Myfortic 180mg [**Hospital1 **] -Tacrolimus 5mg [**Hospital1 **] -Prednisone 5mg daily -Flomax 0.4mg daily Discharge Medications: 1. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 4. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4 hours) as needed for SOB/wheezing. 6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Humalog 100 unit/mL Solution Sig: One (1) injection Subcutaneous four times a day: according to his home sliding scale. 12. Lantus 100 unit/mL Solution Sig: Ten (10) unit Subcutaneous once a day: every morning. 13. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO QMOWEFR (Monday -Wednesday-Friday). 14. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 15. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 16. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 17. fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 18. famotidine 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 19. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 20. gabapentin 100 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 21. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 22. glycopyrrolate 1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 23. labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 24. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. mycophenolate sodium 180 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 27. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 28. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 29. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**] Discharge Diagnosis: Final Diagnoses: Lower GI bleed Polyps in the whole colon Diverticulosis of the transverse colon and sigmoid colon Grade 1 internal hemorrhoids Angioectasia in the cecum Acute anemia of blood loss Chronic renal insufficiency . Secondary Diagnoses: Diabetes Hypertension coronary artery disease status post stent peripheral arterial disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr [**Known lastname 89372**], . It was a great pleasure taking care of you as your doctor. As you know you were admitted to [**Hospital1 1170**] for passing bright red blood per rectum. You stayed in the ICU initially during which you received 5 units of red cells to keep your blood level appropriate. You had some imaging studies which gave us an initial idea of where the bleeding is coming from. After your blood level remained stable, you had a colonoscopy which showed an abnormal vessel on the right side of your colon which was clipped. This is the most likely cause of your presenting symptom. You did not require further transfusions. Your blood level remained stable. You will need to repeat the scope after 3 months to remove polyps that were seen during colonoscopy. . We made the following changes in your medication list: -Please STOP wellbutrin -Please STOP hydralazine -Please DECREASE Lantus to 10u QAM . Please continue taking the rest of your home medications the way you were taking them prior to admission. . Please Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Will need repeat colonoscopy in 3 months. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 7284**]

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icd9cm

[ [ [] ] ]

[ "88.47", "45.43" ]

icd9pcs

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22570

Discharge summary

report

Admission Date: [**2174-8-6**] Discharge Date: [**2174-9-8**] Date of Birth: [**2105-12-29**] Sex: M Service: [**Doctor First Name 147**] Allergies: Oxycodone Hcl/Acetaminophen / Hydrocodone Bit/Acetaminophen Attending:[**Doctor First Name 5188**] Chief Complaint: Abdominal pain/Possible perforated diverticulum Major Surgical or Invasive Procedure: 1. Exploratory laparatomy 2. Small bowel resection History of Present Illness: The patient is a 68 year old male with a 38 year history of Crohn's disease, coronary artery disease, previous small bowel obstruction, and congestive heart failure, status post resection of small bowel three times ([**2136**], [**2154**], [**2164**]) who presented from [**Doctor Last Name 1495**] [**Hospital 107**] Medical center with abdominal pain. He was in his usual state of health until approximately 2 months ago, when he began having increased diarrheal episodes, with up to 30 bowel movements in a 24 hour period. This is compared to his baseline for the last decade is [**5-26**] loose stools a day, but overall has maintained a stable weight and lifestyle on 5-ASA, Imuran, and prednisone maintenance. He has had occasional flares of cramps, partial small bowel obstructions treated with IV fluids and increased doses of prednisone. He also has had complications involving recurrent perianal fistulas as well. This resulted in him presenting to the outside institution for a colonoscopy, and the results demonstrated some ileitis with no colitis. The the next day ([**2174-7-20**]), Three weeks prior to the admission to this hospital, the patient experienced the acute onset of abdominal pain. A CT was suggestive of a potential small bowel perforation. He was kept NPO, started on TPN, and was given antibiotics for 2 weeks, and he improved. However, he had persistent pain that was aggrevated by taking anything by mouth. He did have some fevers on presentation. No nausea, vomiting, melena, hematochezia, hematemesis, recent travel, new foods. Otherwise review of systems was negative Past Medical History: 1. Crohn's disease status post small bowel resections (see HPI) 2. Coronory artery disease 3. Status post exploratory laparotomy complicated by MI (in past) 4. Small bowel obstruction 5. Congestive heart failure ([**7-24**] EF=39% with no reversable defects Social History: Retired, Married, no alcohol, no cigarettes Family History: No history of crohn's disease Physical Exam: Temperature 98.6, Heart rate 76, Blood pressure 110/70, Respiratory rate 20, oxygen saturation 99% on room air General: well nourished and well hydrated Head and neck: pupils equal round and reactive to light. neck supple, trachea midline, no cervical lymphadenopathy Chest: clear to auscultation bilaterally Heart: regular rate and rhythm Abdomen: obese, distended. some focal tenderness in left upper quadrant. No guarding or rebound tenderness Extremities: no clubbing cyanosis or edema Pertinent Results: [**2174-8-6**] 11:09PM BLOOD WBC-9.5 RBC-3.77* Hgb-12.6* Hct-36.6* MCV-97 MCH-33.5* MCHC-34.5 RDW-14.1 Plt Ct-99* [**2174-8-6**] 11:09PM BLOOD PT-13.2 PTT-25.7 INR(PT)-1.4 [**2174-8-6**] 11:09PM BLOOD Glucose-106* UreaN-46* Creat-1.4* Na-131* K-4.3 Cl-94* HCO3-27 AnGap-14 [**2174-8-6**] 11:09PM BLOOD ALT-37 AST-21 AlkPhos-65 Amylase-108* TotBili-0.4 [**2174-8-6**] 11:09PM BLOOD Lipase-62* [**2174-8-6**] 11:09PM BLOOD Albumin-2.5* Calcium-8.0* Phos-2.5* Mg-2.1 [**2174-8-7**], [**2174-8-8**], [**2174-8-9**] Blood Cultures: AEROBIC BOTTLE (Final [**2174-8-10**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. [**2174-8-9**]: Central line tip: Staphlococcus, coagulase negative CT Abdomen and pelvis [**2174-8-8**]: The visualized lung bases demonstrate tiny bilateral pleural effusions and associated atelectatic changes. Allowing for limitations of a noncontrast exam, the liver, spleen, pancreas, adrenal glands, and kidneys appear grossly normal. Sludge and stones are identified within the gallbladder, but no secondary signs of cholecystitis are identified. Evauation of the bowel is limited due to the presence of high- contrast barium material and beam-hardening artifact. Allowing for this, there is a focal loop of small bowel within the left hemiabdomen, likely mid jejunum, which demonstrates wall thickening. At least two, possibly three fluid collections are identified adjacent to this loop of small bowel. This constellation of findings is most compatible with active Crohn's disease. No free air is identified. There are no discernible colonic abnormalities to indicate the occurrence of perforation from recent colonoscopy. These fluid collections measure approximately 5.6 x 4.1 and 6.3 x 2.2 cm. These are seemingly discrete collections, but they may be contiguous by transmural extension. No other abnormal loops of bowel are identified. CT OF PELVIS WITHOUT IV CONTRAST: The urinary bladder is collapsed due to the presence of a Foley catheter, limiting evaluation. There is high-density contrast material within the colon, as above, limiting evaluation. The sigmoid colon is collapsed. No free fluid or air is identified. IMPRESSION: 1. Focal wall thickening of a loop of mid jejunum with at least two adjacent small fluid collections. These findings are most compatible with active Crohn's disease in a patient with this history. 2. Limited evaluation of colon demonstrates no evidence of complications from recent colonoscopy. 3. Sludge and stone-containing gallbladder without evidence of cholecystitis. 4. Tiny bilateral pleural effusions. Brief Hospital Course: The patient was admitted to the surgical service on [**2174-8-8**]. He was kept NPO, was continued on his TPN, and had a CT scan. He was started on levofloxacin/flagyl. He grew out coag negative staph from in his blood cultures, and his central line was pulled and he was started on vancomycin. The GI service thought that this was not consistent with a crohn's flare, and they suggested a rapid taper of his steroids. He was stable until the evening of hospital day number 2, when he had the acute onset of Left lower quadrant abdominal pain. The pain was sharp, and his exam was concerning for some questionable guarding in the left lower quadrant. However, he did not have any truly positive peritoneal signs. His abdomen was more distended than it had been. He got an upright chest and abdominal xray that did not show any free air, but did show dilated bowel loops. An NG tube was placed, and he had serial abdominal exams overnight. His exam worsened, and he had clear peritoneal signs in the left lower quadrant. he also became tachycardic to the 110s, and his urine output decreased. A decision was then made to take him to the operating room. Gross spillage of stool was noted on the exploratory laparotomy, and a segment of small bowel was resected in the area of jejunal diverticuli. He was transfered to the intensive care unit, intubated and required massive fluid resuscititation for his septic picture. Patient remained in the T/SICU and transferred to the floor after 5 days and monitored. The patient was aggresvily diuresed and encouraged to take po. THe patient continued to be diuresed and had wound changes done twice a day. Patient was continued on TPN during his stay on the floor. On [**8-28**], the patient became tachypneic and became tachycardic. The patient was managed cardiovascularily overnight, but spiked a tempature. The patient's line was removed and pan cultured. The patient was transferred to the unit the next day for closer management of his cardiac status. The patient did well during the four days in the SICU and returned again to the floor once cleared by cardiology. His heart rate was controlled with 75 po tid. The patient had a repeat episode of chest pain for approxiamtley for 2 hours on the the 11th and and was evaluted by on surgery and cardiology. Patient was started on heparin and and IV nitro dip and began to cycle his enzymes. The patient ruled out for an myocardial infarction and the nitro drip was discontinued. The patient remained on the cardiac floor during the remaining part of his inpatient stay. Psychiatry was consulted to evaluate the patient's depressed mood and was started on remeron 7.5 and ritalin as per psychiatry requiest. The patient was evalutated by speech and swallow and had a video swallow gram performed which illustrated a normal swallow function and the patient was re-started on a house diet which he tolerated. The patient has done well despite of his tumulotous course in the hospital and is in good condition on discharge to the rehab center. The patient's abdominal wound will still require dressing changes [**Hospital1 **]. Medications on Admission: Medications at home: Immuran 50 mg [**Hospital1 **], Asacol 1200 [**Hospital1 **], Prednisone 60 mg qd, Saltolol 80 mg [**Hospital1 **], Asprin 81 mg qd, Lisinopril 5 mg qd, Digoxin 0.125 mg qd. Meds on transfer: Cefoxitin 1 gram iv q6, Flagyl 500 mg IV TID, Protonix 40 mg IV qd, TPN, and a methylprednisole drip at 2.4 mg/hour Discharge Medications: 1. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO twice a day. Disp:*180 Tablet(s)* Refills:*2* 2. 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* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 6. Methylphenidate HCl 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Percocet 5-325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours for 20 days. Disp:*160 Tablet(s)* Refills:*0* 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 20 days. Disp:*40 Capsule(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: x-lap and small bowel resection of mid-jejunal perforated diverticulum with abdominal spillage [**2174-8-10**] Discharge Condition: Good Discharge Instructions: Please call if you have a fevers >100.5, chills, vomitting, redness or drainage from the the wound. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 5182**] [**Telephone/Fax (1) 5189**] in [**2-22**] weeks [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**] Completed by:[**2174-9-8**]

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icd9cm

[ [ [] ] ]

[ "45.62", "99.04", "99.15" ]

icd9pcs

[ [ [] ] ]

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300, 349

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30,248

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34796

Discharge summary

report

Admission Date: [**2157-8-2**] Discharge Date: [**2157-8-5**] Date of Birth: [**2109-4-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with angioplasty and placement of a bare metal stent History of Present Illness: The patient is a 48 year old man with history of gout presenting with chest pain found to have anterior STEMI now s/p PCI with BMS to LAD. The patient was in his usual state of health until the morning of [**2157-8-1**] when he developed sudden onset of chest heaviness that lasted ~1 hour. The remainder of the day he felt well. In the evening of [**2157-8-1**] while watching the home-run derby (~930-945pm), he noted sudden onset of chest pressure and generalized feeling of being unwell. The chest pressure was described like a brick sitting on his chest. This was associated with sweatiness and mild ache in his jaw. He had no shortness of breath during the episode. After ~1 hour of symptoms the patient was driven by his wife to [**Location (un) 79689**] ER. Upon arrival he was found to have STE in the anterior precordial leads with ST depressions inferiorly. He was started on aspirin, plavix 300mg, heparin, and tirofiban. Shortly after arrival in the ER he loss consciousness and had VT/VF arrest. CPR was administered as well as a 300 mg bolus of amiodarone. He was defibrillated. He had return of spontaneous circulation (after an unknown duration). He was life-flighted to [**Hospital1 18**] for cardiac cath. . During the cath he was found to have a proximal LAD lesion that was treated with angioplasty and stenting. He tolerated the procedure well however at the end of the procedure he vomited 20mL of coffee ground emesis and became hypotensive. His tirofiban was stopped. Following vomiting his blood pressure recovered after transiently requiring dopamine. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, 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: Gout 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 6 kids (age range 18 months to 16 years old). He works from home as a venture capitalist. Family History: There is no family history of premature coronary artery disease or sudden death. His mother died of breast cancer. His father died of natural causes at age 78. His paternal grandfather died of trauma. His two brothers are healthy. Physical Exam: Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. Bilateral sub-conjunctival hemorrhage. PERRL (5->2mm bilat), EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP not elevated CV: PMI located in 5th intercostal space, midclavicular line. irreg irreg, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Neuro: MS: A,Ox3. coherent response to interview. alternates A1/B2 etc well. [**1-20**] objects recalled at 5 minutes CN: II-XII intact Motor: moving all 4 extremities symmetrically [**Last Name (un) **]: light touch intact to face, hands, feet Pertinent Results: [**2157-8-5**] 08:00AM BLOOD WBC-9.0 RBC-4.77 Hgb-14.1 Hct-41.6 MCV-87 MCH-29.6 MCHC-34.0 RDW-13.5 Plt Ct-264 [**2157-8-5**] 08:00AM BLOOD Glucose-131* UreaN-18 Creat-1.1 Na-143 K-3.6 Cl-106 HCO3-24 AnGap-17 [**2157-8-5**] 08:00AM BLOOD Calcium-9.7 Phos-4.4 Mg-2.2 [**2157-8-5**] 08:00AM BLOOD PT-16.2* PTT-97.6* INR(PT)-1.4* . [**2157-8-2**] 01:30AM BLOOD ALT-160* AST-157* CK(CPK)-86 AlkPhos-52 TotBili-0.5 [**2157-8-3**] 08:15AM BLOOD ALT-137* AST-153* CK(CPK)-630* [**2157-8-4**] 06:44AM BLOOD ALT-104* AST-80* AlkPhos-54 TotBili-0.7 [**2157-8-5**] 08:00AM BLOOD ALT-84* AST-53* . [**2157-8-2**] 08:56AM BLOOD CK-MB-230* MB Indx-14.6* cTropnT-4.21* [**2157-8-2**] 11:02PM BLOOD CK-MB-108* MB Indx-9.4* cTropnT-5.21* [**2157-8-3**] 08:15AM BLOOD CK-MB-36* MB Indx-5.7 . [**2157-8-2**] 08:56AM BLOOD Triglyc-67 HDL-38 CHOL/HD-3.4 LDLcalc-79 [**2157-8-2**] 01:00AM BLOOD %HbA1c-5.6 [**2157-8-2**] 08:56AM BLOOD T4-6.2 T3-105 calcTBG-1.06 TUptake-0.94 T4Index-5.8 Free T4-0.99 [**2157-8-2**] 08:56AM BLOOD TSH-1.4 . CARDIAC CATHETERIZATION ([**2157-8-2**]) 1. Selective coronary angiography of this right dominant system revealed single vessel coronary artery disease. The LMCA, LCx, and RCA had no angiographically apparent flow limiting epicardial coronary artery disease. The proximal LAD had a 100% stenosis. 2. Resting hemodynamics revealed no evidence of systemic arterial systolic or diastolic hypertension with SBP 117 mmHg and DBP 89 mmHg. 3. Successful PTCA and stenting of the proximal LAD with a 2.5 x 12 mm VISION BMS which was post dilated with a 2.75 x 10 mm NC [**Male First Name (un) **] balloon at 18 ATM. Final angiography revealed no residual stenosis in the LAD, a pinched S1 and normal flow. (See PTCA comments) 4. Acute anterior STEMI. FINAL DIAGNOSIS: 1. Single vessel coronary artery disease. 2. Acute anterior myocardial infarction, managed by acute PTCA of the proximal LAD. . ECHOCARDIOGRAM ([**2157-8-2**]) The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with septal and apical akinesis. LVEF 35%. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. . ECG on admission showed STE in the anterior precordial leads with ST depressions inferiorly. Brief Hospital Course: 48 year old man with no significant PMHx admitted for anterior STEMI complicated by V fib arrest, s/p cath showing 1-vessel disease with BMS to proximal LAD. . #CAD: The pt presented with nausea, chest tightness, and diaphoresis s/p V fib arrest. His ECG and enzymes were consistent with an anterior STEMI. Pt received a BMS to prox LAD with and experienced hypotension post-procedure which was associated with and resolved after 20 cc coffee ground emesis. The patient was briefly on IVF and a dopamine gtt. The patient was started on aspirin and plavix, which should be continued for 1 year per Dr. [**Last Name (STitle) **] (despite BMS). A high dose statin, beta blocker and ACE inhibitor were also started. A lipid panel was checked; however, it was likely suppressed secondary to recent coronary event and should be rechecked at a later date. . #Rhythm: While in the hospital the patient was in sinus rhythm with repeated episodes of NSVT which were initially treated with amiodarone for 24 hrs. His ectopy greatly decreased during the course of his hospitalization and his rhythm problems were resolved at the time of discharge. . #Pump: A 2D echocardiogram showed a depressed EF of 35%. The echo showed moderate regional left ventricular systolic dysfunction with septal and apical akinesis and the patient was started on anticoagulation with an INR goal of [**2-20**]. The patient is scheduled for outpatient cardiac rehab and is scheduled for a repeat Echo and f/u appointment with Dr. [**Last Name (STitle) **] on [**9-7**] to reevaluate heart function and need for pacemaker/ICD. . #Elevated Liver enzymes: The patient had elevated liver enzymes (AST and ALT) in the context of the cardiac event. His liver enzymes were trending down but were still elevated at the time of discharge. . #Upper GI bleed: The patient had coffee ground emesis after being in the cath lab. His HCT remained stable during his hospitalization and he was discharged on pantoprazole. . #Gout: The patient has a history of gout which was stable during his hospitalization. . #Psych: The patient has a lot of stress in his life. I spoke with the patient and his family about the high risk of depression after MI and they are aware of the signs and symptoms of depression as well as the resources available to them. Medications on Admission: None. Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY 4. Lisinopril 5 mg PO DAILY 5. Warfarin 2.5 mg (2) Tablet PO qHS Please adjust dose as needed per PCP 6. Metoprolol Succinate 100 mg Tablet, 1.5 Tablet PO daily. 7. Pantoprazole 40 mg PO Daily x 1 months: Please reassess with PCP whether medication needs to be continued after 1 month 8. Enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg Subcutaneous [**Hospital1 **] for five days: Please continue until INR therapeutic (goal [**2-20**]) for 2 days 9. Outpatient Lab Work Please have your INR checked on Monday [**8-8**] at [**Hospital **], call results to Dr. [**First Name (STitle) 9054**] [**Name (STitle) 6481**] at [**Telephone/Fax (1) 79690**]. Please also send blood for potassium, BUN, creatinine, ALT, and AST. All results should be sent to Dr. [**Last Name (STitle) 6481**]. Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Primary: ST-elevation myocardial infarction Cardiac arrest Apical hypokinesis Secondary: Gout Discharge Condition: good. ambulating without assist. tolerating oral medications and nutrition. Discharge Instructions: You were evaluated and treated for chest pain. The cause to the symptoms was a heart attack which was caused by a blockage in one of the vessels of your heart. The blockage was opened with angioplasty and stenting. You were prescribed medications that are to protect you from another heart attack and to prevent strokes. . New Medications (first dose of all meds in AM except for Coumadin and last dose of metoprolol tartrate as directed): - Aspirin - Plavix - Coumadin (first dose tonight, will be adjusted by PCP) - Lovenox (please take until Coumadin level is therapeutic) - Metoprolol Succinate SR - Lisinopril - Zocor - Pantoprazole EC (one month) Please take your medications as prescribed. . Your blood needs to be drawn frequently to monitor the coumadin dose. . It is very important that you continue taking the aspirin and plavix uninterrupted until your cardiologist tells you to stop. Stopping either of the medications could put you a risk for a severe heart attack or death. . If you develop any new or concerning symptoms such as chest pain, shortness of breath, bleeding, or fainting; please seek medical attention immediately. . You have been given a prescription at discharge for a INR (coumadin level) to be checked on Monday [**8-8**]. These results will be called to Dr.[**Name (NI) 79691**] office in [**Location (un) **]. Please call Dr.[**Name (NI) 79691**] office at [**Telephone/Fax (1) 4775**] to give the office demographic information next week. Followup Instructions: Please have your INR checked on Monday [**8-8**] at [**Hospital **], call results to Dr. [**First Name (STitle) 9054**] [**Name (STitle) 6481**] at [**Telephone/Fax (1) 79690**]. Please also send blood for potassium, BUN, creatinine, ALT, and AST. All results should be sent to Dr. [**Last Name (STitle) 6481**]. . Primary Care Physician: [**Name10 (NameIs) 9054**] [**Name11 (NameIs) 6481**], MD Phone: [**Telephone/Fax (1) 4775**] Date/Time: Thursday [**8-11**] at 8:15am. Follow-up for hospitalization. . [**Name6 (MD) 9054**] [**Name8 (MD) 6481**], MD Phone: [**Telephone/Fax (1) 4775**] Date/Time: Monday [**10-24**] at 10:45am for new patient exam. . Echocardiogram: 11:00 on [**9-7**] in [**Hospital Ward Name 2104**] building, [**Location (un) **] ([**Hospital Ward Name 516**] of [**Hospital1 18**]). Please call [**Telephone/Fax (1) 62**] if you have questions. . Cardiology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 62**] - Wed [**9-7**] at 3:20pm. [**Hospital Ward Name 23**] building, [**Location (un) 436**]. Completed by:[**2157-8-12**]

[ "578.0", "274.9", "410.11", "458.29", "427.1", "414.01", "427.41", "372.72", "427.5" ]

icd9cm

[ [ [] ] ]

[ "88.53", "88.56", "88.72", "36.06", "37.22", "99.20", "00.40", "00.66", "00.45" ]

icd9pcs

[ [ [] ] ]

10107, 10175

6838, 9146

322, 401

10314, 10393

4179, 5940

11919, 13025

2841, 3074

9202, 10084

10196, 10293

9172, 9179

5957, 6815

10417, 11896

3089, 4160

272, 284

429, 2546

2568, 2574

2590, 2825

8,698

180,818

45743

Discharge summary

report

Admission Date: [**2165-6-24**] Discharge Date: [**2165-7-8**] Date of Birth: [**2084-10-17**] Sex: F Service: MEDICINE Allergies: Protamine Attending:[**First Name3 (LF) 348**] Chief Complaint: Right lower extremity pain and swelling Major Surgical or Invasive Procedure: PICC Line placement by IR Fistulagram by IR History of Present Illness: Ms [**Known lastname **] is a 80 yo female with mechanical AVR, multiple episodes of GI bleed and hemicolectomy [**2-9**] GIB, who recently ([**6-18**]) was started on an unclear dose of Lovenox to bridge her anticoagulation for colonoscopy. Yeaterday patient started having right lower extremity pain. Today she went for her hemodialyis, where she was found to have extensive right thigh swelling. Without undergoing dialysis she was send to ED for further evaluation and treatment. Currently she denies any lightheadedness, chest pain, or SOB but endorses significant pain and discomfort in her right lower extremity w/o being able to ambulate or move actively. She denies any history of recent trauma to this site and endorses a spontaneous appearance. Past Medical History: 1. repeated Hx of gastrointestinal bleeding (most recent [**2165-4-24**]) 2. Left hemicolectomy with transverse colostomy for GIB [**11-13**] 3. Diastolic CHF (EF 65-75%) 4. Status post tracheostomy placement after prolonged intubation in ICU (at time of colectomy) - removed 5. Severe AS s/p mechanical AVR 6. Hypertension 7. Elevated cholesterol 8. Diabetes type 2 9. End-stage renal disease on HD MWF 10. Bilateral total knee replacment 11. Multiple skin lesions removed by general and plastic surgery 12. Hypothyroidism 13. Presumptive history of atrial fibrillation; on amiodarone Social History: Lives at home with husband, and son. [**Name (NI) **] children in the area. Is a non-smoker, no alcohol use, no history of illicit drug use. Retired, former manager Family History: No colon CA, otherwise unremarkable Physical Exam: Initial Physical Exam VS: T 97 BP 224/110 HR 54 RR 18 O2 99RA FS 186 GEN:The patient is in obvious pain SKIN:No rashes or skin changes noted. HEENT: no JVD, neck supple . Oropharynx clear without lesions or exudates. No lymphadenopathy in cervical, posterior, or supraclavicular chains noted. CHEST:Lungs are clear without wheeze, rales, or rhonchi. CARDIAC: Regular rhythm; 3/6 SEM RUSB,no rubs, or gallops. ABDOMEN: non tender, not destended, colostomy bag semi filled, no erythema or discharge EXTREMITIES: 1+ [**Location (un) **], right thigh with bulging hematoma [**2-10**] from iliac creast on lateral aspect NEUROLOGIC: Alert, oriented x3 and appropriate. BUE [**5-13**], and LLE [**5-13**] RLE [**3-13**] sensation preserved, toe strength 5/5 BL VS: 99.3 108/palp 88 16 On discharge: Ext: Right thigh ~57cm in diameter, some tenderness on palpation, L antecubital fossa- thrill palpable, murmur audible on AV fistula. Pertinent Results: Initial CBC: [**2165-6-24**] 02:50PM WBC-5.2 RBC-3.49* HGB-10.8* HCT-33.7* MCV-97 MCH-31.0 MCHC-32.1 RDW-17.7* Initial Chem 7 [**2165-6-24**] 02:50PM GLUCOSE-165* UREA N-62* CREAT-7.7*# SODIUM-135 POTASSIUM-5.8* CHLORIDE-95* TOTAL CO2-28 ANION GAP-18 Imaging: 1. No evidence of DVT in the right lower extremity. 2. Large presumed hematoma deep to the right thigh muscles, extending along the femur, medially and laterally. Recommend clinical correlation. 3. Limited arterial interrogation revealed limited absent diastolic flow. * R femur Xray: Diffuse osteopenia, status post ORIF distal femoral fracture and three-component arthroplasty, without complication or new fracture * Hip Xray: Diffuse osteopenia with no significant change since [**6-15**] and no definite evidence of acute fracture. CBC @ Lowest Point [**6-25**] WBC 7.0 Hgb 7.6* HCT 23.5* 231 CBC @ Discharge WBC 5.8 Hgb 9.0 HCT 27.3 Plt 375 Chem 7 @ Discharge [**2165-7-8**] 06:32AM BLOOD Glucose-134* UreaN-53* Creat-6.5*# Na-129* K-4.1 Cl-92* HCO3-26 AnGap-15 [**2165-7-7**] 01:03PM BLOOD %HbA1c-5.4 AVFistulagram: Performance of PTA of central cephalic arch stenosis with satisfactory post angioplasty result. Brief Hospital Course: Ms. [**Known lastname **] is an 80 yo female on enoxaparin bridge for mechanical AVR in preparation for colonoscopy presented with right thigh hematoma and hematocrit drop. 1. Hematoma: Believed to be secondary to overdosed enoxaparin due to renal failure. Patient was admitted with a Hct of 34 that dropped to 27. Concern for a worsening bleed into her right thigh resulted in transfusion of 4 units PRBCs total during her stay. On hospital day 6 it stablizied at 29. Her right thigh pain was controlled on Morphine IV and Oxycodone. The pain subsided to a single daily dose of oxycodone for pain. Hematocrit should be monitored daily. 2. Hypertensive urgency: SBP in the 220s on presentation to ED as the patient had not taken BP meds on admission. She was transferred to the MICU for closer monitoring. In the ICU, the patient received her home regimen of hydralazine and metoprolol which controlled her blood pressure. There were no more incidents on this home regimen throughout the stay. She should be continued on current regimen of Metoprolol and Hydralazine. 4. s/p Aortic Valve Replacement: Patient has mechanical valve. Patient admitted with INR of 1.7 and 1mg of warfarin qday. Due to acute bleed all anticoagulation was stopped. Anticoagulation with heparin gtt and Coumadin was restarted after hematocrit stabilized. She is currently on Warfarin 5mg PO Qday and heparin gtt should be stopped onced INR is between 2.0-3.0. It is 1.4 at the time of discharged today. 5. End Stage Renal Disease: The patient is anuric and has been on hemodialysis 3 times per week for six months. During her stay she was kept on this regimen. 6. Diabetes (Type II) The patient has an unclear of diabetes versus hyperglycemia. She has not outpatient therapy for diabetes. She was maintained on an insulin sliding scale requring approximately 6units throughout the day. Her hemoglobin A1c is 5.4, and we have put recommendations to stop insulin and start oral therapy forward to the rehabilitation facility. 7. Access: Patient has PICC line and tunnelled line. Medications on Admission: 1.Amiodarone-200 mg Tablet-1 Tablet(s) by mouth Daily- (Prescribed by Other Provider) 2.Aspirin-81 mg Tablet, Delayed Release (E.C.)-1 Tablet(s) by mouth DAILY (Daily)- (Prescribed by Other Provider) 3.B Complex-Vitamin C-Folic Acid [Nephrocaps]-1 mg Capsule-1 Capsule(s) by mouth once a day- (Prescribed by Other Provider) 4.Epoetin Alfa-4,000 unit/mL Solution-1 Solution(s) QMOWEFR (Monday -Wednesday-Friday)- (Prescribed by Other Provider) 5.Esomeprazole Magnesium [Nexium]-40 mg Capsule, Delayed Release(E.C.)-1 Capsule(s) by mouth Daily- (Prescribed by Other Provider) 6.Fluticasone-Salmeterol-250 mcg-50 mcg/Dose Disk with Device-1 Disk(s) inhaled twice a day- (Prescribed by Other Provider) 7.Hydralazine-25 mg Tablet-1 Tablet(s) by mouth every six (6) hours- (Prescribed by Other Provider) 8.Levothyroxine-75 mcg Tablet-1 Tablet(s) by mouth DAILY (Daily)- (Prescribed by Other Provider) 9.Metoprolol Tartrate-50 mg Tablet-1 Tablet(s) by mouth twice a day- (Prescribed by Other Provider) 10.Simvastatin-20 mg Tablet-1 Tablet(s) by mouth once a day- (Prescribed by Other Provider) 11.Warfarin-1 mg Tablet-goal INR 2.5-3.0 Tablet(s) by mouth DAILY (Daily) as needed for mech AVR please dose based on INR result - goal INR 2.5-3.0 with PT/INR checked daily until off heparin and then mon/wed/fri for continued dosing- (Prescribed by Other Provider) Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO qhsprn. 11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for loose stools. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for loose stools. 14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection PRN (as needed) as needed for line flush. 16. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 17. Sodium Chloride 0.9 % 0.9 % Solution Sig: One (1) ML Injection PRN (as needed) as needed for line flush. 18. Sodium Chloride 0.9 % 0.9 % Solution Sig: Three (3) ML Injection PRN (as needed) as needed for line flush. 19. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q2H (every 2 hours) as needed. 20. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED). 21. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 22. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 23. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Primary Diagnosis 1. Right thigh hematoma 2. End stage kidney disease 3. Mechanical Aortic Valve Replacement requiring anticoagulation 4. Hyperglycemia Secondary diagnosis 1. Hypertension 2. History of gastrointestinal bleed necessitating an ostomy 3. Hypothyroidism 4. Atrial fibrillation Discharge Condition: Stable Discharge Instructions: You have been admitted with a right thigh hematoma--bleeding into the thigh itself. The bleeding has stopped, but it will take some time before the thigh returns to normal size. You are going to be discharged to a rehab facility while your blood becomes thin enough to pass easily through your mechanical valve. They will also provide rehabilitation services to help the leg, and dialysis for your kidney disease. Please take all medications as listed in the discharge instructions as below. Of note, you are on a heparin drip along with Coumadin. Once your blood count is between [**2-10**], the heparin drip can be stopped. Under no circumstances should your heparin be changed Lovenox because you have developed problems with your kidneys in the past. Please return to the Emergency department for chest pain, shortness of breath, leg pain or any other medical concerns. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 1266**] [**Telephone/Fax (1) 608**] within a week of discharge from the Rehabilitation facility.

[ "403.01", "459.0", "250.00", "790.01", "272.4", "964.2", "427.31", "V43.3", "996.73", "244.9", "V58.61", "276.7", "E879.1", "585.6", "428.30", "428.0" ]

icd9cm

[ [ [] ] ]

[ "39.50", "39.95", "88.49", "38.93", "00.40", "99.04" ]

icd9pcs

[ [ [] ] ]

9698, 9753

4165, 6232

310, 356

10088, 10097

2953, 4142

11024, 11172

1952, 1989

7636, 9675

9774, 10067

6258, 7613

10121, 11001

2004, 2785

2799, 2934

230, 272

384, 1142

1164, 1753

1769, 1936

11,978

191,277

8756

Discharge summary

report

Admission Date: [**2184-12-28**] Discharge Date: [**2185-1-14**] Date of Birth: [**2122-5-16**] Sex: M Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: This is a 62-year-old male who was diagnosed with esophageal cancer and underwent neoadjuvant chemoradiation for locally advanced disease. He presents now for resection of his tumor. PAST MEDICAL HISTORY: Esophageal cancer as above status post laparoscopy, Port-A-Cath placement, J tube placement, status post chemoradiation. Hypertension. GERD. MEDICATIONS AT HOME: 1. Oxycodone every 4-6 hours. 2. Protonix. 3. Aleve. 4. Hydrocodone every 4-6 hours. 5. Levaquin for recent question pneumonia. 6. Morphine short and long-acting. HOSPITAL COURSE: On [**2184-12-28**], he underwent an [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagogastrectomy. The procedure was uncomplicated and his postoperative course was summarized as follows: Neurologic: His pain initially was controlled with an epidural and then with a PCA with transition to oral medications. He continues to have significant pain issues including right leg pain, which has been chronic and is being worked up in the past. He is now back on all his preoperative pain medications at the slightly higher doses, and in addition, is on a clonidine patch. Cardiovascular: He did present with an episode of atrial fibrillation postoperatively, which was controlled and converted to sinus with beta-blockers. He remains on beta- blockers with good heart rate and blood pressure control. Respiratory: Initially, he had presented with mild hypoxia and dyspnea. This improved with aggressive pulmonary toilet. His last sputum culture grew gram-negative rods and there was a question of possible infiltrate on a CT scan and therefore is being treated with levofloxacin. Prior to discharge, his sats have remained stable and good on room air, and he has not had any complaints of shortness of breath. GI: On postoperative day seven, the patient underwent a swallow study, which showed slow emptying of the stomach, but leak at the anastomosis. After that, his diet was gradually advanced. He is now tolerating a regular soft diet, which should be continued. Since postoperative day one, he has been on tube feeds, which have been increased slowly to goal and is now getting cycled tube feeds at night, which include ProBalance at 85 cc an hour from 6 p.m. to 6 a.m. GU: Patient's renal function has remained normal at all times and his urine output has been good. Heme: During his stay here, the patient was kept on subcutaneous prophylactic Heparin to prevent DVT. Throughout his hospitalization, he required only 1 unit of blood on postoperative day two for a low hematocrit and tachycardia. He has remained stable since and his last hematocrit is 28.6 on [**1-10**]. ID: On [**1-8**], the patient developed fever. At that time, he had central lines in place. Cultures were drawn and the line was removed. Both blood cultures and the line tip grew MRSA, and therefore, it was concluded that the patient had line sepsis with bacteremia. Given the culture results, he is being treated with Vancomycin since IV through his port. He has remained afebrile since and our hope is to complete a two week course of antibiotics through the port, which hopefully can be saved and shows no signs of infection at this time. Musculoskeletal: As noted, the patient is persistently complaining of pain, which has been a chronic problem since preoperative, but at the same time has been able to ambulate independently and with some work with physical therapy. DISCHARGE INSTRUCTIONS: The patient is discharged in stable condition to a rehabilitation facility with the following recommendations: Continue cycled tube feeds and at the same time advance by mouth intake with supplements and diet. Continue Vancomycin for a total of two week treatment. Continue current pain control with followup with the Chronic Pain Service in order to manage his pain issues and consult these treatments. Please refer to the discharge paperwork as to discharge medications. DISCHARGE DIAGNOSES: Esophageal cancer status post chemoradiation. Status post [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagogastrectomy. Hypertension. Atrial fibrillation. Pneumonia. Line sepsis. Bacteremia. Chronic pain. [**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], [**MD Number(1) 367**] Dictated By:[**Last Name (NamePattern1) 28297**] MEDQUIST36 D: [**2185-1-14**] 09:38:19 T: [**2185-1-14**] 10:13:14 Job#: [**Job Number 30631**]

[ "995.91", "V44.4", "150.8", "E879.8", "486", "285.1", "401.9", "038.11", "V09.0", "427.31", "530.81", "196.9", "996.62" ]

icd9cm

[ [ [] ] ]

[ "43.99", "96.6", "34.09", "99.15", "38.91", "99.04", "38.93", "34.04", "89.61" ]

icd9pcs

[ [ [] ] ]

4166, 4674

740, 3642

3667, 4144

557, 722

184, 369

392, 536

27,243

115,240

48936+48937

Discharge summary

report+report

Admission Date: [**2114-10-4**] Discharge Date: [**2114-10-8**] Service: [**Last Name (un) 7081**] ADMISSION DIAGNOSES: 1. Right pleural effusion. 2. Stage IV colon cancer (metastases to liver, pleura). 3. Chronic obstructive pulmonary disease (home oxygen dependent, steroid dependent). 4. Congestive heart failure. 5. Pulmonary hypertension. 6. Macular degeneration. 7. Hypertension. 8. Status post torn right rotator cuff. 9. Atrial fibrillation. DISCHARGE DIAGNOSES: 1. Acute respiratory failure. 2. Status post insertion of right thoracic PleurX catheter. 3. Right pleural effusion. 4. Stage IV colon cancer (metastases to liver, pleura). 5. Chronic obstructive pulmonary disease (home oxygen dependent, steroid dependent). 6. Congestive heart failure. 7. Pulmonary hypertension. 8. Macular degeneration. 9. Hypertension. 10.Status post torn right rotator cuff. 11.Atrial fibrillation. ADMISSION HISTORY AND PHYSICAL: Mr. [**Known lastname 30984**] is an 84-year-old man with stage IV colon cancer with metastases to his liver and his pleura, who has been accumulating large right-sided pleural effusions. He underwent a thoracentesis late in the summer of [**2113**], which drained over a liter of fluid. The cytology at that time was negative for malignancy. He had reaccumulated a large pleural effusion on his right side and was therefore admitted for elective drainage of this effusion, and insertion of a PleurX catheter for future management of his effusion. He was admitted electively in order to allow his INR to become subtherapeutic, as he had been on Coumadin for atrial fibrillation. HOSPITAL COURSE: The patient was admitted on [**2114-10-4**]. His INR had come down to 1.4 by then and the plan was for him to undergo an elective drainage of his effusion on [**10-5**]. The patient became acutely hypoxic on the evening of [**2114-10-4**] secondary to what was felt to be worsening pulmonary edema, given the patient had not been taking his Lasix for several days. He was diuresed aggressively with Lasix at which time his oxygenation improved, and his mental status and respiratory status improved. On the morning of [**2114-10-5**] the patient became increasingly confused and agitated. An arterial blood gas was drawn which showed a pCO2 of 112, indicating that the patient had developed some acute on chronic CO2 retention as his pH at that time was not significantly low (7.27). As the patient was DNR/DNI, his only option was positive pressure ventilation. Therefore, he was transferred to the ICU for drainage of his effusion and possible initiation of positive pressure ventilation if necessary. The patient stabilized with additional diuresis not requiring a BiPAP mask, and on that same day underwent drainage of his pleural effusion, at that time 2.4 liters of clear fluid were drained. There was no evidence of hemothorax or infection in the fluid. A PleurX catheter was placed. The patient's respiratory status still remained somewhat tenuous although he symptomatically felt better and his mental status improved. Extensive discussions were held with the family and eventually the palliative care service, who had been seeing the patient, met with the family and the decision was made that the patient would be placed in hospice palliative care without further aggressive intervention. He was transferred back to the floor on the [**10-6**] and since that time has been doing well, maintaining an oxygen saturation of 93% on 2 liters, which was his baseline. There was no significant reaccumulation of his catheter. He was then set up with discharge to hospice and palliative care on the [**2114-10-8**]. He was discharged afebrile with normal hemodynamics and as noted an oxygen saturation of 93% on 2 liters. DISCHARGE MEDICATIONS: Included albuterol nebulizer treatments q.6h. as needed, diltiazem extended release 240 mg p.o. once daily, fluticasone, Solu-Medrol inhaler 250/50 one inhalation b.i.d., Lasix 80 mg p.o. b.i.d., lisinopril 40 mg p.o. once daily, prednisone 40 mg p.o. once daily until [**10-13**], after that time taper down to 20 mg once daily and continue taper thereafter, Senna 2 mg p.o. at bedtime, tiotropium bromide 1 tablet inhaled daily. DISCHARGE CODE STATUS: DNR/DNI. [**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(2) 286**] Dictated By:[**Doctor Last Name 3763**] MEDQUIST36 D: [**2114-10-8**] 10:46:38 T: [**2114-10-8**] 18:09:28 Job#: [**Job Number 102774**] Admission Date: [**2114-10-4**] Discharge Date: [**2114-10-8**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 281**] Chief Complaint: recurrent right pleural effsuion admitted w/ dyspnea Major Surgical or Invasive Procedure: thoracentesis and pleurex catheter placement History of Present Illness: 84 YO M w/ metastatic colon ca to liver and pleura. Last thoracentesis in [**Month (only) 216**] for 1100cc. Recently admitted for CHF/COPD exaccerbation and seen by palliative care. Admitted w/ recurrent right pleural effusion. Past Medical History: ONC HISTORY: Per Heme/Onc fellow note: Metastatic colon cancer first diagnosed [**2-28**] after labs revealing low HCT and Iron 19, ferritin 30, TIBC within normal limits. - CT scan [**2114-3-20**]: No colon mass visualized. Liver lesions demonstrated, as seen on ultrasound. Pleural effusions, right greater than left. - [**2114-3-15**] CT scan: No evidence of pulmonary embolus or thoracic aortic dissection. Bilateral pleural effusions and diffuse ground-glass opacity which may be seen in the setting of congestive heart failure, central lobular emphysema. Multiple new low-attenuating lesions within the liver, concerning for metastatic disease. - [**2114-3-16**] Right upper quadrant ultrasound: Innumerable liver lesions, concerning for metastatic disease. - CT scan of the abdomen and pelvis [**2114-3-20**]: No overt concentric apple-core mass lesion or stricture. Multiple liver lesions as described in prior ultrasound study, incompletely assessed without IV contrast. Large right and small left pleural effusions. - Colonscopy [**2114-3-19**]: A single sessile polyp of benign appearance is found in the descending colon, a single piece polypectomy was performed using a hot smear. The polyp is completely removed. - Ultrasound-guided liver biopsy, [**2114-3-21**]: Metastatic adenocarcinoma consistent with colonic origin. Immunostain for CK-20 positive, CK-7 negative, consistent with colonic origin. Please note that it is not clear whether this is an ultrasound or CT-guided biopsy. - CEA: [**2-/2114**] 14, [**3-/2114**] 18, [**4-/2114**] 27, [**5-/2114**] 20. - [**2114-6-12**] CT: One moderate sized right pleural effusion with small loculated pneumothorax. The age of the pneumothorax is not clear, but it was present on the CT of [**2114-3-20**]. Innumerable liver metastases which are larger than on prior CT, large necrotic lymph node in the portahepatis. . PMH --Atrial fibrillation --Severe COPD --Secondary pulmonary HTN --CHF --macular degeneration since his 40's --torn R rotator cuff --HTN Social History: Lives at home w/wife of 50+ [**Name2 (NI) 1686**], has 2 children who are involved in his care. Former smoker (40 pk [**Name2 (NI) 1686**]) quit approx 20 [**Name2 (NI) 1686**] pta. No ETOH, no IVDU. Retired. Family History: The patient's parents lived to be elderly. His sister has a history of colon cancer, diagnosed in her 70s. Physical Exam: ROS: c/o 2 days of unequal leg swelling w/ left leg pain per wife. Dyspnea w/ exertion. No cough, fever, chills or other constitional symptoms. general: frail appearing elderly male when sitting in NAD wearing oxygen and SOB w/ movement. HEENT: slight JVD otherwise unremarkable COR: Irreg, Irreg abd: soft, round, NT, ND, +BS extrem: bilat LE edema left >right. Pertinent Results: Portable AP chest radiograph compared to [**2114-10-4**]. Additional increase in already large right pleural effusion is demonstrated. New left retrocardiac opacity might represent a focal area of atelectasis or aspiration. The patient is in mild volume overload. There is no pneumothorax and there is no overt failure. Brief Hospital Course: pt was admitted for dyspnea (O2 dependent)and placement of pleurex catheter for recurrent right effusion. Pt's coumadin had been on hold x1 day PTA. He will have pleurex cathter when INR <1.4. HD#2 pt found w/ sat of 70%; ABG 7.27-PCO2 117, PaO2 66%. CXR w/ increased right effusion. Given 40mg IVP lasix, 100% NRB and then transferred to the SICU for non-invasive ventilation. Pt could not [**Last Name (un) 1815**] CPAP but sats improved to mid 90's on venti mask. INR was 1.3 and interventional pulmonology was able to place a pleurex catheter and drained 2.4 liters. Pt's resp status improved signficantly and he was transferred from the ICU to the floor. He was d/c'd to home on the following day. His family declined hospice services and VNA services were set up. Medications on Admission: coumadin 3mg-stopped [**9-30**], advair 500/50', albuterol nebs, dilt 240', lasix 80", lisinopril 40', kcl 20', prednisone 40' (on taper to baseline dose 20', senna, serax 15 qhs, spiriva 18mcg Discharge Medications: 1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day for 5 days: take 30mg starting [**10-9**] x5days then 20mg daily ongoing. Disp:*15 Tablet(s)* Refills:*0* 9. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day: dr. [**Last Name (STitle) 2168**] will advise you futher. Disp:*60 Tablet(s)* Refills:*2* 10. Serax 15 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day. 12. Outpatient Lab Work have your INR checked on thursday and then as directed by your primary doctor 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: metastatic colon ca to liver and pleura, COPD-O2 dependent, chronic CHF, pul HTN, Macular degeneration, HTN, torn right rotator cuff, AFIB on coumadin Discharge Condition: improved Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500cc Please call Dr.[**Initials (NamePattern4) 14680**] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 10084**] if experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Chest pain -Call immediately if drain comes out. Cover site immediately with a clean dressing -[**Month (only) 116**] shower with water-proof occlusive dressing. -No bathing or swimming Pleurax site keep covered with a clean dressing. Drain every other day: keep log of drainage Do not drain more than 1 liter at a single drainage. Call IP if have questions or concerns, drainage around tube or if drainage less than 50 cc for 3 consecutive drains. [**Telephone/Fax (1) 10084**] Followup Instructions: Follow up with Dr. [**Last Name (STitle) **]- pls call to schedule an apointment. You have a follow up appointment with interventional pulmonology on [**10-16**] at 11am on [**Hospital1 **] one to have your sutures removed. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**] Completed by:[**2114-10-10**]

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36316

Discharge summary

report

Admission Date: [**2191-4-1**] Discharge Date: [**2191-4-2**] Date of Birth: [**2114-4-12**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: gallstone pancreatitis and possible cholangitis Major Surgical or Invasive Procedure: ERCP Emergent bedside EGD bedside emergent explorative laparotomy History of Present Illness: 76F with malaise, mild epigastric pain, severe nausea and vomiting for 9 days, and diarrhea initially, now with abdominal distention & no flatus with subjective fever and chills. The patient was initially evaluated at [**Hospital6 1597**], found to have severe gallstone pancreatitis +/- cholangitis. She was transferred to [**Hospital1 18**] for ERCP. Past Medical History: Hypertension Diabetes hypercholesterolemia osteopenia CAD / no MI PSH: s/p hysterectomy + appy (age 32) s/p CABG x3 '[**76**] ([**Hospital1 112**]) Social History: non-smoker, no ETOH, no IVDU Family History: n/c Physical Exam: Neuro: no corneal reflex, pupils non-reactive to light, unresponsive to painful stimuli. Cardiac: no heart sounds for 1 minute, no radial, femoral, carotid pulses Lungs: no breath sounds, no air movement in mouth Chest: no chest movement. Time of death 1:56 AM [**2191-4-2**] Pertinent Results: [**2191-4-1**] 04:10PM [**Month/Day/Year 3143**] WBC-9.3 RBC-2.86* Hgb-8.9* Hct-25.9* MCV-90 MCH-31.2 MCHC-34.5 RDW-16.0* Plt Ct-211 [**2191-4-1**] 11:51PM [**Month/Day/Year 3143**] WBC-20.6* RBC-UNABLE TO Hgb-4.3*# Hct-14.0* MCV-UNABLE TO MCH-UNABLE TO MCHC-34.0 RDW-UNABLE TO Plt Ct-152 [**2191-4-1**] 09:49PM [**Month/Day/Year 3143**] Type-ART Temp-36.7 pO2-87 pCO2-29* pH-7.17* calTCO2-11* Base XS--16 Intubat-NOT INTUBA [**2191-4-2**] 01:41AM [**Month/Day/Year 3143**] Type-ART pO2-72* pCO2-60* pH-6.67* calTCO2-8* Base XS--34 Brief Hospital Course: The patient was admitted for ERCP. Finding from ERCP included: 1) 50-100 cc pus material mixed with liquid material suctioned from the stomach. 2) Pus in the major papilla 3) Impacted stone in the major papilla 4) Periampullary diverticulum 5) A single 6mm irregular stone that was causing complete obstruction was seen at the major papilla. A sphincterotomy was performed. The stone and sludge mixed with pus were extracted. Post-procedure the patient was admitted to the [**Hospital Unit Name 153**] following ERCP. Post-procedure labs were significant for a decreased hematocrit from an admission level of 25.9 to 15.0. The test was repeated and confirmed. The [**Hospital Unit Name **] bank was contact[**Name (NI) **] and [**Name2 (NI) **] products were ordered. Lactate increased from 8 to 13.0. The patient was transferred to the [**Hospital Ward Name **] SICU. On arrival to the [**Hospital Ward Name **], the patient was evaluated by the surgical service, and was stable. The abdominal exam was soft, without rebound with some moderate distension. She was experiencing some mild epigastric pain. [**Hospital Ward Name **] product delivery was pending. Just prior to midnight, the patient was discovered to be unresponsive. She maintained a [**Hospital Ward Name **] pressure but was experiencing agonal breathing. Anesthesia was contact[**Name (NI) **] stat as was the surgical senior in house. Intubation was initiated. The abdominal exam was significant for increasing distension. [**Name (NI) **] was noted per rectum. Rapid infusion protocol was initiated for delivery of [**Name (NI) **] products. The surgical attending, surgical chief, critical care fellow, GI fellow, and GI attending were contact[**Name (NI) **] by the surgical and ICU teams. About 15 minutes after intubation, a pulse became undetectable. ACLS protocol, including chest compressions, were begun and were carried out for one hour and fifty minutes. The lungs were needled during this period and no tension pneumothorax was suspected. No improvement was noted in vital signs. EGD was carried out at bedside by the Gold chief surgical resident, showing no upper GI source of bleeding. Due to a concern for abdominal compartment syndrome, and significant distension, an emergency explorative laparotomy was performed at bedside. The small bowel and colon showed no obvious evidence of distension. No free [**Name (NI) **] was found in the abdomen. Vital signs did not improve. The patient was pronounced dead at 1:56 AM [**2191-4-2**]. Mrs.[**Name (NI) 82285**] son [**Name (NI) **] was aware and in the hospital while all ICU procedures were taking place. These actions were taken with his understanding and at his request for further possible life saving actions. The family was offered autopsy and the decision was pending at the time of this summary. Medications on Admission: zocor 20', tricor 145', lopressor 50", Actos/metformin 15/500', ASA 325', fosamax 70 wk, iron [**Hospital1 **], Hctz/moexipril 15/12.5' Discharge Disposition: Expired Discharge Diagnosis: cardiopulmonary arrest cholangitis pancreatitis Discharge Condition: expired Completed by:[**2191-4-2**]

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icd9cm

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2172-12-31**] Discharge Date: [**2173-1-2**] Date of Birth: [**2143-7-12**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p Fall ~[**11-12**] ft. Major Surgical or Invasive Procedure: Endotracheal intubation [**2172-12-31**] Extubation [**2173-1-1**] History of Present Illness: 26 yo male s/p ~[**11-12**] foot fall off scaffolding head first onto concrete; no reported LOC. Transported to [**Hospital1 18**] from scene for continued trauma care. Past Medical History: Unknown Social History: +Etoh No family in this country; mother in [**Name (NI) 36978**]. Has a girlfriend here in the USA Family History: Noncontributory Physical Exam: VS upon admission to trauma bay: HR 90 BP 149/81 O2 Sat 96% RR 20 GCS 14 HEENT-Large laceration back of head; TM's clear Neck- cervical collar in place Chest- clear BS bilaterally Abd- soft Pelvis- stable Rectum- normal tone Extr- MAE Pertinent Results: [**2172-12-31**] 10:13PM TYPE-ART PO2-513* PCO2-39 PH-7.38 TOTAL CO2-24 BASE XS--1 [**2172-12-31**] 08:58PM GLUCOSE-95 UREA N-11 CREAT-0.9 SODIUM-141 POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-26 ANION GAP-13 [**2172-12-31**] 08:58PM ALT(SGPT)-28 AST(SGOT)-29 CK(CPK)-395* ALK PHOS-79 AMYLASE-53 TOT BILI-0.4 [**2172-12-31**] 08:58PM CK-MB-8 cTropnT-<0.01 [**2172-12-31**] 08:58PM ALBUMIN-4.2 CALCIUM-8.4 PHOSPHATE-3.8 MAGNESIUM-1.7 URIC ACID-4.8 [**2172-12-31**] 08:58PM WBC-9.9 RBC-4.38* HGB-13.1* HCT-35.5* MCV-81* MCH-29.9 MCHC-36.9* RDW-12.5 [**2172-12-31**] 08:58PM PLT COUNT-235 [**2172-12-31**] 08:58PM PT-12.5 PTT-22.6 INR(PT)-1.1 [**2172-12-31**] 05:40PM ASA-NEG ETHANOL-168* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2172-12-31**] 05:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2172-12-31**] 7:43 PM CT SINUS/MANDIBLE/MAXILLOFACIA Reason: eval facial fx [**Hospital 93**] MEDICAL CONDITION: 26 year old man s/p fall from height with sphenoid sinus fx seen on head CT REASON FOR THIS EXAMINATION: eval facial fx CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: Status post fall with sphenoid sinus fracture seen on head CT. TECHNIQUE: Noncontrast axial images through the facial bones with multiplanar reformatted images. FINDINGS: Please see the head and spine CT dictated report for details of the skull base fracture. Again, there is evidence of pneumocephalus, a fracture through the clivus and bilateral jugular foramen. There is fluid within the left mastoid air cells. There is a fracture through the sphenoid sinus posteriorly as well as hemorrhage within the sphenoid sinus. Fracture lines are extending to the left cavernous carotid canal, but there is no deformity of the bony margins. There is probably no fracture of the left anterior clinoid process or optic strut, as these structures are grossly normal in apperance, but resolution of bony detail in these structures is somewhat limited. There are no definite fractures of the orbits or lamina papyrecea. There is fluid within the ethmoid air cells as well as an air- fluid level within the right maxillary sinus and mucosal thickening within both maxillary sinuses. There are no fractures of the mandible or nasal bones. IMPRESSION: As described on the patient's other CT scans, there is a comminuted fracture through the skull base. No facial or orbital fractures are identified. CTA HEAD W&W/O C & RECONS [**2172-12-31**] 7:43 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Reason: CT angio to evaluate carotids Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 26 year old man with basilar skull fx extending through carotid canal REASON FOR THIS EXAMINATION: CT angio to evaluate carotids CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: Skull base fracture extending through jugular foramen. TECHNIQUE: Axial contrast images from the lung apices through the midbrain. Multiplanar reformatted images were obtained. FINDINGS: Please refer to the multiple other CT's regarding the details of the skull base fracture, which extends through the left and right jugular foramen as well as through the sphenoid sinus. There is flow seen within both internal carotid arteries as well as the vertebral arteries, without evidence of injury. The right internal jugular vein is normal without evidence of injury. There is lack of visualization of the left internal jugular vein filling with contrast, as well as lack of opacification of the left sigmoid sinus. Air is seen within the left sigmoid sinus. There is flow seen within the left transverse sinus. The left jugular vein within the neck is not visualized to contain contrast, although this may be due to the phase of the study. There is also pneumocephalus as well as hemorrhage within the sphenoid sinus and an air-fluid level within the right maxillary sinus. IMPRESSION: Occlusion of the left jugular vein and left sigmoid sinus, with evidence of air within the left sigmoid sinus. These findings were discussed with Dr. [**First Name (STitle) **] at 9:30 p.m. on [**12-31**], [**2172**]. CT HEAD W/O CONTRAST [**2172-12-31**] 6:00 PM CT HEAD W/O CONTRAST Reason: eval head trauma [**Hospital 93**] MEDICAL CONDITION: 26 year old man s/p fall off scaffolding. +EtOH, agitated, confused. Intubated in trauma bay REASON FOR THIS EXAMINATION: eval head trauma CONTRAINDICATIONS for IV CONTRAST: None. 0HISTORY: Fall, agitated and confused. TECHNIQUE: Non-contrast head CT. FINDINGS: There is high attenuation seen within the right frontal cortex, as well as within some of the sulci in the right frontal lobe, consistent with subarachnoid hemorrhage as well as small intraparenchymal hemorrhage. The ventricles are normal in size. The [**Doctor Last Name 352**]-white matter differentiation remains intact. There is no shift of normally midline structures. There is no acute territorial infarct. There is a comminuted fracture through the occipital bone extending to the region of the left lambdoid suture with slight diastasis of the inferior suture. The fracture involves both sides of the foramen magnum and extends into both jugular foramina. There is extension into the left mastoid air cells opacification of a few air cells and pneumocephalus. There is a fracture through the clivus extending into the sphenoid sinus, with evidence of hemorrhage within it. There is fluid within the ethmoid air cells as well as an air-fluid level within the right maxillary sinus. There is bilateral maxillary sinus mucosal thickening. IMPRESSION: 1. Right frontal contusion, small amount of right subarachnoid hemorrhage. 2. Comminuted skull base fracture involving the left mastoid air cells, bilateral foramen magnum, clivus, bilateral jugular foramen. Fluid within the left mastoid air cells. 3. Fracture through the sphenoid sinus with evidence of hemorrhage within it. Air-fluid level in the right maxillary sinus. CT HEAD W/O CONTRAST [**2173-1-1**] 8:36 AM CT HEAD W/O CONTRAST Reason: interval change-- pls do around 8am [**1-1**] [**Hospital 93**] MEDICAL CONDITION: 29 year old man with temporal SAH, and frontal contusions, with occipital skull fx REASON FOR THIS EXAMINATION: interval change-- pls do around 8am [**1-1**] CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Head trauma with intracranial hemorrhage follow-up. TECHNIQUE: Axial non-contrast CT scans of the brain were obtained. Comparison is made to the prior study of [**2172-12-31**]. FINDINGS: Again, noted is a small right anterior frontal lobe contusion. This does not appear to have increased in size since the previous study. There may be a mild degree of subarachnoid blood within some of the frontal sulci. There could also be a little bit of subarachnoid blood in the interpeduncular cistern. The suprasellar cistern is normal in configuration. There is no shift of normally midline structures or hydrocephalus. No abnormal extra- axial collections have developed. Multiple skull base fractures are again identified. IMPRESSION: Stable appearance of the brain, compared to the study of [**2172-12-31**]. CT HEAD W/O CONTRAST [**2173-1-1**] 8:36 AM CT HEAD W/O CONTRAST Reason: interval change-- pls do around 8am [**1-1**] [**Hospital 93**] MEDICAL CONDITION: 29 year old man with temporal SAH, and frontal contusions, with occipital skull fx REASON FOR THIS EXAMINATION: interval change-- pls do around 8am [**1-1**] CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Head trauma with intracranial hemorrhage follow-up. TECHNIQUE: Axial non-contrast CT scans of the brain were obtained. Comparison is made to the prior study of [**2172-12-31**]. FINDINGS: Again, noted is a small right anterior frontal lobe contusion. This does not appear to have increased in size since the previous study. There may be a mild degree of subarachnoid blood within some of the frontal sulci. There could also be a little bit of subarachnoid blood in the interpeduncular cistern. The suprasellar cistern is normal in configuration. There is no shift of normally midline structures or hydrocephalus. No abnormal extra- axial collections have developed. Multiple skull base fractures are again identified. IMPRESSION: Stable appearance of the brain, compared to the study of [**2172-12-31**]. Brief Hospital Course: Patient admitted to the trauma service. Patient intubated in the trauma bay because of increasing agitation and concern for airway protection. Neurosurgery consulted; he was started on Dilantin. Head CT scan revealed basilar skull fracture, right SAH and right frontal contusion. He was admitted to the trauma ICU for close monitoring and neuro checks. Serial head CT scans performed and were stable. He was weaned and extubated on the following day and later transferred to the floor. Social work was consulted because of the fall and EtOH involvement. On hospital day 2 he was stable for discharge. He was given specific discharge instructions. He will follow-up with Neurosurgery in [**3-4**] weeks with a repeat head CT at that time. Medications on Admission: none Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 2. Dilantin 100 mg Capsule Sig: One (1) Capsule PO every eight (8) hours for 7 days. Disp:*21 Capsule(s)* Refills:*0* 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: s/p Fall Basilar Skull Fracture Right Subarachnoid hemorrhage Right Frontal Contusion Discharge Condition: Stable Discharge Instructions: Avoid alcohol consumption. Take all medications as prescribed. You should stay out of work for 2 weeks. After that you may return but you should avoid dangerous situations such as working at a height. Follow up with Neurosurgery in [**3-4**] weeks. Take your medications as prescribed. Return to the Emergency Room if you develop fevers, headache, dizziness, visual disturbances and/or nausea /vomiting. Also return to the ER if you have swelling of your face. Followup Instructions: You will need to be seen in [**3-4**] weeks; call [**Telephone/Fax (1) 1669**] for an appointment with Neurosurgery, Dr, [**Name (NI) 63264**]. Inform the office that you will need a follow up head CT scan for this appointment.

[ "348.8", "851.81", "801.21", "E884.9", "900.81" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.91" ]

icd9pcs

[ [ [] ] ]

10629, 10635

9455, 10194

341, 410

10765, 10774

1061, 2049

11287, 11518

771, 788

10249, 10606

8407, 8490

10656, 10744

10220, 10226

10798, 11264

803, 1042

275, 303

8519, 9432

438, 608

630, 639

655, 755

29,137

157,473

30234

Discharge summary

report

Admission Date: [**2104-8-22**] Discharge Date: [**2104-8-29**] Date of Birth: [**2039-3-9**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Cirrhosis, here for liver transplant Major Surgical or Invasive Procedure: [**2104-8-22**] liver transplant History of Present Illness: 65 y.o. male with ETOH cirrhosis diagnosed [**7-16**] c/b portal HTN, Grade II esophageal varices, liver mass/HCC, rising AFP,and malnutrition on cycled tube feeds called in today for possible liver transplant. MELD 31. Feels well aside from fatigue and complaints of diarrhea from tube feedings. Although, this is improved. Hospitalized from [**7-29**] to [**2104-8-12**] for liver bx and RFA. On [**7-31**] he underwent liver biopsy then RFA which was discontinued due to oozing at site. CT/US revealed multiple lesions without acute bleeding detected and Hct was stable. He underwent 4 liter paracentesis. On [**8-1**] he became confused and had abd discomfort, n/v. A diagnostic tap was performed which grew Klebsiella pneumoniae. This was treated with Cipro x 2 weeks. Repeat tap on [**8-4**] was negative. He also experienced rectal bleeding which was attributed to rectal grade I varices and an EGD confirmed duodenitis neg for H.pylori. He was started on high dose PPI and nadolol. A Left pleural effusion was tapped for 1.7. Tap was negative for infection and cytology was negative for malignant cells. + for mesothelial cells, lymphocytes, monocytes and blood. A w/u for thrombocytosis was initiated and this am he saw a hematologist on the E. Campus. According to his wife, this will not be a hinderance to transplant. Since discharge home, he has felt weak, but ok. Tolerating cycled 12 hour tube feeds now with decreased rate of 20cc/hour. Having [**4-13**] formed stools whereas he had been having diarrhea all day when at higher TF rate. Appetite is better at lower rate and weight is stable. Only taking rifaximin. Off lactulose. Spironolactone added to meds by Dr. [**Last Name (STitle) 497**] on Tuesday. Denies f/c/HA/sore throat/indigestion/CP/SOB/abd pain/falls/dysuria/melena. +voiding frequently [**3-14**] diuretics Past Medical History: EtOH cirrhosis, diagnosed 06/[**2103**]. HCC. Prior complications of ascites, malnutrition (now on tubefeeds), portal hypertension with grade 2 esophageal varices. Peritonitis [**7-17**], Duodenitis [**7-17**], Grade I rectal varices Anemia EtOH abuse, abstinent since [**2103-8-11**] Thrombocytosis [**2104-8-22**] liver transplant from 19 y.o. Brain dead donor Social History: The patient owns business in [**Hospital3 **]: a clothing store and a limousine business. Recently he started working from home due to his poor health. He lives with his wife, who is very supportive. He smokes. No drugs. Family History: Non contributory Physical Exam: 96.9 66 104/64 16 95%RA 5'7", 137lbs this am Alert/oriented,very jaundiced, malnourished male in NAD. Wife present Pupils equal, scleral icterus, MMM, no thrush, PPFT in R nares No JVD, 2+carotids without bruits, no LAD Lungs: absent breath sounds 1/3 up on left, fine rales on RLL Cor: S1S2 nl, no murmurs Abd: ascites, ventral hernia noted when lifting head, distended abd veins, NT, +BS, no guarding/rebound Ext: 3+edema in feet/ankles Vasc: 2+DPs Bilat, Neuro: no flap, strength 5/5 upper/lower. A&O Pertinent Results: On Admission: [**2104-8-22**] WBC-10.8 RBC-3.19* Hgb-10.5* Hct-30.6* MCV-96 MCH-32.8* MCHC-34.2 RDW-19.1* Plt Ct-612* PT-31.2* PTT-85.9* INR(PT)-3.3, Fibrino-66* Glucose-83 UreaN-32* Creat-0.8 Na-137 K-4.7 Cl-103 HCO3-22 AnGap-17 ALT-41* AST-73* AlkPhos-153* TotBili-32.4* Albumin-2.9* Calcium-9.3 Phos-2.9 Mg-2.3 On Discharge: [**2104-8-29**] WBC-11.7* RBC-3.55* Hgb-10.9* Hct-32.3* MCV-91 MCH-30.7 MCHC-33.7 RDW-17.3* Plt Ct-388 PT-11.1 PTT-34.6 INR(PT)-0.9, Fibrino-304 Glucose-121* UreaN-35* Creat-1.1 Na-140 K-3.4 Cl-109* HCO3-25 AnGap-9 ALT-46* AST-18 AlkPhos-48 TotBili-4.4* Albumin-2.4* Calcium-7.5* Phos-1.9* Mg-1.7 FK506-8.3 Brief Hospital Course: On [**2104-8-22**] he underwent liver transplant from 19y.o. brain dead donor from gun shot wound to head. Surgeon was Dr. [**First Name (STitle) **] W. [**Doctor Last Name **] assisted by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21082**], Transplant Fellow. Orthotopic deceased donor liver transplant, portal vein to portal vein anastomosis, common bile duct to common bile duct (no T tube), branch patch (recipient) to celiac patch (donor) with replaced left hepatic artery from the left gastric artery, piggyback was performed. EBL was 3 liters. Please see operative note for details. Two drains were placed. He was given standard immunosuppression induction consisting of solumedrol and cellcept. Postop, he was sent to the SICU intubated. He was weaned on day 1. LFTs trended down. A duplex of the liver was normal on pod 0. There was a moderate-sized left-sided pleural effusion. A small amount of ascites was seen within the right and left lower quadrants. Urine output was adequate. JPs drained serosanguinous fluid. He was transferred out of the SICU on pod 1 in stable condition. Prograf was started on pod 1 and further doses were up titrated with goal level of 10. Tube feedings were started on pod 2. His abdomen was mildly distended with + bowel sounds. He did develop frequent stools (up to 6/day). Stool was sent for c.diff. The lateral drain was removed on pod 3. The medial drain put out ~800cc of serosanguinous fluid. Drainage decreased to ~300cc serous fluid. On [**8-27**], hct was 23. He received 2 units of PRBC with post transfusion Hct increase of 29.9. LFTs trended down until [**8-28**] when t.bili increased to 5.4 from 4.5. The bili trended down again by day of discharge. He was cleared for home by OT and PT. He will continue tube feeds via ND tube. Medications on Admission: mycelex troche 5x day, spironolactone 25mg'(held this am), rifaximin 200tid, nadolol 10mg qd, loperamide 2mg po prn qid (not using)recently, cipro 750mg q Sun, lasix 40mg qd (held this am), prilosec qd, compazine 5mg prn (not using 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Tablet(s) 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. Tacrolimus 1 mg Capsule Sig: Five (5) Capsule PO twice a day. 11. Nutrition Tubefeeding: Nutren Renal Full strength; Additives: Banana flakes, 3 packets per day Goal rate: 70 ml/hr Cycle start: [**2097**] Cycle end: 0800 Residual Check: q4h Hold feeding for residual >= : 100 ml Flush w/ 30 ml water q6h Time may be increased to decrease rate if diarrhea Disp 120 cans Refills 1 12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. Disp:*120 Capsule(s)* Refills:*1* Discharge Disposition: Home With Service Facility: chatam-[**Location (un) **] VNA Discharge Diagnosis: etoh cirrhosis now s/p liver transplant Discharge Condition: good Discharge Instructions: Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, inability to take any of your medications, abdominal distension or diarrhea, jaundice, incision/drain site redness/bleeding or drainage or any concerns. No heavy lifting [**Month (only) 116**] shower, pat incision dry Measure and record drain output. Bring a record of the drain output with you when you have your clinic appointment Labs every Monday and Thursday Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2104-9-4**] 10:20 and [**2104-9-17**] 1:00 [**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2104-9-17**] 1:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2104-9-17**] 1:00 [**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2104-9-17**] 1:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2104-8-29**]

[ "155.0", "263.9", "572.3", "V15.3", "571.2", "V11.3", "789.5" ]

icd9cm

[ [ [] ] ]

[ "99.04", "00.93", "96.6", "99.06", "99.07", "38.93", "50.59" ]

icd9pcs

[ [ [] ] ]

7529, 7591

4124, 5937

350, 385

7675, 7682

3465, 3465

8201, 8913

2902, 2920

6219, 7506

7612, 7654

5963, 6196

7706, 8178

2935, 3446

3793, 4101

273, 312

413, 2258

3479, 3779

2280, 2645

2661, 2886

29,968

147,511

25819

Discharge summary

report

Admission Date: [**2126-5-20**] Discharge Date: [**2126-6-13**] Date of Birth: [**2066-12-31**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: Hypotension and parastomal bleeding Major Surgical or Invasive Procedure: [**2126-5-21**] - TIPS [**2126-5-22**] - TIPS revision intubation HD line placement dobhoff line placement Central venous access Endoscopies TEE History of Present Illness: 59M well-known to our surgical service was recently admitted on [**2126-5-14**] and discharged on [**2126-5-18**] for evaluation of persistent bleeding from his ostomy site. Has noted bloody output since his admission on [**2126-5-10**] (requiring multiple transfusions). During his recent admission, CT scan did reveal fairly prominent parastomal varices although endoscopy (through stoma) did not identify an area of bleed. Bleeding appeared to stop prior to his discharge. His coumadin (portal arterial thrombosis) was held in anticipation of a TIPS procedure. His Hct and INR on discharge were 28.7 and 1.4 respectively. Patient has been doing well since his discharge. He arrived at his dialysis center but was found to be hypotensive (SBP 70). Initially transferred to [**Hospital3 **] and then sent here. His dialysis was held and received a 500ml bolus. Reports normal appetite. Moreover, today's ostomy production has more gross blood compared to output prior to discharge. Patient denies any symptoms of dizziness, nausea, vomiting, diarrhea, fevers. Tolerating foods without issues. No orthostatics. Otherwise asymptomatic. Per patient, baseline BP are in sbp 90's. Past Medical History: PMH: Hepatitis C cirrhosis, History of UGIB - esophageal varices with portal gastropathy s/p banding in past, hx L leg cellulitis/necrotizing fascitis/osteomyelitis and group A strep sepsis [**11/2123**], chronic thrombocytopenia, hypersplenism, MVA [**2101**], surgery to R leg, multiple fractures to L leg, c diff colitis, renal failure from ATN(HD MWF), hepatic artery thrombosis, bile leak, stomal bleeding s/p endoscopy . PSH: [**2123-12-25**] OLT, [**2124-10-25**] re-[**Month/Day/Year **] for hepatic artery thrombosis, [**2124-11-5**] Roux-en-Y hepaticojejunostomy for bile leak, [**2124-3-30**] split thickness skin graft, [**2124-12-12**] total abdominal colectomy w/ ileostomy for worsening Cdiff infection Social History: Denies tobacco use. No alcohol x 18 years. Denies ever using IV drugs. Lives with wife, has 6 children, 5 grandchildren. Owns his own towing/auto body repair business. Family History: Son died of colon cancer, grand father died of colon cancer. No history of liver disease Physical Exam: Physical Exam: 98.3 84 81/50 18 1004L on arrival, General: NADS, AAOx3, comfortable Chest: R HD line w/ no erythema or signs of infection Lungs: clear, crackles at bases Cardio: RRR Abd: soft, incision c/d/i, NT, slightly distended, act BS, ostomy site with gross blood and stool, stoma pink and patent Ext: [**11-24**]+ pedal edema, palpable distal pulses Pertinent Results: [**2126-6-13**] 05:58AM BLOOD WBC-3.1* RBC-2.63* Hgb-8.1* Hct-23.4* MCV-89 MCH-30.8 MCHC-34.6 RDW-20.6* Plt Ct-47* [**2126-6-12**] 05:27AM BLOOD WBC-4.3 RBC-2.98* Hgb-9.1* Hct-27.2* MCV-91 MCH-30.5 MCHC-33.4 RDW-20.3* Plt Ct-55* [**2126-6-11**] 04:27AM BLOOD WBC-3.8* RBC-2.66* Hgb-8.0* Hct-24.7* MCV-93 MCH-30.1 MCHC-32.5 RDW-20.2* Plt Ct-68* [**2126-6-3**] 03:46AM BLOOD Neuts-81.6* Lymphs-13.1* Monos-4.7 Eos-0.4 Baso-0.3 [**2126-6-13**] 05:58AM BLOOD PT-17.5* PTT-54.6* INR(PT)-1.6* [**2126-6-12**] 05:27AM BLOOD PT-18.4* PTT->150* INR(PT)-1.7* [**2126-6-9**] 02:45AM BLOOD PT-17.1* PTT-50.8* INR(PT)-1.5* [**2126-6-1**] 04:18AM BLOOD PT-21.2* PTT-50.5* INR(PT)-2.0* [**2126-6-13**] 05:58AM BLOOD Glucose-93 UreaN-84* Creat-5.5* Na-136 K-3.6 Cl-108 HCO3-18* AnGap-14 [**2126-6-11**] 04:27AM BLOOD Glucose-128* UreaN-65* Creat-4.4* Na-137 K-3.4 Cl-107 HCO3-22 AnGap-11 [**2126-6-8**] 04:57AM BLOOD Glucose-163* UreaN-56* Creat-4.0* Na-133 K-3.5 Cl-103 HCO3-24 AnGap-10 [**2126-5-30**] 03:05AM BLOOD Glucose-84 UreaN-21* Creat-3.2*# Na-135 K-4.2 Cl-103 HCO3-25 AnGap-11 [**2126-6-12**] 05:27AM BLOOD ALT-8 AST-32 AlkPhos-170* TotBili-1.5 [**2126-6-11**] 04:27AM BLOOD ALT-10 AST-32 AlkPhos-151* TotBili-1.6* [**2126-5-30**] 03:05AM BLOOD ALT-40 AST-91* AlkPhos-230* TotBili-3.7* [**2126-6-10**] 04:36AM BLOOD Albumin-2.1* Calcium-7.6* Phos-1.2* Mg-2.0 [**2126-5-27**] 05:30AM BLOOD Calcium-8.3* Phos-5.3* Mg-1.9 Blood Culture, Routine-PRELIMINARY {STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA}; Aerobic Bottle Gram Stain-FINAL INPATIENT Blood Culture, Routine-FINAL {[**Female First Name (un) **] (TORULOPSIS) GLABRATA}; Anaerobic Bottle Gram Stain-FINAL Blood Culture, Routine-FINAL {ENTEROCOCCUS FAECIUM}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL [**2126-5-30**] 04:04PM PLEURAL WBC-340* RBC-5925* Polys-20* Lymphs-71* Monos-4* Atyps-2* Macro-3* [**2126-5-30**] 04:04PM ASCITES WBC-153* RBC-2700* Polys-6* Lymphs-75* Monos-8* Eos-2* Atyps-6* Macroph-3* [**2126-5-27**] 04:37PM ASCITES WBC-300* RBC-4350* Polys-11* Lymphs-76* Monos-0 Plasma-1* Macroph-12* [**6-5**] 1. Similar appearance to multiple large areas of heterogeneous enhancement in the liver when compared to the previous study of [**2126-5-29**], likely representing areas of infarct. The differential again includes biliary necrosis, cholangitis or other infectious processes. However, there has been no interval development of an organized hepatic collection. 2. Thrombosis of the lower superior mesenteric vein, new since the previous study. 3. Partial thrombosis of the superior aspect of the extended TIPS which is also new since the previous study. 4. Focal dilation of the proximal jejunum, which may represent focal ileus. 5. Pigtail catheter in the left lower quadrant. There is a moderate amount of remaining ascites, but this is much reduced in size since [**2126-5-29**]. 6. Parastomal hernia involving loops of small bowel, which is unchanged. No evidence of obstruction. 7. Moderate bilateral pleural effusions, right greater than left with adjacent compressive atelectasis. The left-sided pleural effusion has increased in size since the previous study. 8. Continued extensive varices, splenomegaly and non-visualized hepatic arteries which are likely thrombosed, all unchanged since the previous study [**5-29**]. Interval development of multifocal extensive heterogeneously hypoenhancing hepatic areas, concerning for hepatic infarct/ischemia. DDx includes biliary necrosis, cholangitis, or other infectious process. Cannot exclude early organizing intrahepatic abscess, but no definite thick-walled intrahepatic collection is noted. 2. Interval placement of TIPS stent. Assessment of TIPS patency is limited in this study, but the left portal vein appears widely patent, suggesting the TIPS is likely to be patent. 3. Hepatic arteries not clearly visualized, likely remain thrombosed. 4. Interval moderate increase of ascites, predominantly in the left lower quadrant, but without definite abscess. The presence of large amount of ascites increases risk of spontaneous bacterial peritonitis. 5. Similar splenomegaly, measuring up to 21 cm. Similar perisplenic and perigastric varices. 6. Unchanged moderate right-sided pleural effusion, with bibasilar atelectasis, right greater than left. 7. Similar right-sided parastomal hernia with loops of small bowel involved, but no bowel obstruction. Status post colectomy with Hartmann's pouch without surgical complications. 8. Bilateral atrophic native kidneys, compatible with patient's history of end-stage renal failure. Brief Hospital Course: Mr. [**Known lastname 64239**] was admitted to Dr.[**Name (NI) 670**] [**Name (NI) **] surgical service on [**2126-5-20**] for hypotension and anemia from persistent stomal variceal bleeding. With hypotension, he was admitted to the surgical intensive care unit. Plan for TIPS procedure [**5-20**] to divert portal blood flow to systemic circulation in order to minimize bleeding. Repeat procedure on [**5-22**] due to concerns of portal flow. Shunts were extended and findings of occlusion of proximal portion. Required neo for vasopressor support but was extubated immediately afterwards. Patient tolerated a regular diet and then transferred to surgical floor on [**2126-5-25**] with stable blood pressures. Displayed worsening encephalopathy on [**2126-5-27**] with increasing abdominal distention. Diagnostic paracentesis with cytologies consistent with SBP. Moreover, on [**2126-5-28**], patient developed hematemesis. [**Hospital 64293**] transferred to the SICU. He was intubated and upper endoscopies performed by GI, showed no active bleed but duodenal ulcers. After procedure, hemodynamically unstable and consistent with systemic infectious physiology. He was started on broad spectrum antibiotics and CT scan performed showing increasing abdominal ascites and pleural effusion. Bedside ultrasound guided drainage of both collections, sent for culture and cytology. Drains left in place to decompress both cavities. Cultures returned enterococcus. He continued antibiotics (meropenem, vancomycin). Daily surveillance cultures continued and returned positive. All central and access lines were removed and re-sited. However, continued to be bacteremic. No clear site identified. TEE did not show any vegetations, suggesting likely infected TIPS. Cultures then returned with yeast and vancomycin resistant enterococcus. His antibiotic regimen was switched to daptomycin. Cultures again positive with Stenotrophomonas. Regimen switched to IV Bactrim in addition to meropenem and daptomycin. HD continued as clinically needed based on clinical exam and electrolytes, transfused as needed for low Hct, continued on all immunosuppression medications. On [**2126-6-13**], patient decided to withdraw care and resort to home hospice for further care. He was coherent and mentally capable as this decision was made. He was discharged with palliative care recommendations on [**2126-6-13**]. For more detail, his hospital course can be summarized by the following review of systems Neuro: Pain was well controlled. On [**2126-5-27**], found to be disoriented and encephalopathic, paracentesis showing SBP. He was started on antibiotics, lactulose and rifaximin. Mental status improved and no more episodes until discharge. Patient wishes to leave the hospital for home hospice. Palliative care consulted and discharged with atropine sl drops, morphine and Ativan. Patient was coherent and able to make own medical decisions without compromise. This was confirmed by social worker, wife, sicu staff and [**Date Range **] surgical staff. Cardio: Pt with baseline hypotension while on midodrine and Florinef. He continued to be hypotensive, requiring neo for additional pressor support. TTE/TEE procedures to assess for vegetations given patient's persistent bacteremia and were negative with normal cardiac function. No hemodynamic issues. Pulm: Patient intubated for his procedures. After TIPS, difficult to wean patient off the ventilator as he was dependent. Pleural effusion drained. Patient then successfully extubated and maintained on room air. No respiratory issues for remaining hospital stay. GI: Patient with history of liver [**Date Range **] x 2 c/b hepatic artery thrombosis. Anti-coagulation was held due to parastomal bleeding. TIPS to attempt to divert blood flow. Abdominal fluid was drained via ultrasound guidance and external drain left in place. Patient's LFT continued to be abnormal as CT also suggested areas of necrosis. CT also demonstrated SMA thrombosis. Heparin was started to begin anticoagulation. As patient's clinical status worsened, he began to bleed again from his ostomy. Hct trended and remained fairly stable. Patient was re-listed for another liver [**Date Range **] but he refused. FEN: Patient electrolytes were checked daily and nephrology closely following for dialysis. Due to poor oral nutrition, dobhoff enteral feeding were started. Nutritional recommendations implemented. He continued on regular diet as well. Fluid resuscitation closely monitored due to HD need. ID: With SBP, patient started on meropenem given history of resistant E.coli. Patient with septic physiology, started on empiric antibodies of vancomycin and Flagyl. Patient continued to be bacteremic. Pls see lab section. Daily cultures continued to be positive and microbe returned with Enterococcus. This eventually became Vancomycin resistant and switched to Daptomycin. Additional cultures positive for [**Female First Name (un) **] and Stenotrophomonas. Central, arterial and HD lines re-sited for persistent bacteremia. ID consulted for recommendations and regimen switched to Micafungin, daptomycin, and IV Bactrim. TEE revealed no cardiac source. Ultimately, discussed with patient possible need for another liver to remove likely infected TIPS site. Patient refused after understanding the risks and benefits. Patient also kept on Prograf immunosuppression. Levels were checked and dosing adjusted daily. Heme: Patient transfused with blood as needed for hypotension and other products as needed. His total transfusion requirement for this hospital stay is 8u pRBC, 4u FFP, and 2u platelets. He was also maintained on hep gtt for SMV thrombosis. This was discontinued prior to discharge. Disposition: Patient to be discharged to home hospice. He understands the risk and benefits of his condition. He was completely mentally competent as he was making this decision. Palliative care aware and to follow patient at home. He was discharged [**2126-6-13**]. Medications on Admission: Mirtazapine 15'' PRN. Bactrim 400-80. Zolpidem 5. Ursodiol 300''. Oxycodone 5 q4hrs PRN. B Complex-Vitamin C-Folic Acid. Tacrolimus [**11-23**]. Discharge Medications: Atropine gtt SL Morphine PO Ativan Discharge Disposition: Home Discharge Diagnosis: stomal variceal bleeding Liver failure bacteremia - fungal, bacterial Home hospice FTT Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: N/A Call if questions to [**Month/Day (4) **] coordinator [**Telephone/Fax (1) 3618**] Followup Instructions: N/A

[ "570", "790.7", "348.30", "041.04", "537.89", "V12.51", "557.0", "285.1", "249.81", "E878.0", "511.9", "569.69", "585.6", "567.23", "041.4", "518.82", "783.7", "996.82", "276.8", "458.9", "789.59", "456.8", "V66.7", "V58.61", "287.5", "532.40", "117.9" ]

icd9cm

[ [ [] ] ]

[ "34.91", "96.71", "45.13", "88.72", "96.6", "38.91", "54.91", "39.95", "96.04", "39.1", "38.93" ]

icd9pcs

[ [ [] ] ]

13981, 13987

7738, 13727

350, 497

14118, 14118

3132, 7715

14414, 14421

2648, 2738

13922, 13958

14008, 14097

13753, 13899

14303, 14391

2768, 3112

275, 312

525, 1704

14133, 14279

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2462, 2632

55,273

123,800

7831

Discharge summary

report

Admission Date: [**2156-2-27**] Discharge Date: [**2156-3-10**] Date of Birth: [**2077-10-5**] Sex: F Service: MEDICINE Allergies: Erythromycin Base Attending:[**First Name3 (LF) 1377**] Chief Complaint: bleeding Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 28265**] is a 78 yo female with extensive clot burden (PE, aortic throbus, splenic infarct) now on coumadin, SVT s/p ablation, recent admission cardiac arrest (discharged [**2-20**]); now admit for large thigh hematoma leading to Hct drop and hypotension. Patient was recently discharged to rehab on [**2156-2-20**] after admission for s/p cardiac arrest and AVNRT ablation. Treated for C.diff that admission. Discharged on coumadin and lovenox (until INR therapeutic, given through AM of admission. . On AM of [**2-27**] awoke with L thigh pain and swelling. Had been fine on prior day, went for a walk at rehab. Had CT at rehab and found to have thigh hematoma there. Reportedly did have instrumentation on L femoral region (? only venous or arterial) during last hospital course. . In the ED, T 99, BP 94/65, HR 120, R18, 100% RA. Pressure dropped to 86/43. Hct 22, INR 1.9. Got 1 unit PRBCs, awaiting second. Given 1 L NS. Not reversed given extensive clot burdern and overall stability. On CXR can't rule out pneumonia, written for ceftriaxone and levoflox but has not yet received. Past Medical History: HTN SVT s/p ablation on [**2156-2-16**] hyperlipidemia clot burden with PE, aortic thrombosis, and splenic infacrt seen on [**2-2**] s/p cardiac arrest in [**2-2**] C diff (finished PO vanc on [**2156-2-26**]) small subarachnoid hemorrhage in [**2-2**] Social History: Married, lives in [**Location 4310**]. Retired, had her own business. Denies tobacco, alcohol, or drug use. Family History: Grandmother with nephrolithiasis. No family history of early MI. Physical Exam: T 98.2, BP 122/58, HR 77, RR 20, O2sat 100% RA, wt 53.6kg General: elderly female sitting up in bed. NAD. Oriented to self but not to place or date or person. HEENT: NCAT, aniceteric sclera, non-injected conjunctiva, EOMI, MMM, strong aortic pulsation in neck. Did not appreciate JVP. CV: RRR 3/6 SEM Lungs: CTAB no w/r/r Abdomen: +BS, soft, NTND Ext: left thigh enlarged and tense compared to right. DP and PT 2+ symmetric. No femoral bruit appreciated. Neuro: CN III-XII in tact including hearing to finger rub, Strength seems full throughout but patient not fully cooperating with exam. Sensation appears in tact. alert but not oriented other than to self. Reflexes 2+ bicep, brachioradialis, patellar. Toes mute. Pertinent Results: Admission: WBC-13.8*# RBC-2.41*# Hgb-7.3* Hct-22.2* MCV-92 MCH-30.1 MCHC-32.7 RDW-17.0* Plt Ct-342 PT-20.7* PTT-30.1 INR(PT)-1.9* Discharge: WBC-10.8 RBC-3.79* Hgb-11.3* Hct-34.6* MCV-91 MCH-29.8 MCHC-32.7 RDW-15.1 Plt Ct-691* PT-13.2 PTT-24.4 INR(PT)-1.1 Glucose-85 UreaN-19 Creat-0.6 Na-138 K-4.3 Cl-101 HCO3-27 AnGap-14 ALT-32 AST-30 LD(LDH)-292* AlkPhos-66 TotBili-1.3 Coagulopathy work up done off anticoagulation: [**2156-3-7**] 01:00PM BLOOD AT III-PND ProtCFn-PND [**2156-3-7**] 01:00PM BLOOD Lupus-NEG [**2156-3-3**] 07:15AM BLOOD Thrombn-15.5*# [**2156-3-3**] 07:15AM BLOOD ACA IgG-4.4 ACA IgM-9.4 [**2156-3-3**] 07:15AM BLOOD Inh Scr-NEG AT III-59* [**2156-2-28**] 06:09AM BLOOD LMWH-0.54 Micro: [**2156-3-9**] STOOL C diff positive [**2156-3-3**] STOOL FECAL CULTURE-negative; CAMPYLOBACTER CULTURE-negative; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-negative [**2156-3-1**] URINE URINE CULTURE-negative [**2156-2-28**] MRSA SCREEN MRSA SCREEN-negative [**2156-2-28**] BLOOD CULTURE Blood Culture, Routine-no growth [**2156-2-27**] BLOOD CULTURE Blood Culture, Routine-no growth Urine cytology pending [**2156-2-28**] CT torso and left LE: IMPRESSION: 1. No aortic thrombus. Thrombosis of the celiac axis, as before. 2. Large hypodense area within the spleen, likely sequelae from infarction. 3. Very large left groin/medial thigh hematoma with high-attenuation focus located superiorly and centrally suspicious for arterial extravasation. [**2156-3-6**] CT abdomen/pelvis: IMPRESSION: 1. No evidence of renal stones. 2. Colonic wall thickening and pericolonic stranding is seen along the ascending colon and splenic flexure with mild sigmoid thickening in some areas, concerning for colitis. 3. Cholelithiasis without evidence of cholecystitis. 4. Mild improvement of the left pleural effusion and left lower lobe atelectasis since the prior study. Persistent mild right atelectasis is seen. [**2156-3-8**] CT head without contrast: IMPRESSION: 1. No acute intracranial abnormality. 2. Equivocal left frontovertex focal subarachnoid hemorrhage is no longer seen. 3. Generalized atrophy, likely accounting for the symmetric prominence of the bifrontal extra-axial CSF spaces. [**2156-3-9**] ECHO: Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild mitral valve prolapse. A late systolic jet of Moderate (2+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2156-2-14**], left and right ventricular systolic function has normalized. The severity of mitral regurgitation has decreased. Brief Hospital Course: 78 yo F with HTN, recent cardiac arrest and large clot burden with PE, aortic thrombus, SVT s/p recent ablation who presented with acute blood loss anemia and hypotension and found to be bleeding into her left thigh. Given her clot burden she has been discharged on her prior admission on coumadin and lovenox. She presented with a large left thigh/groin hematoma and hypotension from acute blood loss anemia. She initially required a stay in the MICU and required blood pressor agents and a total of 5 units of PRBCs. Vascular surgery and interventional radiology were consulted initially, but her bleeding quickly slowed down and she responded to blood products, so no procedural intervention was needed. Once she was stabilized she was transferred to the medical floor. Her hematocrit remained stable throughout the rest of the admission. . # acute blood loss anemia: She was subtherapeutic on admission with INR of 1.9 but also on lovenox at the time of the bleed. She had had prior instrumentation through her left groin for SVT ablation procedure and a femoral venous line. This was believed to contribute to the fagility of her vessels. Hematology consult was obtained regarding risks and benefits to restarting anticoagulation (recent bleed and huge fall risk, but large clot burden). Her husband thought she had some bright red blood per rectum at rehab prior to admission, and she had a history of some gross hematuria. To further evaulate this she underwent upper and lower endoscopy which were clean without source of bleeding or polyps and she underwent cystoscopy which was also clean. Urology consult believed that a prior kidney stone had contributed to her prior hematuria. Two urinalyses were negative for blood. She does have a urine cytology pending at discharge. While off of anticoagulation, she also had a work up for coagulopathy which was largely negative. Some tests were still pending at discharge. She should follow up with her outpatient Hematologist. Given this work up, it was decided that she should be restarted on anticoagulation in consultation with the Hematologist. She was discharged on lovenox and coumadin. VNA services will check her INR and HCT and fax them to her PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 679**]. . # diarrhea: She had recently completed a two week course of PO vancomycin for C diff infection on [**2156-2-26**]. She began to have watery guiac negative diarrhea during the admission. Initial stool culture and C diff toxin were negative, but then subsequent C diff was positive. She was sent home on a 2 week course of PO vancomycin for presumed insufficiently treated C diff infection. . # clot burden: She was previously diagnosed with PE and aortic and celiac thrombus and splenic infarcs. It was unclear why she had both venous and arterial clots but had been started on anticoagulation on her prior admission. As above, the risk of further clots outweighted the risk of further anticoagulation once she was stablized from her bleed. She was restarted on anticoagulation as described above with close follow up. A coagulopathy work up was performed off of anticoagulation and she will follow up with her outpatient Hematologist. . # s/p cardiac arrest and subsequent SVT ablation: last month she had cardiac arrest for unclear reason. She was left with possible mild hypoxic brain injury. Her last echo after the arrest showed a stunned myocardium with LVEF of 20%. A repeat echo this admission showed residual moderate mitral regurg but normal biventricular function. . # SVT s/p ablation: She was maintained in sinus rhythm throughout admission. Her metoprolol was increased slightly given ectopy on telemetry. . # s/p falls: With her hypoxic brain injury, she often forgot to call the nurses before getting out of bed. She fell two times in the hospital. Head imaging showed no bleeds after the falls. She did have a left upper lip laceration after the second fall which required 4 sutures by plastic surgery. These should be removed in 7 days on [**2156-3-15**]. Bacitracin should be applied twice a day. She was evaluated by physical therapy and they felt she needed 24 hour care. Her husband wanted to take her home rather than resume a stay at rehab. He worked with physical therapy and they felt she was safe to go home with 24 hour care that her husband said he could provide. It was stressed that she could not be left alone given her fall risk especially in the setting of resuming of her anticoagulation. Medications on Admission: 1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 8 days: completed [**2156-2-26**]. 2. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) subcutaneous Subcutaneous Q12H (every 12 hours): Please discontinue after INR is therapeutic (between [**12-30**]) for 24 hours. Given through [**2-26**] AM. Then given enoxaparin 60 mg [**Hospital1 **] x 2 doses, last [**2-27**] AM 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please adjust dose for INR [**12-30**]. 5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Bactrim 80-400 [**Hospital1 **] ([**Date range (1) 28269**]) for UTI Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Outpatient Lab Work Please check INR and HCT on [**2156-3-12**] Friday and fax to Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] at [**Telephone/Fax (1) 25380**]. Please repeat INR on Monday [**2156-3-15**] and then every three days until instructed otherwise by Dr. [**First Name (STitle) 679**]. 4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 7 days. Disp:*14 syringes* Refills:*2* 6. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 14 days. Disp:*56 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Greater [**Location (un) 1468**] VNA Discharge Diagnosis: acute blood loss anemia from thigh hematoma s/p fall and lip laceration C diff recurrent Secondary diagnosis: clot burden- PE, aortic thrombus and splenic infarct. SVT s/p ablation HTN hyperlipidemia Discharge Condition: stable HCT. Discharge Instructions: You were admitted with bleeding into your thigh (called a hematoma). You were given several units of blood back and the bleeding stopped. You had endoscopy to evaluate for any bleeding from your stomach or colon and they were both normal with no bleeding. You had cystoscopy to evaluate if there was bleeding from your bladder and this was also normal. You likely had some bleeding before from a kidney stone which you passed. You were restarted on coumadin and lovenox until your INR (lab test to show your blood is thin. Goal INR is between [**12-30**]). Please have the VNA check your INR on Friday [**2156-3-12**] and send to Dr.[**Name (NI) 16937**] office to make adjustments as needed. Fax to Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] [**Telephone/Fax (1) 25380**]. Please check every three days until Dr. [**First Name (STitle) 679**] instructs you to change this. You must continue lovenox injections until Dr. [**First Name (STitle) 679**] says to stop. You have a C diff infection causing diarrhea. Please take vancomycin by mouth for 2 weeks. Do not take immodium while you have this infection as it can make things worse. You had sutures to your lip. You will need these removed on [**2156-3-15**] by the visiting nurse. You need to have 24 hour supervision at home because of your falling. This means someone must be with you 24 hours a day. If your husband needs to go out, someone else must come in to help take care you. Please return to the ED or call your physician if you have fevers over 102, chills, signs of bleeding, chest pain or trouble breathing or any other symptoms which are concerning to you. Followup Instructions: Primary care physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**]. Please call to schedule an appointment in [**11-28**] weeks at [**Telephone/Fax (1) 682**]. Hematology/oncology: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28268**], MD Phone:[**Telephone/Fax (1) 22**] Please call to reschedule as you were in the hospital and missed your appointment. Cardiology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2156-3-24**] 10:20 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**] Completed by:[**2156-3-10**]

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icd9cm

[ [ [] ] ]

[ "99.04", "27.51", "45.23", "57.32", "45.13" ]

icd9pcs

[ [ [] ] ]

12006, 12073

5868, 10371

287, 293

12318, 12332

2672, 5845

14044, 14895

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1934, 2653

239, 249

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1726, 1836

24,181

154,701

48832

Discharge summary

report

Admission Date: [**2186-6-23**] Discharge Date: [**2186-6-27**] Service: MEDICINE Allergies: Codeine / Penicillins / Aspirin / Fentanyl Attending:[**First Name3 (LF) 6578**] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 82 year old female with a long history of lung cancer and bilateral lobectomies and current metastases to brain, as well as [**Hospital 11491**] transfered from the MICU after being admitted with a pneumonia. She was transferred to the floor after it was decided not to do any more invasive procedures to prolongue her life. She was established as DNR/DNI and was brought to the floor to be given comfort measures. Past Medical History: # Lung cancer - s/p RUL lobectomy in [**2169**] for bronchoalveolar carcinoma - s/p segemental resection of posterior segment of LUL in [**2173**] - path = adenoca NOS, moderately differentiated features, neg LN - repeat mass found in LUL in [**2183**] -> bronchoscopy -> developed resp failure post bronch requiring ventilation (? [**1-20**] muscle rigidity from fentanyl) - path of [**2184-1-22**] mass = infiltrating adenoca w/ papillary features - then found L hilar mass -> 6 cycles chemo w/ navelbine + XRT - L hilar mass enlarged, plus new mass at R lung base (20 x 13mm) - opted for no further treatment # COPD - last PFTs in [**2173**] - FEV1 1.80, FVC 2.05, FEV1/FVC 88 (125%) # hypothyroidism # h/o TIA/CVA - MRA in [**2172**] showed 80%+ stenosis of [**Doctor First Name 3098**], 90%+ of [**Country **] - s/p L CEA in [**2172**] (h/o R CEA in past) - [**2182**]: R ICA w/ 70-79% stenosis L ICA w/ 60-69% stenosis - MRA in [**2182**] showed subacute vs. acute infarct L internal capsule - per neuro notes, strokes have been bilateral and had residual L sided hemiparesis (though not noted on neuro exams) # Parkinson's # PVD and claudication # Cervical stenosis - s/p anterior cervical disk excision and fusion of screws # HTN # Osteoarthritis and osteoporosis # s/p R THR in [**2171**] for OA - then had R hip dislocation in [**2181**], s/p closed reduction # OSA - not on CPAP # h/o PUD # Depression # CRI - baseline Cr is 1.7 - 3.2 in last 2 yrs Social History: Lives at [**Location 5583**] House x 2 yrs. 90 pack-yr smoker. h/o EtOH abuse. Widowed, husband died in [**2171**]. Family History: NC Physical Exam: AM on the floor: Vitals: RR 8 General: sick female in respiratory distress Skin: pink, no rashes HEENT: NCAT, MMM dry CV: HRRR, nl S1 and S2, no m/r/g Pulm: Bilateral rhonchi and rales. Patient with agonal gasps. ABD: S/NT/ND/no HSM, BS wnl Ext: no c/c/e Neuro: no response to voice. Upon pronounciation: no pupillary reflex no heart sounds auscultated no breath sounds auscultated no radial pulse Pertinent Results: Hct ranged from 30 to 35.1 peak WBC 21.2 on [**6-26**] Cr peaked at 2.1 on [**6-26**] Peak blood glucose 166 on [**6-23**] TroponinT 0.05, 0.11, 0.32, 0.48, 0.53 pO2 66 on [**6-24**] on [**6-25**] Lactate 2.9 on [**6-24**] Negative UAs on [**6-23**] and [**6-24**] Sputum Cx [**6-26**]: RESPIRATORY CULTURE (Final [**2186-6-26**]): SPARSE GROWTH OROPHARYNGEAL FLORA. Blood Cx negative x 4. UCx negative x 2. Head CT [**6-23**]: IMPRESSION: At least two hyperdense lesions at the [**Doctor Last Name 352**] white matter junction with associated vasogenic edema worrisome for new metatatic intracranial disease. Additional areas of vasogenic edema detected raising suspicion for additional lesions. No resultant mass-effect or midline shift. Correlation with MRI is recommended to further evaluate. Head CT [**6-24**]: IMPRESSION: Multiple supra- and infratentorial enhancing nodules, the majority of which demonstrate fast diffusion, which argues against abscess and in favor of metastatic disease. CXR [**6-23**]: IMPRESSION: 1. Persistent opacity at the left lower lobe and perihilar region likely related to known left hilar mass. Post obstructive changes in the left base likely represent atelectasis and/or pneumonia. CXR [**6-23**]: IMPRESSION: 1. OG tube tip in the stomach. 2. Increased opacity over the left upper lobe which might be due to worsening atelectasis due to known left perihilar mass. 3. Unchanged right lower retrocardiac consolidation which may be due to aspiration or infection. CXR [**6-24**]: IMPRESSION: Worsening left upper lung collapse. Worsening airspace opacity involving the right lung. Diagnostic considerations include pulmonary edema. Pneumonia is not excluded. Small right-sided effusion. CXR [**6-25**]: IMPRESSION: Marked improvement in aeration of the left upper lung with persistent left mid and upper lung airspace opacity. Unchanged right mid and lower lung airspace opacity and right-sided pleural effusion. Diagnostic considerations again include asymmetric pulmonary edema and pneumonia. ECG [**6-24**]: Normal sinus rhythm. Left atrial abnormality. Q waves in leads V1-V2 suggest the possibility of anteroseptal myocardial infarction. There are also T wave inversions in leads V1-V3. Compared to the prior tracing #1 the anteroseptal abnormalities are new. Clinical correlation is suggested. Brief Hospital Course: Ms. [**Known lastname 102586**] was brought to the floor on comfort care. She was tachypneic at that time. After discussions with the health care proxy, antibiotics were d/c'd on [**6-25**], as were other medications not involved in comfort care. She was given a morphine drip and tylenol for fever. She was given oxygen, which was d/c'd on [**6-26**]. She was given scopolamine and hyoscyamine to control oral secretions. She began agonal breathing on [**7-19**] and her RR decreased over until she became apneic on [**6-27**]. She was pronounced at that time. Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure due to pneumonia, lung cancer with metastases, and COPD. Discharge Condition: Expired

[ "V10.11", "332.0", "403.90", "585.9", "197.0", "198.3", "518.81", "486", "244.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5814, 5823

5192, 5762

270, 276

5943, 5953

2804, 5169

2365, 2369

5785, 5791

5844, 5922

2384, 2785

211, 232

304, 730

752, 2215

2231, 2349

30,705

102,036

51105

Discharge summary

report

Admission Date: [**2180-7-26**] Discharge Date: [**2180-7-31**] Date of Birth: [**2101-9-13**] Sex: F Service: SURGERY Allergies: Alendronate Sodium Attending:[**First Name3 (LF) 2534**] Chief Complaint: s/p Pedestrian struck by auto Major Surgical or Invasive Procedure: None History of Present Illness: 78 yo female pedestrian who was struck by car at low speed in mall parking lot. + brief LOC. She was taken to an area hospital where she was found to have a cervical spine injury and facial fractures; she was then transferred to [**Hospital1 18**] for further management. Past Medical History: CAD s/p CABG [**2161**] HTN Social History: Recently widowed Family History: Noncontributory Pertinent Results: [**2180-7-26**] 09:23PM GLUCOSE-132* LACTATE-1.7 NA+-141 K+-3.9 CL--111 TCO2-22 [**2180-7-26**] 09:15PM UREA N-23* CREAT-0.5 [**2180-7-26**] 09:15PM AMYLASE-88 [**2180-7-26**] 09:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2180-7-26**] 09:15PM WBC-12.3* RBC-3.75* HGB-12.7 HCT-36.9 MCV-99* MCH-34.0* MCHC-34.5 RDW-13.6 [**2180-7-26**] 09:15PM PT-12.1 PTT-21.7* INR(PT)-1.0 [**2180-7-26**] 09:15PM PLT COUNT-336 CT SINUS/MANDIBLE/MAXILLOFACIA Reason: frax [**Hospital 93**] MEDICAL CONDITION: 78 year old woman with ped vs MVA REASON FOR THIS EXAMINATION: frax CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 78-year-old pedestrian struck by auto. COMPARISON: Non-contrast head CT performed concurrently. TECHNIQUE: Contiguous axial images were obtained through the facial bones without intravenous contrast. Multiplanar reconstructions were performed. FINDINGS: There are minimally displaced bilateral nasal bone fractures. There is also a nondisplaced fracture through the lateral wall of the right maxillary sinus. A high-density fluid level in the right maxillary sinus presumably represents hemorrhage. An incompletely imaged fracture through the anterior of C1 is characterized fully on the accompanying cervical spine CT. The globes appear intact and no retrobulbar hematoma or edema is present. There is moderate soft tissue swelling and hyperdense foci in the soft tissues over the forehead, which may represent retained foreign bodies. Evaluation of the mandible was limited due to streak artifact from dental hardware. The TMJs appear well seated. IMPRESSION: 1. Minimally displaced fractures of the nasal bones and lateral wall of the right maxillary sinus. 2. C1 vertebral bfracture. See accompanying CT cervical spine for further details. 3. Frontal soft tissue swelling with imbedded hyperdense foci, which may represent retained foreign bodies. Please correlate clinically. ELBOW (AP, LAT & OBLIQUE) RIGH; SHOULDER (AP, NEUTRAL & AXILLA Reason: frax [**Hospital 93**] MEDICAL CONDITION: 78 year old woman with ped vs MVA REASON FOR THIS EXAMINATION: frax RIGHT UPPER EXTREMITY RADIOGRAPHIC SERIES. COMPARISON: None. CLINICAL HISTORY: 78-year-old pedestrian struck by car, rule out fracture. FINDINGS: Nine views of the right upper extremity are obtained. RIGHT SHOULDER: A fracture is noted through the right humeral neck which is nondisplaced but appears impacted. Findings are best appreciated on axillary view. The AC joint is unremarkable. RIGHT ELBOW: The right elbow appears unremarkable. There is no evidence of dislocation or fracture in the osseous structures. There is no evidence of elbow joint effusion or soft tissue swelling. RIGHT WRIST: The right wrist appears intact. A well-corticated ossific density is seen adjacent to the ulnar styloid, which may represent sequelae of prior trauma. The carpal alignment appears intact. Mild degenerative changes are noted at the basal joint of the right hand. Osteopenia is noted. IMPRESSION: 1. Right humeral neck fracture, impacted. 2. No acute injury present in the right elbow or right wrist. CT C-SPINE W/O CONTRAST Reason: cspine [**Hospital 93**] MEDICAL CONDITION: 78 year old woman with ped vs MVA REASON FOR THIS EXAMINATION: cspine CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 78-year-old struck by automobile. COMPARISON: Non-contrast head CT performed concurrently. TECHNIQUE: MDCT axial images through the cervical spine without intravenous contrast. Multiplanar reconstructions were performed. FINDINGS: The skull base through the T3 vertebral body are well visualized on the lateral view. Assessment of fine detail is limited due to severe osteopenia. There are nondisplaced fractures through the anterior and posterior arches of C1. Fracture lines extend to the left lateral mass and appear to extend to the left transverse foramen. No other fractures are identified. No prevertebral or paraspinal soft tissue abnormality is seen. There is extensive multilevel degenerative change with exaggeration of the cervical lordosis, loss of disc space height, facet hypertrophy and marginal osteophytosis. The atlanto-occipital and atlantoaxial relationships are maintained. There is mild right foraminal stenosis at C3-4 secondary to facet hypertrophy and uncovertebral spurring. There is no significant osseous encroachment upon the spinal canal. The lung apices demonstrate calcified granulomas consistent with prior granulomatous infection. An air-fluid level is present in the right maxillary sinus. Visualized mastoid air cells are well aerated. IMPRESSION: 1. Non-displaced C1 fracture with apparent fracture lines through the left transverse foramen. Further characterization with MRA would be useful for evaluation of the traversing vertebral artery. 2. Multilevel degenerative change with features as described above. ATTENDING REVIEW: I don't see definite fractures in the transverse process or posterior arch. However, the anterior arch cleft is new since previous neck CT of [**2179-5-26**] and is consistent with acute fracture. CT HEAD W/O CONTRAST Reason: ICH [**Hospital 93**] MEDICAL CONDITION: 78 year old woman with ped vs MVA REASON FOR THIS EXAMINATION: ICH CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 78-year-old pedestrian versus MVA. COMPARISONS: None. TECHNIQUE: Contiguous axial images were obtained through the brain. No intravenous contrast was administered. FINDINGS: There is no evidence of hemorrhage, mass effect, masses, shift of normally midline structures or hydrocephalus. A crescent upper density anterior to the left frontal lobe presumably represents volume averaging from the adjacent osseous inner table. The ventricles and sulci are normal in caliber and configuration. [**Doctor Last Name **]-white matter differentiation is preserved. Bone algorithm windows demonstrate a non-displaced fracture through the lateral right maxillary sinus wall. There are minimally displaced nasal bone fractures, incompletely imaged. A fluid level, likely hemorrhage, is seen in the right maxillary sinus. Several ethmoid air cells are opacified. A fracture through the anterior C1 arch is more fully assessed on the accompanying cervical spine study. IMPRESSION: 1. No intracranial hemorrhage or mass effect. 2. Non-displaced fracture of the lateral right maxillary sinus and minimally displaced nasal bone fractures. Further characterization with CT of the facial bones is recommended. 3. Incompletely imaged C1 fracture, please refer to the CT cervical spine, (clip [**Clip Number (Radiology) 106130**]) for additional details. Brief Hospital Course: She was admitted to the Trauma Service. Her injuries were nonoperative. Her cervical spine injury was evaluated by Orthopedic Spine; clinically she had no posterior neck tenderness. She underwent an MRI of her cervical spine which revealed that the fracture was a new vs old injury. It was recommended that she remain in a hard collar by Dr. [**Last Name (STitle) 1352**], Orthopedic Spine Surgery, for at least 8 weeks. She will return in [**1-23**] weeks for repeat imaging. She was started on bone prophylaxis with Calcium and Vitamin D. OMFS was consulted because of her facial fractures; these were nonoperative as well. It is being recommended that she maintain a full liquid/soft diet for the next 2 weeks and will follow up Dr. [**First Name (STitle) **] at that time. Any chewing motion should be avoided until follow up. Orthopedics was consulted for the right distal humerus fracture; this did not require surgical intervention. She is to wear a sling for comfort and remain non weight bearing until follow up in 2 weeks with Dr. [**Last Name (STitle) **]. Physical and Occupational therapy were consulted and have recommended short rehab stay. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for HR <60; SBP<110. 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO at bedtime. 8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 15. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: s/p Pedestrian struck by auto C1 [**Location (un) 5621**] type fracture Left mandible fracture Right maxillary sinus fracture (non-displaced) Bilateral nasal bone fractures (minimally displaced) Right proximal humerus fracture Discharge Condition: Good Discharge Instructions: It is being recommended by Spine Surgery that you continue to wear the cervical collar for the next 2 weeks until follow up. DO NOT bear any weight on your right arm because of your fracture. Wear the sling for comfort. Avoid foods that you have to chew. You must maintain a full liquid/soft diet. Followup Instructions: Follow up with Dr. [**First Name (STitle) **] in [**Hospital 40530**] Clinic on Friday [**8-4**], call [**Telephone/Fax (1) 274**] for an appointment time. Follow up with Dr. [**Last Name (STitle) **], Orthopedics, in 2 weeks. Call [**Telephone/Fax (1) 1228**] for an appointment. Follow up with Dr. [**Last Name (STitle) 1352**], Orthopedic Spine Surgery in 2 weeks, call [**Telephone/Fax (1) 1228**] for an appointment. Completed by:[**2180-7-31**]

[ "E812.0", "V45.81", "802.0", "414.00", "812.01", "401.9", "801.02", "805.01", "802.20" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10023, 10093

7428, 8588

308, 315

10364, 10371

754, 1264

10720, 11175

718, 735

8611, 10000

5944, 5978

10114, 10343

10395, 10697

239, 270

6007, 7405

343, 617

639, 668

684, 702

50,824

140,020

42415

Discharge summary

report

Admission Date: [**2190-2-23**] Discharge Date: [**2190-2-25**] Date of Birth: [**2127-1-30**] Sex: F Service: MEDICINE Allergies: Cephalexin / Cephalexin Attending:[**First Name3 (LF) 2297**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 63yo F with h/o smoking, pulmonary HTN diagnosed in [**2189**], transfered from [**Hospital1 18**] [**Location (un) 620**] for futher workup of pulmonary HTN including R heart catheterization. Pt states she was in her usual state of health when polycythemia was noted on her labs at annual physical exam in [**Month (only) 547**] or [**2189-5-24**], leading to a workup in which she was diagnosed with pulmonary HTN. She had noted some dyspnea on exertion prior to that time but was generally active and not bothered by her symptoms, which she associated with her past smoking history. PFTs showed moderate obstructive airway disease with severely reduced DLCO; CT showed apical bullous emphysema as well as basilar pulmonary fibrosis. In [**8-/2189**], she reports starting home O2 that she has required constantly since then. She reports starting Spiriva and Symbicort around that time. Her condition worsened subacutely in [**12/2189**], when she was found to have low blood pressure at an outpatient visit and admitted to the hospital for a week. She was readmitted about 3 weeks ago with 3-4 days of worsening dyspnea and some lethargy. On admission, she had a WBC of 15 on prednisone and was on 3L O2 with a sat of 76%. Her sat improved on CPAP, although it was difficult for her to tolerate. She was treated for a possible PNA with antibiotics levofloxacin/vancomycin (completed 14 day course) and also received solumedrol. Her sats have usually been 91-93% on a 50% venti mask, although she desats with anxiety. She was treated with an insulin sliding scale for new hyperglycemia in the setting of steroids. She received diltiazem during the admission but it was held [**2-23**] for SBP 80s which responded to a 500 cc bolus. Pt had an episode of urinary retention, with placement of a foley 3 days ago. Pt reports sore throat, nasal congestion, and cough productive of sputum that was initially dark brown (weeks ago) and is now yellowish. She denies pleuritic chest pain, fevers/chills, and palpitations although she notes occasional panic attacks. +constipation. Past Medical History: hyperglycemia--first noted on current admission in the setting of steroids, pt has been on insulin sliding scale as inpt Pulmonary HTN as above, R sided heart failure. Social History: Lives with daughter in [**Name (NI) 1411**], used to work in home decor until economy crashed. Was able to walk comfortably, climb stairs prior to diagnosis. Smoked [**1-26**] pack per day for "many" years, quit smoking 2.5 years ago, denies history of EtOH and illicit drugs. Family History: Both parents died of MI, brother has a defibrilator. One uncle had pulmonary disease with a history of asbestos exposure. Physical Exam: ADMISSION EXAM Vitals: T 95.7 (was 99.6 at OSH today) HR 115 BP 92/65 (84-97 systolic) RR 30 sat 92% on shovel mask. Gen: Lying in bed, alert, interactive, increased work of breathing HEENT: +oral thrush Neck: JVP at angle of jaw with bed at 30 degrees Lungs: Crackles at bases b/l Cardiac: RV heave, rapid rate, regular, harsh systolic murmur loudest at LUSB Abd: +BS, soft, nondistended, mildly tender to deep palpation in LUQ and RUQ, no hepatosplenomegaly Ext: 2+ pedal pulses, 1+ pitting edema in LE Skin: Superficial skin breakdown on buttocks bilaterally Neuro: PERRL, alert, oriented DISCHARGE EXAM [patient expired] Pertinent Results: [**2190-2-24**] 02:20AM BLOOD WBC-17.5* RBC-5.04 Hgb-15.8 Hct-46.8 MCV-93 MCH-31.3 MCHC-33.7 RDW-16.1* Plt Ct-133* [**2190-2-24**] 02:20AM BLOOD Neuts-81* Bands-2 Lymphs-6* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-2* [**2190-2-24**] 02:20AM BLOOD PT-13.2* PTT-23.3* INR(PT)-1.2* [**2190-2-24**] 02:20AM BLOOD Glucose-102* UreaN-33* Creat-0.7 Na-137 K-4.4 Cl-108 HCO3-19* AnGap-14 [**2190-2-24**] 02:20AM BLOOD ALT-117* AST-67* AlkPhos-56 TotBili-1.6* [**2190-2-24**] 12:27PM BLOOD Calcium-9.3 Phos-5.2* Mg-2.7* [**2190-2-24**] 02:20AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2190-2-24**] 02:20AM BLOOD [**Doctor First Name **]-NEGATIVE [**2190-2-24**] 02:20AM BLOOD TSH-1.8 [**2190-2-24**] 02:20AM BLOOD HIV Ab-NEGATIVE [**2190-2-24**] 02:20AM BLOOD HCV Ab-NEGATIVE CXR [**2190-2-24**] Small contiguous thick septated radiolucency seen at the bases consistent with pulmonary fibrosis. Larger pattern of radiolucency is seen in the upper lung fields consistent with emphysema. Pulmonary vasculature and interstitium is consistent with heart failure. Prominence of pulmonary artery is consistent with pulmonary hypertension. Brief Hospital Course: Ms. [**Known lastname **] is a 63y/o lady with pulmonary hypertension of unknown etiology, with subacute worsening of her dyspnea, who was transfered after 3 week admission to [**Hospital1 18**] [**Location (un) 620**] for further workup of pulmonary HTN. She had increasing O2 requirements and complained of worsening dyspnea throughout her stay. She was uncomfortable lying flat, and did not undergo right-heart catheterization. She eventually required 100% NRB, and then non-invasive ventilation with PEEP and 100% FiO2 in order to maintain oxygenation. Her labs and ABGs suggested respiratory fatigue and systemic ischemia (rising lactate; antibiotics were started in case this represented sepsis). A family meeting was held with the patient and her family; she had a significant risk of mortality from CPR and intubation, and might possibly never be able to be weaned from a ventilator in the setting of her bad emphysema, pulmonary fibrosis, and pulmonary hypertension. Patient and family decided to decline intubation and her management was shifted towards comfort-focused care. She expired with family at the bedside. Medications on Admission: Meds on Transfer: Spiriva 1 cap daily, DuoNeb PRN, prednisone 50 mg daily (starting [**2-23**]), ASA 81mg, omeprazole 20 mg PO daily, lorazepam 0.5 mg [**Hospital1 **], lantus 18 units at night, diltiazem 60 mg PO q6h Discharge Medications: [patient expired] Discharge Disposition: Expired Discharge Diagnosis: [patient expired] Discharge Condition: [patient expired] Discharge Instructions: [patient expired] Followup Instructions: [patient expired]

[ "249.00", "416.8", "112.0", "428.0", "V66.7", "V15.82", "V46.2", "788.20", "515", "599.70", "238.4", "492.0", "E932.0" ]

icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

6298, 6307

4854, 5988

292, 298

6368, 6387

3687, 4831

6453, 6473

2903, 3026

6256, 6275

6328, 6347

6014, 6014

6411, 6430

3041, 3668

245, 254

326, 2401

2423, 2592

2609, 2887

6032, 6233

61,568

189,476

40770

Discharge summary

report

Admission Date: [**2167-3-30**] Discharge Date: [**2167-4-4**] Date of Birth: [**2134-2-24**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: "Headache" Major Surgical or Invasive Procedure: R craniotomy for SDH [**2167-4-2**] Dr. [**First Name (STitle) **] History of Present Illness: This is a 33 year old female who stood up suddenly from bed on [**2-28**] and became dizzy, fell striking her head, and had loss of consciousness. She attributes her fall to not feeling well for several days prior and possibly being dehydrated. Since that time she has had persistent headache that is generally a level [**5-21**] on a [**12-23**] pain scale. She states that it is worse in the early morning and after a full day of work reaching to a level of 10 on a [**12-23**] pain scale. The patient states that she is a pharmacist and after working all day, she is dizzy and has difficulty with concentration. In addition she has experienced intermittent periods of decreased hearing. The patient has been followed by her PCP for these headaches and had been recommended to have a Head CT prior to an elective surgery at [**Location (un) 745**] [**Hospital 18650**] Hospital for lower body lift later this week. A Head CT was performed today which was consistent with a subacute on chronic SDH and that patient was brought here for further evaluation nd treatment. The patient denies weakness, numbness, tingling sensation, bowel or bladder deficit, vision changes Past Medical History: HTN, gastric bypass [**2164**], cholecystectomy [**2157**] Social History: works as a pharmacist, denies ETOH/illicit drug uses Family History: non contributory Physical Exam: O: T:98.8 BP: 138/83 HR:68 R: 16 O2Sats:100% Gen: NO otorrhea, NO rhinorrhea, NO raccoons eyes or Battle sign comfortable, NAD. HEENT: Pupils: 4-3mm EOMs:intact Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-14**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 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 [**4-18**] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements On Discharge: non focal. sutures c/d/i Pertinent Results: CT HEAD W/O CONTRAST [**2167-3-31**] Bilateral subdural hematomas on the right greater than the left with no change in size or evidence of acute bleeding from [**2167-3-30**]. There is 5-mm of leftward midline shift, which is stable. [**4-2**] CXR: FINDINGS: No previous images. The heart is normal in size and lungs are clear without evidence of vascular congestion or pleural effusion. [**4-2**] CT Head- IMPRESSION: 1. Expected postoperative appearance status post right craniotomy and evacuation of large right subdural hematoma from [**2167-3-31**] with no evidence of acute bleeding and slightly decreased leftward midline shift from the prior study. 2. Stable small left subdural hematoma. Brief Hospital Course: This is a 33 year old woman presents s/p fall after standing with dizziness striking her head a month ago. Head CT reveals a right SDH with minimal midline shift. She was admitted to the floor for further neurosurgical monitoring and evaluation. On [**3-31**], repeat head CT was stable and her PO dilaudid was added to her pain medication regimen with success. She was consented for OR procedure and pre-oped. On [**4-1**], patient remains stable and awaits surgical procedure. She proceeded to the OR on [**4-2**] for a right craniotomy. The patient tolerated the procedure well and was extubated and taken to the SICU. Post-op CT head was without hemorrhage and she was neurologically intact. On [**4-3**] she was neurologically stable and cleared for transfer to the floor. She was tolerating a PO diet and pain was controlled. After remaining stable overnight she was cleared for discharge home on [**4-4**]. She was ambulating independently and voiding without difficulty. Medications on Admission: Toprol XL 100 mg qd, cozaar 50 mg qd Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 3. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. Fioricet 50-325-40 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for headache: use to wean off dilaudid. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: R SDH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures have been removed. ?????? 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. ?????? You have 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 [**6-23**] days(from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Physician Assistant or [**Name9 (PRE) **] Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.[**First Name (STitle) **] to be seen in _4_weeks. ?????? You will need a CT scan of the brain without contrast. Completed by:[**2167-4-4**]

[ "E885.9", "852.22", "401.9", "112.1", "V45.86" ]

icd9cm

[ [ [] ] ]

[ "01.31" ]

icd9pcs

[ [ [] ] ]

5495, 5501

3835, 4815

317, 385

5550, 5550

3111, 3812

7235, 7901

1760, 1779

4903, 5472

5522, 5529

4841, 4880

5700, 7212

1794, 2021

3066, 3092

266, 279

413, 1590

2314, 3052

5565, 5676

1612, 1673

1689, 1744

26,872

161,391

2519

Discharge summary

report

Admission Date: [**2185-7-22**] Discharge Date: [**2185-7-29**] Date of Birth: [**2131-11-6**] Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin / Lipitor / Glucophage Attending:[**First Name3 (LF) 783**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: Upper endoscopy- showed 3 AVMs (2 in stomach, 1 in duodenum) History of Present Illness: 53 yo F on life-long anticaogulation with coumadin and plavix for massive LLE DVT s/p thrombectomy, stenting, and IVC filter placement in [**2-/2184**] admitted with bloody (not black) stools and progressive weakness for two days. She has had nine upper endoscopies, two small bowel enteroscopies, five colonoscopies and one sigmoidoscopy over the last six years. Multiple AVMs have been found and treated in her duodenum and jejunum. Her most recent scopes were last [**Month (only) 547**], when 2 angioectasias in the stomach, one in the jejunum, one in the descending [**Month (only) 499**] were found. Her initial Hct was 14.8 which is the lowest it has ever been, baseline iron def anemia is in mid 20s. . In the ED, initial vs were: T97.2 P74 BP105/54 R15 O2 sat 97ra. Patient was given 10 units of vitamin K IV for an INR of 5.1. NG tube was not placed for lavage over concern for traumatic insertion with her high INR. One unit off FFP was given in the ED and the first unit of blood was started in transit to the MICU. CXR notable for perihilar opacities improved from prior CXR one month ago (CT in the interim showed bronchiectasis and atelectasis. Pt c/o chest pain starting in the ED, substernal and worse with cough/movement. No hx of of exertional or unstable angina. No known CAD despite multiple risk factors. EKG not significantly changed in the ED or in the MICU. First set of enzymes negative. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath currently (did have DOE last two days). Denied chest pain or tightness, palpitations. Denied nausea, vomiting, constipation or abdominal pain. No recent change in bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: -GI Hx as of [**7-/2185**]: nine upper endoscopies, two small bowel enteroscopies, five colonoscopies and one sigmoidoscopy over the last six years. Multiple AVMs have been found and treated in her duodenum and jejunum. Her most recent scopes were last [**Month (only) 547**], when 2 angioectasias in the stomach, one in the jejunum, one in the descending [**Month (only) 499**] were found. -Poorly controlled DMII -hypertension -asthma -anemia - profound iron deficiency [**2-21**] gastric and duodenal AV malformations as above, transfusion dependent, Hct baseline around 22-29 -depression -migraines -obesity -chronic abdominal pain -delayed gastric emptying -diverticulosis -extensive DVT [**2-27**] s/p thrombectomy, IVC filter placement, common and external iliac vein stenting on coumadin/plavix -OSA, on home BiPAP vs CPAP -? Meningioma (lesion identified by CT on [**6-27**] in left perimesencephalic region, being followed) -S/p appendectomy -S/p bilateral oophorectomy and hysterectomy -gout Social History: Was unable to come to the hospital when she first noted blood in her stool two days ago b/c her son is hospitalized at [**Hospital1 2177**] and she is currently primary caretaker for her grandson. Daughter aware she is in the hospital. She is currently out of work, but formerly worked as a special needs counsellor. She does not drink alcohol. She quit smoking one year ago, but had a history of 1 pack per week for 40 years. She has no history of any drug use. Family History: Mother and father both died of [**Hospital1 499**] CA, and she also has a grandmother and uncle with [**Name2 (NI) 499**] CA. No hx of hypercoagulability or AVMS. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2185-7-22**] 02:00PM HGB-4.9* calcHCT-15 LACTATE-3.5* K+-5.3 [**2185-7-22**] 02:19PM WBC-5.4 RBC-1.82*# HGB-4.1*# HCT-14.8*# MCV-82# MCH-22.6*# MCHC-27.7* RDW-20.6* NEUTS-78.1* LYMPHS-16.3* MONOS-4.6 EOS-0.8 BASOS-0.2 HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TARGET-1+ TEARDROP-OCCASIONAL PLT COUNT-493* PT-48.1* PTT-30.2 INR(PT)-5.2* ALT(SGPT)-8 AST(SGOT)-25 CK(CPK)-65 ALK PHOS-55 TOT BILI-0.2 ALBUMIN-3.4 LIPASE-43 GLUCOSE-367* UREA N-19 CREAT-1.0 SODIUM-133 POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-12 [**2185-7-22**] 02:24PM HGB-4.5* calcHCT-14 [**2185-7-22**] 02:19PM cTropnT-0.02* CK(CPK)-65 [**2185-7-22**] 08:54PM CK-MB-NotDone cTropnT-0.03* CK(CPK)-61 [**2185-7-23**] 04:13AM CK-MB-NotDone cTropnT-0.02* CK(CPK)-43 [**2185-7-23**] 04:13AM BLOOD WBC-7.6 RBC-3.22* Hgb-8.6*# Hct-26.6* MCV-83 MCH-26.6* MCHC-32.2 RDW-18.2* Plt Ct-383 [**2185-7-23**] 07:11AM BLOOD WBC-7.8 RBC-3.15* Hgb-8.3* Hct-25.9* MCV-82 MCH-26.4* MCHC-32.1 RDW-19.2* Plt Ct-394 [**2185-7-23**] 01:30PM BLOOD Hct-26.9* [**2185-7-23**] 09:20PM BLOOD Hct-27.5* [**2185-7-24**] 06:30AM BLOOD WBC-7.6 RBC-3.38* Hgb-8.9* Hct-28.3* MCV-84 MCH-26.3* MCHC-31.4 RDW-20.3* Plt Ct-391 [**2185-7-25**] 07:05AM BLOOD WBC-6.8 RBC-3.31* Hgb-9.0* Hct-28.6* MCV-86 MCH-27.1 MCHC-31.4 RDW-19.2* Plt Ct-339 [**2185-7-26**] 06:00AM BLOOD WBC-6.1 RBC-3.25* Hgb-8.6* Hct-28.2* MCV-87 MCH-26.3* MCHC-30.3* RDW-19.5* Plt Ct-318 [**2185-7-27**] 07:00AM BLOOD WBC-6.5 RBC-3.04* Hgb-8.2* Hct-26.4* MCV-87 MCH-26.9* MCHC-31.0 RDW-18.8* Plt Ct-308 [**2185-7-27**] 03:00PM BLOOD Hct-25.3* [**2185-7-28**] 06:00AM BLOOD WBC-6.3 RBC-2.84* Hgb-7.4* Hct-24.1* MCV-85 MCH-26.0* MCHC-30.6* RDW-19.6* Plt Ct-297 [**2185-7-28**] 03:15PM BLOOD Hct-24.5* [**2185-7-29**] 11:25AM BLOOD Hct-25.0* [**2185-7-23**] 04:13AM BLOOD PT-15.0* PTT-21.0* INR(PT)-1.3* [**2185-7-23**] 04:13AM BLOOD Plt Ct-383 [**2185-7-23**] 07:11AM BLOOD PT-14.4* PTT-21.9* INR(PT)-1.3* [**2185-7-23**] 07:11AM BLOOD Plt Ct-394 [**2185-7-24**] 06:30AM BLOOD PT-12.8 PTT-22.7 INR(PT)-1.1 [**2185-7-24**] 06:30AM BLOOD Plt Ct-391 [**2185-7-25**] 07:05AM BLOOD PT-12.4 PTT-22.9 INR(PT)-1.0 [**2185-7-25**] 07:05AM BLOOD Plt Ct-339 [**2185-7-26**] 06:00AM BLOOD PT-11.9 PTT-22.9 INR(PT)-1.0 [**2185-7-26**] 09:00PM BLOOD PTT-74.7* [**2185-7-27**] 07:00AM BLOOD PT-14.0* PTT-82.9* INR(PT)-1.2* [**2185-7-27**] 07:00AM BLOOD Plt Ct-308 [**2185-7-27**] 03:00PM BLOOD PTT-60.7* [**2185-7-27**] 09:00PM BLOOD PTT-54.7* [**2185-7-28**] 06:00AM BLOOD PT-13.4 PTT-56.4* INR(PT)-1.1 [**2185-7-28**] 06:00AM BLOOD Plt Ct-297 [**2185-7-28**] 07:20PM BLOOD PTT-62.6* [**2185-7-28**] 09:45PM BLOOD PTT-73.0* [**2185-7-29**] 11:25AM BLOOD PT-13.3 PTT-52.7* INR(PT)-1.1 [**2185-7-23**] 04:13AM BLOOD Glucose-112* UreaN-14 Creat-0.8 Na-142 K-4.1 Cl-109* HCO3-25 AnGap-12 [**2185-7-24**] 06:30AM BLOOD Glucose-210* UreaN-10 Creat-0.9 Na-139 K-4.3 Cl-104 HCO3-26 AnGap-13 [**2185-7-25**] 07:05AM BLOOD Glucose-150* UreaN-12 Creat-0.9 Na-139 K-4.4 Cl-103 HCO3-27 AnGap-13 [**2185-7-26**] 06:00AM BLOOD Glucose-195* UreaN-9 Creat-0.9 Na-138 K-4.6 Cl-101 HCO3-30 AnGap-12 [**2185-7-27**] 07:00AM BLOOD Glucose-192* UreaN-14 Creat-0.8 Na-137 K-5.2* Cl-100 HCO3-31 AnGap-11 [**2185-7-27**] 03:00PM BLOOD K-4.7 [**2185-7-28**] 06:00AM BLOOD Glucose-160* UreaN-15 Creat-0.8 Na-137 K-4.9 Cl-98 HCO3-29 AnGap-15 [**2185-7-29**] 07:20AM BLOOD Glucose-125* UreaN-13 Creat-0.7 Na-134 K-4.6 Cl-96 HCO3-27 AnGap-16 [**2185-7-23**] 04:13AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.1 [**2185-7-24**] 06:30AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.1 [**2185-7-25**] 07:05AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1 [**2185-7-28**] 06:00AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.9 Upper Endoscopy- 3 AVMs (2 in stomach, 1 in duodenum) Brief Hospital Course: # GI Bleed - On presentation, the patient reported that she had been having bloody non-melanotic stools over two days. This was most suggestive of a slow bleed in the lower GI tract; however, an upper GI bleed was not excluded because an NG tube was not placed. Her hematocrit at presentation was 14.8. She was initially given 1 unit of FFP and 10 units of Vitamin K to reverse her anticoagulation. She was also given blood and transferred to the MICU. In the setting of a GI bleed, the patient's coumadin and plavix were held. Her home metoprolol, nitrate, and lisinopril were also held in the setting of normotension with a significant bleed. Serial hematocrits were followed in the patient. After being given a total of 5 units of blood, her hematocrit had risen to 26.6. On the second day of her admission, the patient had not had any more episodes of bloody stools. Additionally, on the second day of her admission, the patient underwent EGD, where 3 AVM's were found. At this point, the patient was transferred to the floor. Once on the floor the patient did not have a bowel movement until a more advanced bowel regimen was implemented. She was given lactulose and began having BMs- each was black, which was expected given lack of BM's in prior days. No bright red blood. No signs of new GI bleed despite being on heparin drip. Upon discharge, patient had no new signs or symptoms of GI bleed. # Hx LLE DVT - On admission, the patient was given FFP and Vitamin K to reverse her anticoagulation. She was also continued on her home medications for the chronic pain in her left leg. However, it was unclear what the long-term plan was for the patient's anticoagulation. It was determined that the patient's various physicians should discuss her situation and come to a concensus regarding her anticoagulation. Once transferred to floor, pts hematocrit initially trended down once on the floor (28.3 to 24.1). Again, there were no signs of a new GI bleed. Upon discharge patient's Hct was >25. She was seen and evaluated by [**Month/Day/Year 1106**] surgery, heme/onc and GI to determine if she should continue her lifelong anti-coagulation. Her coumadin and plavix had been discontinued since admission. Her team of physicians determined that she should continue her life-long anticoagulation given the severity of her DVT history. Her new goal INR is to be between 1.6-2.5. She was restarted on coumadin 5mg daily in the hospital. In addition, we placed her on a heparin drip on [**7-26**] to monitor for any new GI bleeds in addition to transitioning to PO coumadin as an outpatient. PTT"s monitored closely. Patient did not have any new GI bleeds while in hospital. Remained hemodynamically stable. Upon discharge, she was continued on 5mg coumadin daily. Plavix remained discontinued. Patient was counseled on importance of following-up regularly with the her clinic to get her INR checks. She understood and agreed to do so. # Chest Pain - The patient did present with some chest paint. There was a low suspicion for ACS, but it was thought that the pain could represent demand ischemia in setting of a low hematocrit. The patient ruled out for ACS with three sets of cardiac enzymes. # DM2 - The patient was placed on Lantus and sliding scale insulin. Her blood sugars were monitored throughout her admission. She continued to have high FSBS's while on the floor so her full home regimen of insulin was resumed (lantus 75 with breakfast and at bedtime). Sugars trended down from upper 190s/low 200s down to 125 on discharge. # Hx of Diastolic Dysfunction - At home, the patient intermittently uses Lasix for management of fluid overload. On admission, the plan was to use Lasix if necessary for any volume overload she experienced after receiving blood. However, as of her transfer out of the MICU, the patient had not required any Lasix. Did not require any while on the floor either. # Hypoxia- Patient continued to require her CPAP (uses at home also) while in the hospital. She generally did not require any O2 during the day except for a transient period where she occaisionally required it. We considered CTA given patients clotting history if symptoms did not resolve. It resolved itself and she did not need any supplemental O2 during her last three days in the hospital. Was able to ambulate with PT throughout the halls without experiencing any shortness of breath/dyspnea on exertion at the end of her hospitalization. Upon discharge, patient was satting well on RA with no SOB/DOE. # HTN- Patient's had some elevated blood pressures while in the hospital. Her home regimen was continued and she was placed on a clonidine patch .1mg for additional BP control (as well as pain control). It was continued on discharge. # Pain- Patient initially had some pain issues while on the floor. Was related to her post-phlebitic syndrome from her prior DVT. Chronic pain was consulted and recommended placing patient on a clonidine patch .1mg as well as lidocaine patches. In addition, she was started on cymbalta (trazadone was discontinued due to risk of NMS if given with cymbalta). The patient did not like the lidocaine patches so they were discontinued but the clonidine patch seemed to provide the patient some pain relief (as well as BP control) so it was continued on discharge. Patient is to follow-up with the pain clinic. Medications on Admission: ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs every 4-6 hours as needed ARTHRITIC/DIABETIC GEL SOCKS - use as directed daily BUTALBITAL-ACETAMINOPHEN-CAFF [FIORICET] - 50 mg-325 mg-40 mg Tablet - 1 (One) Tablet(s) by mouth every six (6) hours as needed for headache CLOPIDOGREL - 75 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) CPAP 16 WITH 2 LITERS OXYGEN - (Dose adjustment - no new Rx)- for severe sleep apnea FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 2 sprays in each nostril twice a day FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs twice a day FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day if gain 2 pounds or more in one day. If you gain over 4 pounds in a day call the health center GABAPENTIN - 800 mg Tablet - 1 Tablet(s) by mouth three times a day HYDROCORTISONE ACETATE [ANUSOL-HC] - 25 mg Suppository - 1 per rectum rectally once per day after BM as needed INSULIN GLARGINE [LANTUS] - 100 unit/mL Cartridge - 75 units at noon and at bedtime sq daily INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - according to sliding scale administer twice a day - No Substitution INSULIN SYRINGES - ULTRA COMFORT 28 - - USE AS DIRECTED ISOSORBIDE MONONITRATE - 30 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth four times a day before meals and at bedtime METOPROLOL TARTRATE - 100 mg Tablet - take one Tablet by mouth twice a day OLOPATADINE [PATANOL] - 0.1 % Drops - 1 gtt OU twice a day OXYCODONE [OXYCONTIN] - 15 mg Tablet Sustained Release 12 hr - 1 Tablet(s) by mouth twice a day OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - 1 to 2 Tablet(s) by mouth q 6 h PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime UREA [CARMOL 40] - 40 % Cream - apply to both feet twice a day as needed for thickened and dry skin WARFARIN [COUMADIN] - 5 mg Tablet - 1 [**1-21**] Tablet(s) by mouth on Mon, Tues, Wed, [**Month/Day (2) **], Sun. 1 tablet on Thurs and Sat. and as needed Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). Disp:*4 Patches* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for leg pain. 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 13. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)). 14. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). 15. Coumadin 5 mg Tablet Sig: Five (5) Tablet PO once a day. 16. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal [**Hospital1 **] (2 times a day). 17. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 18. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. 19. Lasix 20 mg Tablet Sig: One (1) Tablet PO qday:PRN as needed for gain 2lbs in one day: 1 Tablet(s) by mouth once a day if gain 2 pounds or more in one day. If you gain over 4 pounds in a day call the health center . 20. Hemorrhoidal-HC 25 mg Suppository Sig: One (1) supp Rectal daily PRN as needed for pain. 21. Insulin fixed and sliding scale Please continue your insulin glargine and humalog as you have been taking it at home 22. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 23. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. 24. CARMOL 40 40 % Cream Sig: One (1) app Topical PRN as needed for thickened and dry skin : apply to both feet twice a day as needed for thickened and dry skin . Discharge Disposition: Home Discharge Diagnosis: Primary: Upper gastrointestinal bleed Secondary: History of left leg DVT Hypertension Diabetes Mellitus Discharge Condition: Good. Vital signs stable. Discharge Instructions: You were admitted on [**2185-7-22**] for a two day history of blood in your stool. You were admitted to the ICU because some of your blood levels were low. To remedy this, you were given 5U of blood and your numbers normalized. Your coumadin was held while you were in the hospital. Once you were stable you were transferred to the floor for further care. While here you remained stable and had no new GI bleeds. Pain management, [**Date Range 1106**] surgery and hematology all came and evaluated you. Together we determined that you should be on an anti-coagulation therapy but at a lower dose than before, with an INR goal of 1.6-2.5. You were stable when you were discharged from the hospital The following changes were made: 1. Coumadin- 5mg by mouth daily 2. Clonidine patch- .1mg patch per week was added 3. We stopped your trazadone If you experience any new GI bleed, extreme nausea or vomiting, chest pain, profound shortness of breath, new onset severe leg pain, or any other medically concerning symptom, please contact your primary care physician or come to the emergency department Followup Instructions: Please follow-up with your [**Hospital 2786**] clinic on Monday ([**8-1**]) to monitor your INR level Please follow-up with the Pain [**Hospital 9085**] Clinic in [**1-21**] weeks ([**Telephone/Fax (1) 1652**]) Provider: [**Name (NI) **] [**Name (NI) 12853**], PT Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2185-8-2**] 2:30 Provider: [**Name10 (NameIs) **] MAMMOGRAM [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2185-8-9**] 10:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2185-9-9**] 9:00 [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2185-8-10**]

[ "428.30", "790.92", "250.00", "535.40", "428.0", "562.10", "327.23", "789.00", "311", "414.8", "346.90", "280.0", "493.20", "285.1", "338.29", "338.19", "V12.51", "401.9", "455.6", "459.10", "274.9", "278.01", "537.83" ]

icd9cm

[ [ [] ] ]

[ "99.07", "99.04", "45.13", "93.90" ]

icd9pcs

[ [ [] ] ]

18556, 18562

8208, 13608

313, 376

18733, 18762

4413, 8185

19918, 20692

3760, 3925

15891, 18533

18583, 18712

13634, 15868

18786, 19895

3940, 4394

1839, 2238

265, 275

404, 1820

2260, 3264

3280, 3744

32,477

184,358

33865+57876

Discharge summary

report+addendum

Admission Date: [**2125-4-27**] Discharge Date: [**2125-5-3**] Date of Birth: [**2053-7-4**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6075**] Chief Complaint: episodes of confusion Major Surgical or Invasive Procedure: CT/CTA head and neck; MRI History of Present Illness: HPI: 71yo RH F with no past history who was well until two days ago, when she began to have "episodes of confusion", by which her family means repetitive questions and stories and she became slow to answer questions. She usually is an avid complainer and this has not been the case the past two days; in fact, she has been apathetic to what has been happening, including the need to seek medical attention. She complained only of a headache yesterday and took aleve. Her husband became concerned today when her deficits persisted and she was brought to Addison-[**Doctor Last Name **]. In the past couple of days, the patient had continued to be able to perform her usual activities, baking and cleaning. No weakness or gait difficulty was noted. No other speech abnormality. No visual difficulties. When I asked her what was the matter and why she was here, she replied, "it's just one of those things". Told she had a bleed in her brain, she simply shrugged. She denied all deficits or complaints and was not concerned to be here ("maybe they wanted to get rid of me"). Head CT showed a bleed and the patient was loaded with dilantin 1g IV x 1 and transferred here. ROS: On review of systems, the pt denied recent fever or chills. No night sweats or recent weight loss or gain. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Denied rash. Past Medical History: none Social History: no tob/etoh/illicits. Part-time bookkeeper family is heavily involved with her care Family History: negative for stroke Physical Exam: VS 97.7 77 12 148/81 100% Gen 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 Lungs CTA bilaterally CV RRR, nl S1S2, no M/R/G noted Abd soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted Ext No C/C/E b/l Skin no rashes or lesions noted NEURO MS Awake, alert. Fully oriented. Unable to perform months of year backwards (D...N...O) or days of week (and perseverates). Counts 20->1 with urging. Speech fluent, with normal naming, [**Location (un) 1131**], comprehension and repetition. Normal prosody. There were no paraphasic errors. Able to follow both midline and appendicular commands. No apraxia. Neglects the left side of the cookie jar picture. No dysarthria. Unable to perform luria sequencing. Prefers to keep her eyes closed. CN CN I: not tested CN II: Visual fields were full to confrontation, no extinction. Pupils 3->2 b/l. Fundi clear b/l CN III, IV, VI: EOMI no nystagmus or diplopia CN V: intact to LT throughout CN VII: full facial symmetry and strength CN VIII: hearing intact to FR b/l CN IX, X: palate rises symmetrically CN [**Doctor First Name 81**]: shrug [**5-7**] and symmetric CN XII: tongue midline and agile Motor Normal bulk and tone. L pronator drift. L-sided asterixis. Motor impersistence. I cannot get her to cooperate with power testing fully; she is [**5-7**] at least in b/l triceps and deltoids. Withdraws all limbs equally and purposefully to noxious stimuli. Sensory intact to light touch, pinprick, vibration throughout; I cannot get a response to JPS. No extinction to double simultaneous stimulation. Reflexes Br [**Hospital1 **] Tri Pat Ach Toes L 2 2 2 2 2 down R 2 2 2 2 2 down Coordination Fine finger movements, rapid alternating movements, finger-to-nose, and heel-to-shin were all normal Gait can sit unassisted. Requires significant prodding to get her to stand, which she can do unassisted. Walks with perhaps some circumduction of the left leg. Pertinent Results: [**2125-5-3**] 06:10AM BLOOD WBC-11.3* RBC-4.51 Hgb-13.3 Hct-39.1 MCV-87 MCH-29.4 MCHC-33.9 RDW-12.6 Plt Ct-365 [**2125-4-27**] 03:40PM BLOOD WBC-9.1 RBC-4.53 Hgb-13.1 Hct-38.7 MCV-86 MCH-29.0 MCHC-34.0 RDW-12.3 Plt Ct-346 [**2125-4-27**] 03:40PM BLOOD Neuts-70.8* Lymphs-23.5 Monos-5.1 Eos-0.2 Baso-0.4 [**2125-4-28**] 05:00AM BLOOD PT-12.8 PTT-28.7 INR(PT)-1.1 [**2125-4-27**] 03:40PM BLOOD PT-12.5 PTT-26.1 INR(PT)-1.1 [**2125-5-3**] 06:10AM BLOOD Glucose-109* UreaN-15 Creat-0.6 Na-138 K-4.0 Cl-105 HCO3-23 AnGap-14 [**2125-4-27**] 03:40PM BLOOD Glucose-105 UreaN-25* Creat-0.7 Na-140 K-4.5 Cl-105 HCO3-24 AnGap-16 [**2125-4-29**] 06:50AM BLOOD ALT-34 AST-30 LD(LDH)-340* CK(CPK)-277* AlkPhos-64 TotBili-0.6 [**2125-5-2**] 06:05AM BLOOD CK(CPK)-213* [**2125-4-27**] 03:40PM BLOOD CK(CPK)-1074* [**2125-5-2**] 06:05AM BLOOD CK-MB-6 cTropnT-0.03* [**2125-4-30**] 04:30PM BLOOD CK-MB-6 cTropnT-0.03* [**2125-4-29**] 06:50AM BLOOD CK-MB-6 cTropnT-0.02* [**2125-4-29**] 06:05AM BLOOD CK-MB-7 cTropnT-0.02* [**2125-4-28**] 05:00AM BLOOD CK-MB-8 cTropnT-<0.01 [**2125-5-3**] 06:10AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.1 [**2125-4-27**] 03:40PM BLOOD Calcium-9.9 Phos-3.7 Mg-2.1 [**2125-5-2**] 09:44AM BLOOD %HbA1c-4.9 [**2125-4-30**] 04:30PM BLOOD TSH-2.7 [**2125-4-30**] 05:17PM URINE Blood-LG Nitrite-POS Protein-30 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-1 pH-6.5 Leuks-MOD [**2125-4-30**] 05:17PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.024 [**2125-4-30**] 05:17PM URINE RBC->50 WBC->50 Bacteri-MANY Yeast-NONE Epi-0 ---- [**2125-4-30**] 5:17 pm URINE Source: Catheter. **FINAL REPORT [**2125-5-2**]** URINE CULTURE (Final [**2125-5-2**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN---------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S -------- ECG ([**2125-4-27**]): Sinus rhythm. Left atrial abnormality. Non-specific inferior ST-T wave changes. No previous tracing available for comparison ---- CT head ([**2125-4-27**]): IMPRESSION: Right frontal intraparenchymal hemorrhage with mild surrounding edema and 6-cm leftward midline shift. Given history, this likely represents hemorrhagic conversion of a prior infarct. ---- CXR ([**2125-4-27**]): IMPRESSION: No acute cardiopulmonary process. ---- CT head ([**2125-4-27**]): IMPRESSION: Unchanged appearance of right frontal intraparenchymal hemorrhage and mild regional mass effect and 6 mm leftward subfalcine herniation. --- MR head ([**2125-4-29**]): CONCLUSION: Right frontal hematoma again identified without a definite etiology revealed by this study. However, there are scattered cortical infarctions suggesting embolic disease. There is no abnormal enhancement. Differential included hemmorhagic conversion of infarct with embolic infarctions versus amyloid disease with hemmorhage and superimposed embolic infarctions. ---- MR head - limited study ([**2125-4-30**]): IMPRESSION: No significant change compared to one day prior. Stable right frontal hematoma and scattered cortical infarctions. The differential again includes embolic infarctions versus amyloid disease. --- ECHO ([**2125-5-1**]): The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is moderate thickening of the mitral valve chordae. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. ---- CTA ([**2125-5-2**]): IMPRESSION: 1. Evolution and contraction of right intraparenchymal hemorrhage with slightly decreased mass effect. 2. Normal CTA of the head and neck with no evidence of stenosis, aneurysm, or arteriovenous malformation. An underlying vascular lesion as etiology for the intraparenchymal hemorrhage cannot be fully evaluated due to the acuity of the hemorrhage. A followup MRI with gadolinium could be obtained in three months to evaluate for an underlying abnormality. Brief Hospital Course: [**Known firstname **] was admitted on [**2125-4-27**] to the ICU for observation due to the size of her right frontal hemorrhage. She remained stable until the PM of her second night when she was thought to be more somnolent. A repeat head CT ([**4-28**]) was obtained and found to demonstrate a stable bleed. By the AM of [**4-29**] - she was found to be in new onset atrial fibrillation. A diltiazem drip was started. She was otherwise found to be stable for transfer to the floors. An MRI was obtained on ([**4-29**]) in order to evaluate for a potential underlying mass as the etiology of the bleed. There was no evidence of a mass, but multiple ischemic punctate infarcts were concurrently noted in bilateral hemispheres. Due to the showering distribution of the infarcts, the source was thought to be most likely cardioembolic in nature. An ECHO was then pursued ([**2125-5-1**]), and this did not show any abnormalities. She continued to be observed on the floors for further management of her atrial fibrillation. She was continued on PO diltiazem (up to 120mg PO 4 times a day) and metoprolol (75mg PO TID). The clinical manifestations of her strokes stabilized, and per recommendations by physical therapy, she was then set for discharge to a rehab facility. She will need follow-up with a neurologist as an outpatient upon discharge from the hospital (Dr. [**First Name (STitle) **]. She should also have her atrial fibrillation managed via her PCP / referral to a cardiologist as an outpatient. Medications on Admission: none Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 days: last dose to be given [**2125-5-4**] PM. 4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 5. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: intraparenchymal hemorrhage multiple punctate ischemic infarcts new onset atrial fibrillation Discharge Condition: stable. Has residual left sided weakness. Speech is fluent but she is not consistently oriented to place, time or situation. Discharge Instructions: Please monitor for worsening weakness on the left or new weakness on the right side. Please monitor for changes in speech or vision. You are at risk for further ischemic strokes due to your new onset atrial fibrillation. Your hemorrhage was likely due amyloid angiopathy in the setting of transient high blood pressure. In order to prevent future events you should make sure that your blood pressure is well controlled. You will have to start on Asprin 325mg by mouth once a day on [**2125-5-10**]. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2125-6-8**] 10:30 Please call your primary care doctor for follow-up upon discharge from your rehab facility. Completed by:[**2125-5-3**] Name: [**Known lastname 12619**],[**Known firstname 779**] Unit No: [**Numeric Identifier 12620**] Admission Date: [**2125-4-27**] Discharge Date: [**2125-5-3**] Date of Birth: [**2053-7-4**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1725**] Addendum: Please make sure to start [**Known firstname **] [**Known lastname **] on Aspirin 325mg PO Qday on [**2125-5-10**]. Thank you. Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] [**First Name11 (Name Pattern1) 657**] [**Last Name (NamePattern4) 1735**] MD [**MD Number(1) 1736**] Completed by:[**2125-5-3**]

[ "729.89", "599.0", "459.9", "277.30", "348.5", "041.4", "401.9", "427.31", "431", "368.46", "342.90" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12967, 13196

9212, 10745

336, 364

11484, 11613

4206, 9183

12165, 12944

2078, 2099

10800, 11253

11367, 11463

10771, 10777

11637, 12142

2114, 4187

275, 298

392, 1933

1955, 1961

1977, 2062

17,589

107,404

45478+58821

Discharge summary

report+addendum

Admission Date: [**2113-4-6**] Discharge Date: [**2113-4-10**] Date of Birth: [**2050-9-6**] Sex: F Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 62-year-old female with a complicated past medical history including Takayasu arteritis, idiopathic pulmonary fibrosis, Parkinson's disease, COPD, who presents with a fall at home. The patient apparently fell at home and as she lives by herself, the patient called EMS as she had symptoms of shortness of breath. The patient was unable to provide a full detailed history as to events surrounding her fall. The patient had a pulse of 78, blood pressure 136/64, respirations 24, and was saturating 98% on nonrebreather when the EMTs found her. She was also complaining of being cold. She did state that her 02 tank appeared to be broken. The patient did state that she had head trauma. In the Emergency Room, the patient's temperature was 95.1, pulse 100, blood pressure 90/59, respiratory rate 26, saturating 81%. The patient was given Albuterol nebulizer treatments, 700 cc of lactated Ringer's, 800 cc of normal saline, and 2 units of packed red blood cells. There was some question of an AP pelvis film that could not conclusively rule out fracture and given that the patient had a hematocrit of 28.2 at the time of admission, there was concern that she could have been actively bleeding. Thus, the patient was given aggressive fluid hydration as well as 2 units of packed red blood cells. In this setting, she developed flash pulmonary edema and required intubation. The patient was also given 100 mg of hydrocortisone IV and 500 mg of levofloxacin as well as 600 mg of clindamycin. Post intubation, the patient had an arterial blood gas of 7.17, 92, 146. She was then given 80 mg of IV Lasix in the Emergency Room. The patient was then transferred to the Intensive Care Unit for further care. PAST MEDICAL HISTORY: 1. Takayasu arteritis diagnosed in [**2108**] after a syncopal episode. The patient was found to have nonpalpable radial pulses. The patient had an MRA which indicated bilateral subclavian artery stenoses with subclavian steel. The patient has been treated with chronic steroids. She is normally on 5 mg of prednisone p.o. q.d. 2. Idiopathic pulmonary fibrosis diagnosed in [**2109**]. The patient had a BAL and lung biopsy in [**2110**] which showed hemosiderin bleed-in, macrophages, ANCA negative, [**Doctor First Name **] negative. The patient was treated with CellCept for this. 3. COPD: The patient's last known pulmonary function tests revealed an FEV1 of 45% and FVC of 63% and baseline 02 saturation of 89-92% on room air. The patient is on home 02 as well as home BIPAP. 4. Type 2 diabetes mellitus (question if steroid-induced). 5. Iron-deficiency anemia: The patient had a normal colonoscopy in [**2112-8-8**] and has a baseline hematocrit of 28-30. 6. Parkinson's disease: On carbidopa, levodopa. 7. Question of hypothyroidism. 8. T11-12 disk herniation with compression fracture. 9. Osteoporosis. 10. Mitral stenosis. 11. Question of CAD: The patient had an echocardiogram in [**2111-3-12**] with moderate MR valve area of 0.5, EF 63% with a MIBI in [**2109-3-11**] that was nondiagnostic per report at an outside hospital. 12. Anxiety. 13. Chronic pain, primarily in the back. 14. Pulmonary embolus in [**2112-8-8**]. DISCHARGE MEDICATIONS (PER DISCHARGE SUMMARY [**2-10**]): 1. Methadone 5 mg p.o. t.i.d. 2. Percocet 7.5/325 p.o. p.r.n. 3. Alendronate 70 mg q. week. 4. Salmeterol two puffs inhaled b.i.d. 5. Flovent 110 micrograms two puffs b.i.d. 6. Prozac 60 mg p.o. q.d. 7. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. q.d. 8. Prevacid 40 mg p.o. q.d. 9. Calcium carbonate 1,000 mg p.o. t.i.d. 10. NPH 16 units q.a.m. 11. Aricept 5 q.h.s. 12. Sinemet 25/100 two b.i.d. 13. Aspirin 325 mg p.o. q.d. 14. Metoprolol 12.5 mg p.o. b.i.d. 15. Klonopin 1 mg p.o. b.i.d. 16. Lasix 40 mg p.o. q.d. 17. Prednisone 5 mg p.o. q.d. 18. CellCept [**Pager number **] mg p.o. b.i.d. 19. Colace 100 mg p.o. b.i.d. 20. Senna two tablets p.o. b.i.d. 21. Albuterol inhalers p.r.n. These medications are unknown but were documented on the EMS sheet. 1. Synthroid. 2. Seroquel. 3. Remeron. ALLERGIES: Sulfa which causes hives, bananas and shellfish, unknown reactions. SOCIAL HISTORY: The patient has a ten pack year history of tobacco use which she quit in [**2108**]. No history of alcohol use. She lives alone. The patient's former primary care physician is [**Last Name (NamePattern4) **]. [**First Name (STitle) **] .................... at [**Hospital6 1129**]. The patient's current primary care physician is listed as Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**Hospital 191**] Clinic, however, he also does not appear to be the patient's primary care physician at the time. The patient has a daughter, [**Name (NI) 1356**], and a son, [**Name (NI) **], phone number [**Telephone/Fax (1) 97040**]. The patient's next of [**Doctor First Name **] is [**Doctor First Name **], phone number [**Telephone/Fax (1) 97041**]. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 100.6, pulse 97, blood pressure 86/58 by blood pressure cuff and 116/81 by A line. Ventilatory settings: AC 400, tidal volume times 22, respiratory rate 50% FI02, saturating 94%. General: Intubated, sedated, able to mouth words. HEENT: Moist mucous membranes. No teeth. Pupils small but reactive. Neck: C-spine collar, supple. Respiratory: Coarse breath sounds throughout, occasional expiratory wheezes. Cardiovascular: Tachy/normal S1, S2, II/VI systolic murmur. Abdomen: Soft, nontender, nondistended. Extremities: No cyanosis, clubbing, or edema, 1+ DP/PT bilaterally. Neurological: Tremor. LABORATORY DATA AT THE TIME OF ADMISSION: White blood cell count 17.6, hematocrit 28 with a baseline between 28-31, platelets 417,000, MCV 81. The differential revealed neutrophils 78%, basophils 0.6%, bands 0, lymphocytes 13%, monocytes 3%, eosinophils 5%. PT 12.9, INR 1.1, PTT 25.2. Sodium 134, potassium 5.3, chloride 90, bicarbonate 29, BUN 16, creatinine 1.0, glucose 213. The initial CK was 234. Troponin less than 0.3. Urinalysis: Negative. Chest x-ray: Infiltrates in the left midlung zone, right upper and middle lobe which were worse compared to prior study of [**2113-2-15**], consistent with infection versus asymmetric pulmonary edema. AP pelvis film: Question of right pubic rami fracture cannot be excluded. Noncontrast CT of the chest: Small bilateral effusions, air space consolidation, mediastinal lymphadenopathy, no fractures, no evidence of solid organ injury. Head CT: No change compared to prior. CT C-spine: No cervical spine fractures. EKG: Sinus tachy at a rate of 102, axis 30 degrees, intervals okay, Q wave in lead III. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit secondary to intubation from volume overload after aggressive fluid resuscitation as well as red blood cell transfusion. 1. RESPIRATORY: The patient was intubated primarily in the setting of acute pulmonary edema from volume overload. The patient was diuresed aggressively with good results, diuresing approximately 4 liters while in the Intensive Care Unit. The patient did continue to have diffuse wheezing and required frequent nebulizer treatments with Albuterol. She was titrated down to nasal cannula 3 liters, saturating 92-96% given her underlying interstitial pulmonary fibrosis as well as COPD. The patient had a repeat chest x-ray on [**2113-3-30**] which revealed coarse reticular opacities in the bilateral lungs, no pleural effusions, and marked interval improvement of her bilateral opacities. The patient's Lasix was held for one day given that she had diuresed so well. However, the patient then redeveloped some increasing wheezing and 02 requirement. She was diuresed again with Lasix 40 IV with good results and repeat chest x-ray revealed good resolution of her CHF. The patient was then restarted on her home dose Lasix regimen of 40 mg p.o. q.d. The patient also had marked improvement in her wheezing and did not require frequent Albuterol treatments. The patient subjectively felt dyspnea on exertion but no shortness of breath at rest. On [**2113-4-9**], the patient did have another acute episode of left-sided pleuritic chest pain and shortness of breath. Given her prior history of pulmonary embolus, there was a low threshold to evaluate for this. The patient had a CT angio which was negative for pulmonary embolism. In addition, the patient was started on a rule out for myocardial infarction. 2. HYPOTENSION: The patient had a history of reported hypotension by the Emergency Department notes. However, given the patient's subclavian stenosis and lack of palpable radial pulses there is the added element of about 15 mmHg difference between her arterial line measurement as well as her cuff blood pressure measurement. The patient had good blood pressure monitoring with an A line which was discontinued prior to her transfer out of the Intensive Care Unit. Subsequently, the patient had blood pressures that ranged from 90-120 systolic. 3. CARDIOVASCULAR: The patient again with CHF in the setting of rapid volume resuscitation. The patient had an echocardiogram that revealed a mildly dilated left atrium and normal left ventricle with an EF greater than 55%, positive basal septal hypokinesis, mitral valve mildly thickened, consistent with rheumatic deformities, fused commissures, and leaflets tethering, mild mitral stenosis, 1+ mitral regurgitation, and eccentric jet, mild pulmonary artery systolic hypertension. There was no evidence for LVH or for decreased ejection fraction. Thus, the patient likely has diastolic dysfunction. The patient was also ruled out for a myocardial infarction subsequent to her episode of left-sided chest pain. Her first two sets of cardiac enzymes were negative with CKs of 23 and 18 respectively with negative troponins. There was a low threshold of suspicion for myocardial infarction and the patient also has an EKG without abnormalities during the episode of chest pain. 4. INFECTIOUS DISEASE: The patient was with an elevated white blood cell count which appears to be somewhat elevated at baseline given her chronic steroid use. The patient was initially placed on levo/clinda. However, her lack of teeth makes anaerobic coverage unnecessary. Therefore, clinda was discontinued. The patient was then taken off of her antibiotics given that there was no clear infiltrate or evidence of pneumonia without any productive sputum or fever. However, the patient will likely complete a one week course of Levaquin given that her underlying pulmonary disease makes interpretation of consolidation or infiltrate difficult and she does have a persistently elevated white blood cell count. The patient had blood cultures with no growth and urine culture with no growth as well. 5. FALLS: The patient is with an unclear etiology of frequent falls. However, she did have a recent admission with evaluation for this and this does appear to be a chronic problems for the past 12 years, probably concomitant Parkinson's, T12 compression fracture, as well as multiple medical conditions and the fact that the patient lives alone. PT consultation was obtained and they recommended rehabilitation for this patient. 6. NEUROLOGIC: The patient is with a history of Parkinson's disease. She was continued on her carbidopa, levodopa at the time of admission. 7. PSYCHIATRY: The patient was continued on her Prozac. 8. ANXIETY: The patient was initially treated with Ativan p.r.n. However, she states that this has not had good results. The patient was restarted on her home dose of Klonopin 1 mg p.o. b.i.d. given her increase in anxiety. Initially, this was held given that the patient came in with an unclear mental status and we did not want to add a long-acting benzodiazepine in that setting. 9. TAKAYASU'S ARTERITIS: The patient was continued on prednisone 5 mg after receiving stress-dose steroids in the Intensive Care Unit. The interpretation of her cortisol stim test is confounded as she is on chronic prednisone which is essentially normal replacement physiologic dose. Thus, inappropriate bump in cortisol does not imply that the patient has adrenal insufficiency on that basis. 10. IPF: The patient was restarted on her CellCept on [**2113-4-10**] for treatment of her IPF. Her chest x-ray revealed her baseline interstitial pulmonary disease. 11. DISPOSITION: The patient will likely be discharged to a rehabilitation facility after appropriate screening. DISCHARGE CONDITION: Stable. The patient is not at her baseline status as she needs rehabilitation for her deconditioning. DISCHARGE DIAGNOSIS: 1. Congestive heart failure secondary to volume overload, likely diastolic dysfunction. 2. Takayasu's arteritis. 3. Interstitial pulmonary fibrosis. 4. Parkinson's disease. 5. Pneumonia. MEDICATIONS AT THE TIME OF DISCHARGE: All home dose medications noted at the beginning of this discharge summary with the exception of Aricept and metoprolol, with the addition of levofloxacin. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By:[**Name8 (MD) 231**] MEDQUIST36 D: [**2113-4-10**] 03:02 T: [**2113-4-10**] 15:31 JOB#: [**Job Number 97042**] Name: [**Known lastname 15450**], [**Known firstname **] [**Last Name (NamePattern1) **] Unit No: [**Numeric Identifier 15451**] Admission Date: [**2113-4-6**] Discharge Date: [**2113-4-13**] Date of Birth: [**2050-9-6**] Sex: F Service: A-Cove ADDENDUM: This is a Discharge Summary Addendum to the previously dictated Discharge Summary. The patient remained clinically stable throughout the remainder of her hospital course. She was screened and accepted to [**First Name4 (NamePattern1) 3008**] [**Last Name (NamePattern1) **] Rehabilitation facility; however, the patient did not feel that this rehabilitation facility was up to an appropriate standard of care and did not want to go to this rehabilitation facility. In addition, she stated she wanted her family to screen these facilities; however, we were unable to get in touch with her family members. Subsequently, the patient was reassessed by the Physical Therapy Service who deemed that she did not need physical therapy as she was able to ambulate without difficulty and remained with good oxygen saturations of 94% with ambulation on her oxygen. The patient was deemed able to return to home without any further need for physical therapy. Anticipated day of discharge is [**2113-4-13**] or [**2113-4-14**]. [**Name6 (MD) 27**] [**Name8 (MD) **], M.D. [**MD Number(1) **] Dictated By:[**Name8 (MD) 4791**] MEDQUIST36 D: [**2113-4-13**] 18:20 T: [**2113-4-13**] 20:06 JOB#: [**Job Number **]

[ "280.9", "786.59", "332.0", "518.81", "251.8", "V58.69", "428.0", "446.7", "516.3" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

12778, 12881

12902, 15096

6912, 12757

6731, 6894

5190, 6721

1912, 4354

4371, 5175

16,921

114,716

27413

Discharge summary

report

Admission Date: [**2183-6-18**] Discharge Date: [**2183-7-15**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2145**] Chief Complaint: 86 y/o M s/p fall from standing- pt. transferred from OSH w/films demonstrating SAH and hemorrhagic contusions bilaterally Major Surgical or Invasive Procedure: Intubated in the ED trach/peg placement History of Present Illness: 86 y/o M w/history of dementia fell from standing earlier on day of admission. +LOC. Pt. brought in by Med Flight after eval at OSH showing SAH. On arrival pt. w/GCS of 15. Pt. with acute decompensation in trauma bay to GCS of 10 and electively intubated. Past Medical History: - HTN - diabetes - dementia Social History: unknown Family History: unknown Physical Exam: Admission PHYSICAL EXAM: BP: 101/58 HR: 59 Gen: WD/WN, comfortable, NAD HEENT: unable to assess, bleeding abrasion on left forehead Neck: in C-collar Lungs: CTA bilaterally, no w/c/r Cardiac: RRR. S1/S2. Abd: Soft, BS+, nd Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: intubated and sedated, follows commands but does not open eyes to instruction Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. III, IV, VI: unable to assess V, VII: unable to assess. VIII: unable to assess. IX, X: intubated unable to assess. [**Doctor First Name 81**]: unable to assess XII: unable to assess Motor: will move all extremities, Vec from ED wearing off Discharge EXAM: Gen: NAD HEENT: NCAT, neck somewhat stiff (tone is increased throughout) Lungs: diffuse rhonchi Cardiac: RRR. S1/S2. Abd: Soft, BS+, nd Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: occasional spont eye opening, grimace to sternal rub, non verbal, does not follow commands Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. III, IV, VI: no obvious droop V, VII: unable to assess. VIII: unable to assess. IX, X: gag present [**Doctor First Name 81**]: unable to assess XII: unable to assess Motor: moves extremities intermittently. Sometimes withdraws to pain Pertinent Results: [**2183-6-24**] 03:20AM BLOOD WBC-10.5 RBC-2.60* Hgb-8.7* Hct-24.6* MCV-95 MCH-33.3* MCHC-35.1* RDW-13.1 Plt Ct-173 [**2183-6-24**] 03:20AM BLOOD Plt Ct-173 [**2183-6-24**] 03:20AM BLOOD PT-13.2* PTT-33.1 INR(PT)-1.2* [**2183-6-18**] 04:33PM BLOOD Fibrino-448* [**2183-6-24**] 03:20AM BLOOD Glucose-198* UreaN-37* Creat-1.5* Na-136 K-4.1 Cl-104 HCO3-25 AnGap-11 [**2183-6-18**] 04:33PM BLOOD ALT-13 AST-18 AlkPhos-72 Amylase-55 TotBili-0.5 [**2183-6-24**] 03:20AM BLOOD Calcium-7.2* Phos-3.5 Mg-2.4 [**2183-6-24**] 03:20AM BLOOD Vanco-11.7* [**2183-6-22**] 01:55AM BLOOD Phenyto-13.0 [**2183-6-18**] 04:33PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG IMAGING: EKG:[**2183-6-19**]: NSR at around 60, nl axis, nl intervals, no ST-T changes. No previous for comparision . Radiologic: Head CT [**6-18**]: Bilateral hemorrhagic contusions and subarachnoid blood, most significant along the left frontal and left temporal areas. Fractures of the left maxillary sinus are identified, but would be better assessed by dedicated sinus CT. Opacified right mastoid air cells may also belie subtle base of skull fractures in the trauma setting despite the lack of an identifiable fracture lines, and clinical correlation is recommended. . Repeat Head CT [**6-18**]: 1. Bilateral subarachnoid hemorrhage, slightly increased, and left temporal and frontal contusions, not significantly changed, compared to the recent study. 2. Disproportionate prominence of the lateral and third ventricles c/w cortical sulci, raising possibility of underlying communicating hydrocephalus (doubt obstructive, as no intraventricular hemorrhage). 2. Fracture of the left maxillary sinus lateral wall, with blood in that sinus, as well as the left zygomatic arch. 3. Probable acute-on-longstanding inflammatory disease in the right mastoid process and middle ear; review of bone algorithm images from previous head/maxillofacial/cervical CT studies demonstrates no definite temporal bone or other skull base fracture. . MRI head [**6-20**]: No evidence of diffuse axonal injury. Left frontal and temporal and small right frontal subarachnoid hemorrhages, corresponding with prior CT. . EEG [**2183-6-26**]: IMPRESSION: Abnormal portable EEG due to the slow and disorganized background and bursts of generalized slowing. These findings indicate a widespread encephalopathic condition affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. Trauma and raised pressure are also possible causes. No prominent lateralized findings were evident to correlate with the history of subdural hematoma. There were no epileptiform features. . CT sinus [**6-18**]: Air-fluid level with hemorrhage in the left maxillary sinus, with minimally displaced fracture of the posterior wall of the left maxillary sinus. No displacement of intra-orbital content. . Portable Chest [**6-25**]: Tracheostomy and percutaneous gastrostomy in standard positions. Slightly worsened left basilar atelectasis, aspiration, or pneumonia. Probable small bilateral layering pleural effusions. . [**7-4**] CXR: Patient is status post tracheostomy. The cardiomediastinal silhouette is unchanged. There is a persistent left lower lobe consolidation. This is unchanged appearance compared to the prior examination. There is a small left pleural effusion. The right lung is clear. . [**7-3**]: No DVT on bilat LENI's. . [**7-3**]: Abd US: This exam is limited secondary to patient unresponsiveness. The visualized liver demonstrates normal echogenicity with no focal lesions identified. The gallbladder is unremarkable. The common duct is not dilated. There is appropriate forward portal venous flow. The right kidney measures 9.5 cm. The left kidney measures 8.9 cm. There is no evidence of hydronephrosis, masses, or stones. The pancreas and aorta are not well visualized. Brief Hospital Course: Pt. was transferred to the [**Hospital1 18**] ED after evaluation in an OSH. At the OSH the pt. was found to have SAH s/p a fall from standing and down about 4 stairs. The pt. was brought by [**Location (un) **] to the [**Hospital1 18**] ED where he was immediately transferred to the trauma bay. There he reportedly had a GCS of 15 before acutely decompensating to a GCS of 10 for which he was electively intubated. The pt. underwent CT scan on admission that confirmed the presence of SAH. The pt. was then admitted to the trauma ICU for care. Neuro: The pt. underwent serial head CT scans over the first 24 hours of his hospitalization. They were stable, showing only slight increase in the amount of bleed the pt. had suffered. On HD 3 the pt. underwent an MRI that was negative for diffuse axonal injury. The pt.'s exam remained relatively unchanged from the day of admit during which his pupils were equal and reactive, he localizes with his left upper extremity and will withdraw bilateral lower extremities. He is intermittently awake and will open his eyes intermittently spontaneously. No verbal response. He was put on phenytoin for seizure prophylaxis but developed a transaminitis. Dilantin was changed to Keppra and the transaminitis resolved over a matter of days. He has had no seizure activity. Resp: Pt. was intubated electively in the ED because of acute decompensation. He remained on the ventilator until HD8 - at which time he underwent a trach. Moreover, he began spiking fevers on HD 4 and at that time CXR showed slight patchy infiltrates. By HD 7 the pt continued spiking fevers occasionally and the patchy infiltrates had organized in the LLL suggesting a pneumonia. He received a one week course of antibiotics and was able to wean down to a trach mask at the time of discharge. He then developed a second fever and grew stenotrophomonas on sputum. ID was consulted and suggested a 14 day course of bactrim and levoquin, which he is currently on at the time of discharge. He is sating well on 35% trach mask but requires frequent suctioning for clear/white secretions. He has a good cough. Cardiac: Pt. was initially hemodynamically stable. On HD [**4-30**] the pt. had a few episodes of SBP in the 80s. At that time the pt. was also being given lasix and it was believed that he had become hypovolemic. His pressure rose with fluid and a CVL was placed to better assess his volume status. He did stablize and at the time of discharge he did not have any cardiac issues. GI/FEN: The pt. was started on tube feeds after receiving his PEG and tolerated tube feeds at goal during his hospitalization. He was found to have low serum sodium levels and was started on salt tabs. Sodiums were followed and improved, salt tablet taper begun. At the time of discharge he is not on any salt. Endo: He did have elevated serum glucoses. Medicine recommended insulin doses and these were adjusted as needed. GU: no issues. The pt initially had a foley but this was discontinued in the days prior to discharge. He does have a stage II decubitous ulcer that should be dressed per wound care recs - see discharge paperwork. ID: Pt. started on abx because of intermittent fevers early in his hospital course. Sputum cultures demonstrated gram positive cocci and gram negative rods. He was given a week of vancomycin and zosyn. An infectious disease consult was called for his intermittent fevers despite antibiotics. They recommended switching his dilantin to keppra to r/o drug fever as above. Repeat sputum revealed Stenotrophomonas on [**6-28**] and bactrim/levoquin were initiated for a planned 14 day course (to end on [**7-19**]). The pt defervesced. He developed a LGF to 100.1 the day prior to discharge - no source is identified. His WBC have been elevated to [**1-11**] since his admission to [**Hospital1 18**]. This has not changed. He has a neutrophil predominence but has no bandemia. He has a known healing sinus fracture, a sacral decubitus ulcer, white/clear sputum (and is on treatment for stenotrophomonas), and gout as below. Also in the fever differential is SAH itself. GOUT: His knee was found to be edematous and was tapped on [**7-4**] and fluid was consistent with gout. Culture negative. The pt is currently finishing a steroid taper for gout. Allopurinol could be started at a dose of 100-300 per day but should be delayed until mid-[**Month (only) 205**] as it should not be started during an acute flare. Dispo: acute rehab The patient is full code per the wishes of his appointed guardian (his son). The patient did receive heparin sq at this hospitalization. Medications on Admission: - metformin - lopressor Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 days. 9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days: start on [**7-13**]. 10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days: until [**7-19**]. 12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 8 days: until [**7-19**]. 13. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed for fever < 101.4. 14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Eight (28) units Subcutaneous twice a day: before breakfast and before dinner. 15. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection qid ac: Sliding Scale: 0-150 - 0 units 151-200 - 2 units 201-250 - 4 units 251-300 - 6 units 301-350 - 8 units 351-400 - 10 units. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: bilateral subarachnoid hemorrhage with contusions transaminitis from dilantin - resolving off dilantin pneumonia hypertension Discharge Condition: Neurologically stable Discharge Instructions: Please come to the emergency room if you have fever >101.4, nausea or vomiting, shortness of breath, or any other symptoms concerning to you. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in [**2-28**] weeks. Call his office at [**Telephone/Fax (1) 2992**] for an appointment. Will need an outpatient CT head mid-[**Month (only) 205**]. Call Dr.[**Name (NI) 9034**] office to set up. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2183-7-15**]

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icd9cm

[ [ [] ] ]

[ "96.72", "03.31", "81.91", "96.6", "96.04", "43.11", "31.1" ]

icd9pcs

[ [ [] ] ]

12502, 12573

6162, 10811

386, 427

12743, 12767

2212, 6139

12958, 13331

810, 819

10886, 12479

12594, 12722

10837, 10863

12791, 12935

859, 1107

1560, 1746

223, 348

455, 717

1869, 2193

1761, 1853

739, 769

785, 794

29,649

156,794

34261

Discharge summary

report

Admission Date: [**2127-5-9**] Discharge Date: [**2127-5-17**] Date of Birth: [**2063-9-2**] Sex: F Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6440**] Chief Complaint: Bladder cancer Major Surgical or Invasive Procedure: Radical cystectomy with ileal loop conduit History of Present Illness: 63F with muscle invasive bladder cancer. She has received intravesical BCG in the past and approximately ten TURBT. Past Medical History: Past med/[**Doctor First Name **] history: Breast implant ~ 2 years ago to correct a congenital defect. Physical Exam: Afebrile Comfortable Abd soft, NTND Incision clean, dry, intact; no signs of wound infection [**Doctor First Name **] pink and well perfused at RLQ Urine yellow with small amount of mucus Mitrofanoff capped Ureteral stents x2 in place at LLQ Pertinent Results: [**2127-5-16**] 07:30AM BLOOD WBC-12.5* RBC-3.29* Hgb-10.0* Hct-28.6* MCV-87 MCH-30.5 MCHC-35.1* RDW-14.3 Plt Ct-383 [**2127-5-16**] 07:30AM BLOOD Glucose-96 UreaN-7 Creat-0.6 Na-138 K-3.7 Cl-104 HCO3-26 AnGap-12 [**2127-5-10**] 1:03 pm BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2127-5-16**]** Blood Culture, Routine (Final [**2127-5-16**]): NO GROWTH. Brief Hospital Course: Ms. [**Known lastname 78879**] [**Last Name (Titles) 1834**] a radical cystectomy and ileal conduct as described in operative note with Dr. [**Last Name (STitle) 365**]. The patient was transferred from PACU to the MICU for pressor support POD0. She was transfused 1U PRBC on POD1 for goal Hct 26. She was then transferred to the urology floor in stable condition. NGT removed POD4. Patient was advanced to clears by the evening of POD7 after passage of flatus, regular diet POD8. The patient was ambulating and pain was controlled on oral meds by this time. JP removed at discharge. The [**Last Name (STitle) 9341**] was perfused and patent, with ureteral stents sutured in place. The [**Last Name (STitle) 9341**] nurse saw the patient for [**Last Name (STitle) 9341**] teaching. Mitrofanoff is capped and has been flushed since POD1. SPT irrigated since POD1. At the time of discharge the wound was was healing well with no evidence of erythema, swelling, or purulent drainage. She will follow up in clinic for wound check and will have a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 9341**] care. Medications on Admission: Effexor and just started Atenonol for 5 days before surgery Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation for 2 weeks. Disp:*0 Tablet(s)* Refills:*0* 2. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 2 weeks: Use until mitrofanoff is removed. Disp:*0 * Refills:*0* 3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-25**] Sprays Nasal QID (4 times a day) as needed for nasal congestoin. Disp:*0 * Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 2 weeks. Disp:*0 Capsule(s)* Refills:*0* 5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 1 weeks: no alcohol or driving on this medication . Disp:*40 Tablet(s)* Refills:*0* 6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). Disp:*0 Capsule, Sust. Release 24 hr(s)* Refills:*0* 7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take until seen by Dr. [**Last Name (STitle) 365**] in follow-up. Need for further atenolol to be discussed at that time. Disp:*0 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Bladder cancer Discharge Condition: Stable Discharge Instructions: -Please resume all home meds -Do not drive while taking oxycodone. Please take Tylenol in addition to oxycodone, and transition to Tylenol as pain improves. -You may shower, but do not immerse incision, no tub baths/swimming. -Small white steri-strips bandages will fall off in [**4-30**] days, you may remove at that time if irritating. -Call if incision becomes markedly more red, swollen, or begins to drain purulent fluid, or for fever more than 101.5. -Please refer to visiting nurses (VNA) for management of your tubes. Instill 60cc of sterile water into 12F foley (mitrofanoff) [**Hospital1 **]. Irrigate suprapubic tube with 60cc of sterile water [**Hospital1 **] Followup Instructions: Call Dr. [**Last Name (STitle) 365**] for follow-up appointment and for all questions. Please call the office to arrange for follow-up visit on [**5-23**] with [**Doctor First Name 41356**] for staple removal, mitrofanoff removal and stent removal.

[ "E878.8", "285.9", "V85.30", "E849.7", "458.29", "998.2", "518.0", "276.4", "188.8", "518.5" ]

icd9cm

[ [ [] ] ]

[ "93.90", "56.51", "68.8", "99.04", "57.81", "40.3", "46.75", "65.61", "68.49" ]

icd9pcs

[ [ [] ] ]

3770, 3819

1354, 2481

327, 372

3878, 3887

922, 1331

4615, 4867

2592, 3747

3840, 3857

2507, 2569

3911, 4592

660, 903

273, 289

400, 517

539, 645

5,727

178,576

51927

Discharge summary

report

Admission Date: [**2156-2-26**] Discharge Date: [**2156-3-2**] Date of Birth: [**2096-11-3**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 678**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: none History of Present Illness: From admission note: 59 y/o M with PMHx of ESRD on HD, GI bleeds, CAD and polysubstance abuse who was brought into the ED via EMS after his wife witnessed a syncopal episode. Pt was complaining of left sided chest pain but was drowsy on arrival. In the ED, initial vs were: T 96.8 P 60 BP 92/52 R O2 sat 100% on NRB. Pt some new TWI on EKG in V2-V6 and was being bolused for hypotension. At midnight, pt was noted to be having possible seizure activity with left eye deviation and foaming at his mouth. After this activity ceased, pt was post ictal and unable to be aroused. He was intubated with etomidate and rocuronium due to concern for inability to protect his airway. Pt remained mildly hypotensive and hct came back at 24 (down from baseline of 30). He had a right femoral CVL placed and rectal exam revealed brown stool mixed with blood. OG tube was placed and there was no evidence of hematemesis. Pt was typed and crossed for 4u prbcs and bolused with a total 3L IVF. He received Aspirin 325mg, Zofran, Protonix, Vanc & Zosyn for possible sepsis and was transferred to the ICU. On arrival to the ICU, pt was intubated and sedated. Review of sytems: unable to obtain Past Medical History: # ESRD on [**First Name3 (LF) 13241**] (Tues/Thurs/Sat, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] Dialysis, [**Location 1268**], [**Telephone/Fax (1) 69669**]) # Type 2 diabetes mellitus - peripheral neuropathy # CAD s/p MI (patient cannot recall) - cardiac catheterization in [**9-/2155**] without flow limiting stenoses - MIBI in [**11/2152**] showed reversible defects inferior/lateral # CHF with EF 30-35% ([**9-/2155**] TEE) # Atrial fibrillation/atrial flutter s/p Aflutter ablation [**8-/2153**] - not on anticoagulation # h/o atrial tachycardia s/p EPS [**9-21**] and ablation x 2 for L sided, triggered (not reentrant) Atachs # Hypertension # Dyslipidemia: [**9-/2155**] TC 101, LDL 54, HDL 29, TG 112 # History of gastrointestinal bleed: - Duodenal, jejunal, and gastric AVMs s/p thermal therapy - diverticulosis throughout colon # Chronic pancreatitis # ? Hepatitis C, positive HCV Ab in [**10/2150**], subsequently negative x 2 [**4-/2154**], [**5-/2154**] # GERD # Gout s/p arthroscopy with medial meniscectomy [**5-/2149**] # Depression s/p multiple hospitalizations due to SI # Polysubstance abuse: crack cocaine, EtOH, tobacco - frequent bouts of chest pain following crack/cocaine use # Erectile dysfunction s/p inflatable penile prosthesis [**5-/2148**] Social History: He lives with a female partner in [**Location (un) 686**], MA. 42 pack-year smoking history, recently up to 6 cigarettes per day. He has a history of alcohol abuse, with DTs and detoxification, with last drink on [**Holiday 1451**]. History of crack cocaine use, with last use ~2 weeks ago. Family History: Father with alcoholism. Mother with type 2 diabetes, renal failure, died at age 58. Son with diabetes. Cousin with [**Name2 (NI) 14165**] cell disease. Physical Exam: On discharge: VSs: 98, 133/86, 93, 22, 96% 2L Finger sticks: 212, 238, 93 Gen: Well-appearing. NAD. scratching skin. Skin: Numerous macular lesions diffuse over the trunk and limbs. No apparent involvement of the palms. HEENT: PERRL. MMM CV: RRR. Normal S1 and S2. No M/R/G. Pulm: CTA bilaterally. Abd: Soft, mildly distended. No rebound or guarding. Ext: Trace bilateral edema. Neuro: A&Ox3. Pertinent Results: CT head [**2156-2-26**]: FINDINGS: There is no intracranial hemorrhage, shift of normally midline structures, or evidence of acute major vascular territorial infarct. Ventricular and sulcal size are unchanged. Other than a small mucus-retention cyst in the right maxillary sinus the paranasal sinuses remain well aerated as are the mastoid air cells. The 3.4 x 1.1-cm hyperdense mass overlying the right occipital bone is unchanged compared to [**2152-4-29**]. IMPRESSION: No intracranial hemorrhage or edema. CXR [**2156-2-29**]: Again seen is moderate cardiomegaly. The endotracheal tube has been removed and the NG tube has been removed. There is a moderate right effusion with associated right lower lobe volume loss. There continues to be pulmonary vascular redistribution with perihilar haze, however, this is improved in appearance compared to the film from three days ago. RUQ US [**2156-3-1**]: 1. No intra- or extra-hepatic bile duct dilatation. 2. No significant gallbladder disease with redemonstration of a tiny gallbladder polyp and likely adenomyomatosis. 3. Increased hepatic echogenicity suggest diffuse fatty infiltration although more advanced forms of liver disease such as fibrosis/cirrhosis cannot be excluded. [**2156-2-25**] 11:00PM BLOOD WBC-6.5 RBC-2.60* Hgb-8.0* Hct-24.9* MCV-96# MCH-30.7 MCHC-32.1 RDW-18.3* Plt Ct-254 [**2156-3-2**] 07:45AM BLOOD WBC-6.4 RBC-3.08* Hgb-9.2* Hct-28.4* MCV-92 MCH-29.9 MCHC-32.5 RDW-17.0* Plt Ct-235 [**2156-2-25**] 11:00PM BLOOD Neuts-74.7* Bands-0 Lymphs-16.6* Monos-6.2 Eos-1.9 Baso-0.5 [**2156-2-27**] 04:34AM BLOOD PT-15.0* PTT-27.6 INR(PT)-1.3* [**2156-3-2**] 07:45AM BLOOD Glucose-91 UreaN-58* Creat-6.9* Na-135 K-5.5* Cl-98 HCO3-24 AnGap-19 [**2156-2-25**] 11:00PM BLOOD Glucose-242* UreaN-40* Creat-5.3* Na-135 K-8.1* Cl-91* HCO3-29 AnGap-23* [**2156-3-2**] 07:45AM BLOOD ALT-30 AST-27 AlkPhos-262* Amylase-166* TotBili-1.0 [**2156-2-29**] 08:00AM BLOOD GGT-296* [**2156-2-25**] 11:00PM BLOOD CK(CPK)-172 [**2156-2-26**] 04:27AM BLOOD CK-MB-NotDone cTropnT-0.29* proBNP-[**Numeric Identifier 35433**]* [**2156-3-1**] 07:15AM BLOOD Albumin-3.6 Iron-74 [**2156-2-29**] 08:00AM BLOOD Calcium-9.5 Phos-4.0 Mg-1.9 [**2156-3-1**] 07:15AM BLOOD calTIBC-328 Ferritn-535* TRF-252 [**2156-2-26**] 04:27AM BLOOD VitB12-1252* Folate-13.9 [**2156-2-26**] 12:07PM BLOOD Ammonia-32 [**2156-2-26**] 04:27AM BLOOD Osmolal-310 [**2156-2-26**] 04:27AM BLOOD TSH-3.8 [**2156-2-25**] 11:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2156-2-26**] 03:01AM BLOOD Lactate-3.9* RPR neg Blood cultures neg Brief Hospital Course: 59 y/o M with PMHX of ESRD, GI bleed, CAD and polysubstance abuse who presents with borderline hypotension, MS changes and GI bleed. # Hypotension: Suspected etiology most likely hypovolemia exacerbated by GI bleed, with further drop peri-intubation. Given lack of tachycardia, fever or leukocytosis, sepsis was considered unlikely. Pt remained in baseline Wenkebach with rate in 70s-80s, without any additional symptoms or episodes on telemetry, specifically no intermittent complete heart block. BP improved with volume resuscitation. # MS changes/Seizure?: Suspect that hypotension lead to hypoperfusion and MS changes. It is unclear if there was true seizure activity prior to intubation. CT head negative for acute IC pathology. TSH, RPR, folate, Vit B12 were all normal # GI bleed: Pt with long standing history of AVMs and GI bleeds. OG did not reveal any coffee grounds but frank red stool in vault. Hematocrit stabilized after 2 units of PRBCs, although with persistent maroon stools. Pt was treated with IV PPI, and evaluated by GI who did not feel a scope was necessary at the time. On discharge pt was still having guaiac positive stools but Hct remained stable at 28.4. # Resp Failure: Pt was mildly hypoxic on arrival and CXR showed vascular congestion. Ultimately, pt was intubated after possible seizure activity and decreased responsiveness with successful extubation on [**2156-2-26**]. # CAD: Cath in [**9-21**] showed no flow limiting disease. He presented with CP and new TWIs in V2-V6. However, CK/MBs flat and troponin close to baseline given ESRD. Low suspician for ACS but was monitored on telemetry. He was continued on a statin while ASA and BP meds held. These were restarted prior to discharge once BP had stabilized. Pt may be in decompensated heart failure but unclear given unusual presentation. # ESRD on HD: Pt was maintained on his usual HD regimen and tolerated all dialysis sessions well. # Diabetes: Pt was monitored QID and treated with humalog sliding scale. Medications on Admission: Labetalol 100 mg TID Amiodarone 200 mg daily Lisinopril 10 mg daily Atorvastatin 20 mg daily Cinacalcet 30 mg daily Pantoprazole 40 mg daily Sertraline 100 mg daily Multivitamin daily Gabapentin 300 mg q48hr DILT-XR 180 mg daily Diphenhydramine HCl 25 mg QID NPH 15units [**Date Range **] & 10units qpm Insulin lispro Sevelamer 800mg TID Discharge Medications: 1. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed. [**Date Range **]:*56 Capsule(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Insulin Continue NPH 15units every morning and 10units every evening; also continue lispro as before. 4. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Date Range **]:*30 Tablet(s)* Refills:*2* 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Date Range **]:*30 Tablet(s)* Refills:*2* 9. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three times a day. 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO once a day. 12. Labetalol 100 mg Tablet Sig: One (1) Tablet PO three times a day. 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 14. DILT-XR 180 mg Capsule,Degradable Cnt Release Sig: One (1) Capsule,Degradable Cnt Release PO once a day. 15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO every other day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] [**Hospital 2256**] Discharge Diagnosis: Primary: Syncope, GI bleed Secondary: h/o GI bleeds, ESRD on [**Hospital 13241**]. Discharge Condition: Stable, Hct 28.4 Discharge Instructions: You were admitted for bloody bowel movements and syncope. The gastroenterology team evaluated you and decided there was no need to re-scope your colon, but recommended that you get a small bowel capsule study as an outpt. Your blood counts stabilized with transfusion. Please take all of your medications as prescribed and follow up with the [**Hospital 4314**] below. Please bring your prescription bottles to your appointment with Dr [**First Name (STitle) 216**]. If you develop fever/chills, fainting, blood in your stool or any other concerning symptoms, please contact your doctor or go to the emergency room. It was a pleasure taking care of you, we wish you the best! Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2156-3-3**] 3:50 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2156-3-10**] 1:40 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**] Completed by:[**2156-3-3**]

[ "414.01", "578.9", "305.90", "250.60", "276.52", "585.6", "357.2" ]

icd9cm

[ [ [] ] ]

[ "96.04", "39.95", "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

10082, 10151

6355, 8369

295, 301

10279, 10298

3742, 6332

11025, 11447

3161, 3314

8758, 10059

10172, 10258

8395, 8735

10322, 11002

3329, 3329

3343, 3723

228, 257

1492, 1511

329, 1474

1533, 2834

2850, 3145

80,843

157,991

40172

Discharge summary

report

Admission Date: [**2126-12-4**] Discharge Date: [**2126-12-14**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2248**] Chief Complaint: Fatigue and dyspnea Major Surgical or Invasive Procedure: BiV Pacemaker Placement Arterial line placement History of Present Illness: [**Age over 90 **] yof with pacer and dCHF p/w 3 weeks of progressive LE edema, SOB. She has been taking lasix 80mg Qam and 40mg Qpm (recent increase) and was started on O2 at home for hypoxia 4-5L/min. She had a presycnopal episode last night at dinner table, worsening lethargy, daughter reports that she will make something to eat but then fall asleep before she eats it, desats if O2 is off with perioral cyanosis. Supposed to have pacer upgraded in [**Month (only) 404**]. In the ED she got 80mg IV lasix x1 and put out 700cc. No fever/cough. 4+ LE edema. Is on 80/40 PO lasix at home. She is alert and able to answer questions. She is still making >100cc urine/hour . On review of systems, she denies any f/c/ns, cough. she does complain of feeling cold all the time. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: Pacer [**1-15**] syncope/block 3. OTHER PAST MEDICAL HISTORY: Osteopenia Cataract Blepharitis PNA in [**2126-8-14**] SCC skin Basal cell carcinoma scalp s/p excision Pseuophakia diastolic CHF Pulmonary hypertension Detrusor instability Breast cancer s/p lumpectomy and radiation Spinal Compression fractures Social History: -Tobacco history: None Currently living in senior housing, walks with a walker since PNA in [**Month (only) 462**]. Retired receptionist, has several children living nearby. Family History: Noncontributory Physical Exam: Admission Exam: VS: T= 97.9 BP= 137/65 HR= 60 RR= 20 O2 sat= 95% 2L Wt: 59.4kg GENERAL: NAD. Oriented x3. Mood, affect appropriate, pleasant, conversant, able to [**First Name8 (NamePattern2) **] [**Doctor Last Name 1841**] in reverse w/o difficulty. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP to jaw sitting upright CARDIAC: RRR, III/VI HSM at LLSB LUNGS: Decreased BS in right base and crackles in left base ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. +HJR EXTREMITIES: 3+ pitting edema to knee bilaterally SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 1+ PT trace Left: DP 1+ PT trace Pertinent Results: = = =========================LABS=================================== Admission Labs: [**2126-12-4**] 08:15PM BLOOD WBC-7.3 RBC-4.64 Hgb-14.7 Hct-46.1 MCV-99* MCH-31.7 MCHC-32.0 RDW-15.2 Plt Ct-229 [**2126-12-4**] 08:15PM BLOOD Neuts-72.5* Lymphs-19.4 Monos-6.5 Eos-0.8 Baso-0.8 [**2126-12-4**] 08:15PM BLOOD Glucose-166* UreaN-32* Creat-1.4* Na-138 K-4.5 Cl-92* HCO3-39* AnGap-12 [**2126-12-4**] 08:15PM BLOOD Albumin-3.8 Calcium-10.5* Phos-3.3 Mg-2.1 . Discharge Labs: patient expired . Other Notable Labs: [**2126-12-4**] 08:15PM BLOOD proBNP-2351* [**2126-12-4**] 08:15PM BLOOD cTropnT-0.02* [**2126-12-7**] 07:40AM BLOOD CK-MB-5 cTropnT-0.01 [**2126-12-7**] 07:40AM BLOOD VitB12->[**2115**] Folate->20 [**2126-12-6**] 06:40AM BLOOD TSH-7.8* [**2126-12-4**] 08:15PM BLOOD TSH-6.1* [**2126-12-6**] 06:40AM BLOOD T4-6.5 T3-63* calcTBG-0.99 TUptake-1.01 T4Index-6.6 Free T4-1.2 [**2126-12-12**] 06:59AM BLOOD Ammonia-37 [**2126-12-11**] 04:27AM BLOOD Cortsol-33.8* [**2126-12-12**] 07:01AM BLOOD Type-ART pO2-68* pCO2-78* pH-7.32* calTCO2-42* Base XS-9 [**2126-12-9**] 05:09PM BLOOD Lactate-1.4 [**2126-12-10**] 10:45AM PLEURAL WBC-324* RBC-619* Polys-3* Lymphs-66* Monos-4* Meso-2* Macro-20* Other-5* [**2126-12-10**] 10:45AM PLEURAL TotProt-2.3 Glucose-119 LD(LDH)-86 . =========================STUDIES================================ CXR Portable ([**2126-12-4**]) FINDINGS: AP portable upright view of the chest is obtained. Evaluation is limited given the low lung volumes and the patient's kyphotic and slightly rotated positioning. There is a single-lead pacer device projecting over the left chest wall with single lead tip terminating in the expected location of the right ventricle. There is a large right pleural effusion with probable atelectasis in the right middle and lower lobes. Cannot exclude underlying infection. There is a rounded density projecting over the left lower lung, which could represent a prominent nipple shadow. The left lung is otherwise grossly unremarkable. The heart appears enlarged, though this is difficult to quantitate given the study limitations and the lack of prior studies. The aorta appears extensively calcified and unfolded. No pneumothorax is seen. Bones are demineralized with a marked dextroscoliosis of the spine with the scoliotic apex at the thoracolumbar junction. IMPRESSION: Large right pleural effusion with probable collapse of the right middle and lower lobes, though infection in the right lower lung cannot be entirely excluded. Probable nipple shadow accounting for rounded density projecting over the left lower lung. Cardiomegaly. Followup to resolution is advised. . Echo: The left atrium is normal in size. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is markedly dilated with moderate global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets are mildly thickened (?#). There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a very small pericardial effusion. . Pleural fluid cytology: POSITIVE FOR MALIGNANT CELLS; CONSISTENT WITH ADENOCARCINOMA . CXR: FINDINGS: Right pleural effusion has decreased in size following thoracentesis, with residual moderate effusion remaining. No visible pneumothorax, but extreme right lung apex is partially obscured by the flexed position of the patient's chin and neck. Asymmetrical airspace process within the right mid and lower lung could potentially represent reexpansion pulmonary edema in the setting of recent thoracentesis. Infectious process is also a consideration in the appropriate clinical setting. On the left, a small pleural effusion is unchanged, but retrocardiac atelectasis has worsened. Brief Hospital Course: [**Age over 90 **] yo F with dCHF p/w worsening SOB and LE over last 3 weeks with increasing O2 requirements whose hospital course included aggressive diuresis with lasix gtt, pacemaker exchange, and transfer to the CCU for increasing respiratory distress. . # Hypoxic/hypercarbic respiratory failure: After pacemaker exchange, the patient required noninvasive positive pressure ventilation to oxygenate properly with hypercarbia to the 90s. She did not require intubation and was able to be weaned to a Venti mask and eventually to high-flow O2 through a nasal canula. Her respiratory issues were multi-factorial: (1) large plerual effusion, with a thoracentesis that showed malignant cells consistent with adenocarcinoma and minimal symptomatic relief. (2) Severe pulmonary hypertension with markedly reduced right ventricular function. (3) Likely intrinsic lung disease. Initial echocardiogram findings were suspicious for a PE given the level of RV failure, but this was felt to be a progression of her pulmonary hypertension. A family meeting was held with Dr. [**Last Name (STitle) **] and it was determined to make her CMO, given that she would never achieve the level of independence that she was accustomed to and the family did not feel that was an acceptable quality of life for her. All labs draws were stopped, her invasive monitoring was discontinued, and she expired shortly thereafter. . # CHF exacerbation with hypotension: Though she was volume overloaded on exam from heart failure, she could not tolerate any appreciable diuresis due to her low blood pressures, requiring increasing amount of peripheral dopamine for support. She was unable to maintain her pressures without dopamine, as multiple attempts at weaning were unsucessful. AM cortisol was appropriately elevated, ruling out adrenal insufficiency. . # 3rd degree heart block s/p pacemaker placement: Patient had 3rd degree AV block on admission. Given CHF symptoms and declining respiratory status at home, it was though this may be due to AV dysynchrony and the decision was made to upgrade her pacer to a BiV pacemaker. EP replaced the pacemaker, but the patient's respiratory status required CCU transfer and her cardiac and pulmonary comorbidities did not allow for any true resolution of her symptoms despite a well-functioning pacer. . Medications on Admission: lisinopril 20 mg Tab Oral 1 Tablet(s) Once Daily Lasix 80mg qam/40mg Qpm minocycline 50mg Q12 Calcium +D MVI Vitamin B complex ASA 81 Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: Severe Pulmonary Hypertension Congestive Heart Failure - Diastolic Dysfunction Complete Atrioventricular Heart block status post pacemaker upgrade Osteopenia Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2264**]

[ "199.1", "426.0", "V10.3", "428.0", "511.81", "511.9", "737.10", "428.33", "799.02", "403.90", "585.9", "518.81", "V10.83", "733.90", "416.8", "276.3" ]

icd9cm

[ [ [] ] ]

[ "37.73", "37.87", "34.91", "38.91" ]

icd9pcs

[ [ [] ] ]

9527, 9536

6974, 9303

272, 321

9738, 9743

2646, 2715

9795, 9893

1815, 1832

9487, 9504

9557, 9717

9329, 9464

9767, 9772

3116, 6951

1847, 2627

1231, 1330

213, 234

349, 1124

2731, 3100

1361, 1608

1146, 1211

1624, 1799

22,921

103,590

15763

Discharge summary

report

Admission Date: [**2171-3-14**] Discharge Date: [**2171-3-20**] Date of Birth: [**2111-9-22**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3326**] Chief Complaint: Pneumonia, Alcohol Withdrawal, Alcohol Dependence with Acute Intoxication Major Surgical or Invasive Procedure: none History of Present Illness: 59 year old male with a history of polysubstance abuse and chronic pain, recently discharged from the medical service for alcohol withdrawal and pneumonia, who was brought in by EMS after he was found intoxicated at a T-stop. In the ED, the patient sobered from his acute alcohol intoxication. However, he then went into withdrawal. He began [**Doctor Last Name **] 22 on CIWA and was given 3 doses of ativan. Of note, the patients last admission one month prior to this presentation was complicated by pneumonia, for which he was discharged on amoxicillin/clavulonate. The patient continues to note a persistent cough, although denies fever or chills. He underwent chest X-ray in the ED was concerning for either a recurrence of his pneumonia or a persistence of the prior pneumonia. ROS: GEN: - fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, - Constipation, - Hematochezia PULM: + Dyspnea, + Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache Past Medical History: - Benign Hypertension - Alcohol abuse - 1qt vodka per day - chronic pain on methadone - h/o [**Doctor Last Name 8751**] with multiple traumatic injuries and subsequent surgeries including splenectomy, fracture repairs, skin grafts - h/o polysubstance abuse -asplenia Social History: Currently homeless. Smokes 1ppd for the past 40 years. Drinks about a pint of vodka daily with history of withdrawal. He denies any IVDU. Family History: Parents were alcoholics. He notes a significant family history of cancer in his mother and father as well as his siblings. He thinks most were esophageal cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VSS: 98.6, 166/94, 68, 20, 96%2L GEN: Cachectic, Uncomfortable, Tremulous Pain: [**3-5**] HEENT: EOMI, MMM, - OP Lesions, + tongue fasiculations PUL: coarse b/l rhonchi on all fields, EE Wheezes COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CCE NEURO: CAOx3, course tremor, CN II-XII grossly normal . DISCHARGE PHYSICAL EXAM: GEN: awake, alert, intermittently follows commands (has to be reminded to take deep breaths during lung exam) HEENT: EOMI, MMM, - OP Lesions PUL: mild diminished BS on b/l lower lobes COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: - CCE NEURO: AOx3, mild course tremor, CN II-XII grossly normal Pertinent Results: Admission Labs [**2171-3-15**] 06:45AM: WBC-6.2 RBC-4.56* Hgb-14.5 Hct-47.0 MCV-103* MCH-31.7 MCHC-30.8* RDW-14.2 Plt Ct-192 Neuts-51 Bands-0 Lymphs-34 Monos-10 Eos-5* Baso-0 Atyps-0 Metas-0 Myelos-0 PT-10.6 PTT-34.6 INR(PT)-1.0 Glucose-170* UreaN-9 Creat-0.6 Na-137 K-5.5* Cl-96 HCO3-31 AnGap-16 ALT-24 AST-25 LD(LDH)-198 CK(CPK)-105 AlkPhos-84 Amylase-920* TotBili-0.3 Calcium-10.1 Phos-5.0* Mg-1.8 Discharge Labs: WBC-4.6 RBC-4.26* Hgb-13.7* Hct-44.0 MCV-103* MCH-32.1* MCHC-31.0 RDW-14.1 Plt Ct-242 Neuts-39* Bands-1 Lymphs-40 Monos-9 Eos-7* Baso-1 Atyps-3* Metas-0 Myelos-0 PT-11.0 PTT-36.5 INR(PT)-1.0 Glucose-95 UreaN-13 Creat-0.6 Na-138 K-4.4 Cl-99 HCO3-32 AnGap-11 ALT-19 AST-23 LD(LDH)-199 AlkPhos-63 TotBili-0.3 Albumin-3.8 Calcium-9.4 Phos-3.5 Mg-1.8 Lactate-0.5 Micro: Blood cultures 4/20, [**3-19**], [**3-20**] pending CHEST (PA & LAT) Study Date of [**2171-3-14**] 9:29 PM 1. Continued right middle lobe opacification concerning for pneumonia. As the findings appear similar when compared to prior study, chest CT should be obtained to evaluate for the presence of an obstructing central or endobronchial lesion. 2. Improved aeration of the left lower lobe with residual linear opacities which may be reflective of atelectasis. CT Chest non-con, [**3-16**]: 1. Right middle lobe collapse with bronchial obstruction. Right lower lobe bronchus severely narrowed proximally with distal reconstitution. In the setting of involvement of two adjacent airways, lesion extrinsic to the airways is more likely than endobronchial lesions, but evaluation is limited in the absence of intravenous contrast. Repeat chest CT with intravenous contrast could be performed for further evaluation. Alternatively, direct visualization could be performed. 2. Prominent mediastinal and hilar lymph nodes. 3. Subcentimeter nodules and ground-glass opacity in the left lower lobe, concerning for infection. In the presence of centrilobular emphysema, close interval follow up is recommended after treatment or within 3 months. 4. Mild anterior wedging of the T11 and T12 vertebral bodies. 5. Predominantly left-sided coronary artery calcifications. CXR portable Study Date of [**2171-3-19**] 1:39 AM: Mild-to-moderate bibasilar atelectasis has been present without appreciable change since [**2-3**]. Previous small bilateral pleural effusions have decreased. Upper lungs are clear. Heart size is normal. There are no findings to suggest pneumonia currently. What appears to be a 5-cm long segment of catheter tubing crosses the paramedian left hemithorax obliquely. In order to clarify whether there is a retained catheter fragment, routine chest radiograph should be obtained, and the radiologist notified before the patient leaves the department. Brief Hospital Course: 58 year old man with a history of polysubstance abuse, admitted to the hospital with intoxication/withdrawal symptoms and hypoxia; admission complicated by hypercarbic respiratory failure. # Hypercarbic and Hypoxic Respiratory failure: On admission, the patient was noted to be hypoxic. He also has chronic CO2 retention related to baseline COPD. He underwent CT chest on admission that showed RML collapse, likely by extrinsic compression by mass. He was started on ceftriaxone and azithromycin for CAP coveraged. He was evaluated by interventional pulmonary with plan for bronchoscopy to further evaluate bronchial obstruction. However, with the use of benzodiazepines for alcohol withdrawal (described below), he became somnolent and began to go into hypercarbic and hypoxic respiratory failure. He was transferred to the MICU. In the ICU, the patient was reversed with 4 doses of flumazenil. He did not require invasive ventilation. The benzodiazepines cleared from his system, and he awoke. He eloped from the hospital prior to planned bronchoscopy. The patient should follow up with interventional pulmonology for further evaluation of his right middle lobe collapse. # Alcohol Withdrawal, Alcohol Dependence with Acute Intoxication: The patient presented to the emergency department with alcohol intoxication, and was admitted to the hospital floor as he started to withdraw. In the first 24 hours of his hospital stay, he received >100mg valium. By hospital day 3 symptoms of withdrawal had improved, however, the patient became increasingly somnolent. Respiratory drive was decreased by cumulative effect of benzodiazepines, and the patient was transferred to the MICU as above. # Chronic Pain: Per prior notes and patient report, he takes methadone 10mg TID for chronic pain after a motor vehicle accident. On admission, he was continued on methadone 10mg TID. This medication was held on admission to the ICU, as the patient experienced increasing somnolence. # Benign Hypertension: The patient was continued on home Toprol-XL 25mg daily. # Lung nodules: CT chest showed "Subcentimeter nodules and ground-glass opacity in the left lower lobe, concerning for infection. In the presence of centrilobular emphysema, close interval follow up is recommended after treatment or within 3 months." The patient was recommended to follow up regarding these findings in 3 months. No follow-up was arranged for him, as he eloped from the ICU. ================================================ TRANSITIONAL ISSUES: Patient with RML collapse likely secondary to extrinsic compression, and left lower lobe lung nodules. Patient should follow up with interventional pulmonology regarding these findings and should undergo repeat CT scan chest in 3 months Medications on Admission: albuterol 90 mcg MDI 2 Puffs Q6H methadone 10 mg PO TID Toprol-XL 25 mg PO Daily MVI Daily Discharge Medications: Patient eloped from the ICU prior to planned discharge Discharge Disposition: Home Discharge Diagnosis: Alcohol withdrawal Bacterial pneumonia Lung [**Hospital3 45395**] failure Discharge Condition: patient eloped from the hospital while admitted to the ICU Discharge Instructions: Patient was admitted with alcohol withdrawal and shortness of breath. He was found to have pneumonia and a mass in his lung. Admission complicated by ICU transfer for somnolence in the setting of benzodiazepines used to treat alcohol withdrawal. Benzodiazepines cleared, and the patient returned to baseline mental status. The patient insisted on leaving the hospital against medical advice. Before the entire team had a chance to speak with the patient about the full risks that he was facing, he left the Unit without being observed. During admission, patient was found to have lung nodules on a CT scan of the chest. He will need to have another CT scan of the chest in 3 months to follow these nodules. Followup Instructions: The patient left the ICU against medical advice and prior to arranging followup for his outstanding problems.

[ "518.81", "V60.0", "291.81", "482.9", "496", "305.1", "519.19", "518.0", "401.1", "507.0", "303.01", "V45.79", "786.6" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8800, 8806

5805, 8319

378, 385

8924, 8985

3027, 3431

9743, 9857

2169, 2332

8721, 8777

8827, 8903

8606, 8698

9009, 9720

3448, 5782

2372, 2681

8340, 8580

265, 340

413, 1707

1729, 1997

2013, 2153

2706, 3008

12,706

181,053

11059

Discharge summary

report

Admission Date: [**2112-3-14**] Discharge Date: [**2112-3-18**] Date of Birth: [**2049-9-30**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5368**] Chief Complaint: Choked, dyspnea. Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: Mrs. [**Known lastname 4553**] is a 62 year old female with history of IDDM x 25 years, ESRD on HD, 5 vessel CABG in [**2103**], CHF (EF 55% in [**8-30**], with diastolic dysfunction), HTN, hypercholesterolemia, and COPD, who presented on [**2112-3-13**] s/p an episode of choking on coffee. The patient reports that she simply choked on the coffee, and this is not a frequent occurrence. Denies any dysphagia. She does note increased coughing over the last couple of months, non-productive. She denies any [**Date Range 5162**] or chills. Denies shortness of breath prior to this hospitaliztion, but says since the choking episode she has been more short of breath. She denies chest pain. She does note orthopnea, but no LE edema. While in the E.D. she was found to have a saturation of 88% on RA, and was markedly hypertensive (236/73). She was started on levaquin/flagyl for presumed aspiration (question of slight PNA on CXR which has since been read as negative). There was also felt to be a component of CHF, confirmed on CXR, and she was given lasix 40 mg IV, however subsequently required fluids for DKA as her nightly glargine was unfortunately not given in the ED. Her sugars on the following morning were noted to be 700s, with an anion gap of 19 and hyperkalemia. She was transferred to the MICU where she was started on an insulin drip, with improved control and closure of her gap. However, during the course of her MICU stay she is more than 2 L positive. She was ruled out for MI by cardiac enzymes, EKG unchanged. Also in the MICU she had a RUQ US secondary to complaint of RUQ pain on admission, however this was normal and her pain has resolved. She is not being called out to the floors. Past Medical History: 1. s/p banding of AV fistula [**10-30**] 2. s/p EGD [**8-29**] mild duodonitis, gastritis, esophageal candidiasis, [**Doctor First Name 329**] [**Doctor Last Name **] tear 3. IDDM 25yrs, hx DKA/ neuropathy/ nephropathy 4. ESRD on HD 5. CAD s/p 5v CABG [**2103**]- cath [**8-30**] sever native 2v CAD presumed total occl of SVG-D1- echo [**8-30**] EF 55% 1+MR- PMIBI [**2-29**] no rev defects 6. CHF EF 55% 7. HTN 8. hyperchosterolemia (no statin [**12-30**] lft abn) 9. fibroids 10. PVD s/p L CEA 11. pubic ramus fx [**12-30**] 12. hx MRSA UTI 13. s/p CCY 14. hx pleural effusions tapped [**12/2110**] after rll pulm mass seen on CT- negative serologies 14. dizziness 15. pancreatitis Social History: She has a 100 pack year smoking history, and continues to use tobacco. She only drinks alcohol occasionally. She lives with her mother who is 85, at home. She says that they take care of each other. She has 2 children, but is divorced. Family History: Father died of myocardial infarction at the age of 65. Her mother had a heart attack and had cardiac surgery in [**2101**]. She has a history of hypertension. No history of cancer, strokes or liver or kidney disease. Physical Exam: VS: 97.0, afebrile, 59, 152/44, 20, 97% on RA Gen: Slim caucasian female appearing mildly tachypneic, but comfortable otherwise. Neck: JVP at 10 cm. Cor: RR, normal rate, 1/6 systolic murmur at RSB. Lungs: Rales at L base, decreased breath sounds at R base with dullness to percussion. Abd: NABS, soft, NT/ND. No [**Doctor Last Name **] sign. Extr: No c/c/e. Single non-erythematous erosion in medial aspect of L foot, without discharge or exudate. Neuro: AAO x 3. Resting tremor which does not cease with activity. CN II-XII intact. Patient has decreased stregth of L hand (says [**12-30**] AVF creation). Otherwise strength 5/5 upper and lower extremities. Sensation intact to proprioception in hands and feet. [**First Name8 (NamePattern2) **] [**Last Name (un) **], monofilament sensation lost, and lost vibration in feet. Pertinent Results: VIDEO OROPHARYNGEAL SWALLOW: The examination was performed in conjunction with a speech therapist. Barium was administered in various consistencies under fluoroscopic guidance, including thick barium, thin, puree, barium- soaked cookie, cheerios, and a barium tablet. The patient was able to swallow thick barium liquid without difficulty. When a teaspoon of thin barium was administered, there was trace penetration before the swallow, and aspiration during the swallow. There is no spontaneous cough. However, when thin barium was administered in a cup, no aspiration occurred. When the patient took straw sips of thin, trace penetration occurred without aspiration. The penetration of thin barium was cleared with a cued cough. With the barium tablet administration, the patient aspirated a mild amount of water, which was not cleared with a spontaneous cough. IMPRESSION: Trace aspiration episodes with thin liquids as described. For a more detailed report, please refer to the report of the speech pathologist. [**3-13**]: PA AND LATERAL CHEST: Comparison is made to [**2111-12-5**]. Again, seen is a dual lumen central venous line with the tip in the distal SVC, unchanged. Cardiac size is unchanged. There are chronic appearing changes in the pulmonary vasculature with mild CHF, and small bilateral effusions. Osseous structures are diffusely demineralized. IMPRESSION: Stable mild CHF. No evidence of pneumonia. [**3-14**]: RIGHT UPPER QUADRANT ULTRASOUND: There is no intra or extrahepatic biliary ductal dilatation, with the common bile duct measuring approximately 2-3 mm. No focal hepatic masses or fluid collections are seen. The gallbladder has been removed surgically. Evaluation of the distal duct near the pancreas was severely limited by overlying bowel gas. The pancreas is not visualized. There is a 3 cm cyst in the upper pole of the right kidney, as seen on the prior [**2111-3-12**] study. IMPRESSION: No biliary ductal dilatation or evidence of retained stone. Distal CBD and pancreas not visualized. [**2112-3-14**] 11:15PM GLUCOSE-479* UREA N-49* CREAT-4.5* SODIUM-144 POTASSIUM-5.4* CHLORIDE-102 TOTAL CO2-29 ANION GAP-18 [**2112-3-14**] 11:15PM CK(CPK)-94 [**2112-3-14**] 11:15PM CK-MB-4 cTropnT-0.19* [**2112-3-14**] 11:15PM CALCIUM-9.3 PHOSPHATE-4.3 MAGNESIUM-2.3 [**2112-3-14**] 11:15PM ACETONE-POS [**2112-3-14**] 05:47PM GLUCOSE-95 UREA N-46* CREAT-4.3* SODIUM-146* POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-29 ANION GAP-16 [**2112-3-14**] 07:58AM LACTATE-3.4* K+-6.2* [**2112-3-14**] 05:50AM WBC-16.4*# RBC-3.70* HGB-12.0 HCT-38.0 MCV-103* MCH-32.4* MCHC-31.5 RDW-14.4 [**2112-3-13**] 09:16PM ALT(SGPT)-18 AST(SGOT)-19 CK(CPK)-66 ALK PHOS-115 AMYLASE-34 TOT BILI-0.3 [**2112-3-13**] 09:16PM LIPASE-17 SPUTUM GRAM STAIN (Final [**2112-3-17**]): <10 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [**2112-3-19**]): SPARSE GROWTH OROPHARYNGEAL FLORA. **FINAL REPORT URINE CULTURE (Final [**2112-3-16**]): <10,000 organisms/ml. **FINAL REPORT [**2112-3-20**]** AEROBIC and ANAEROBIC BOTTLE (Final [**2112-3-20**]): NO GROWTH. calTIBC VitB12 Folate Ferritn TRF IRON 203* 651 GREATER TH1 924* 156* 27 Brief Hospital Course: Ms. [**Known lastname 4553**] is a 62 year old female with IDDM x 25 years, ESRD on HD, 5 vessel CABG in [**2103**], CHF(EF 55% in [**8-30**], but diastolic dysfunction as well), HTN, hypercholesterolemia, and COPD, who presented s/p an aspiration event with O2 sat 88% on RA in the ED, subsequently transferred to the MICU with DKA secondary to missing her nightly glargine then stabilized and transferred to the floors. 1) Hypoxia: Thought secondary to aspiration pneumonia/pneumonitis given aspiration event at home, however likely component of CHF as well, as CXR did not demonstrate an infiltrate, but did demonstrate mild CHF, and BNP 50,000. Nevertheless, given that this episode began after choking on coffee, still treating with abx for aspiration PNA. The speech and swallow team was involved and determined that she should take her pills in soft solids. Patient initially got lasix, however with DKA she required fluids. She continued to get HD, and her O2 saturations stayed 97% on RA. Her antibiotics were stopped when it was determined that she did not have a pneumonia. In terms of etiology of CHF exacerbation, her dysfunction seems to be mostly diastolic, and her blood pressure was markedly elevated on admission. Ms. [**Known lastname 4553**] came in on Hydralazine 25 mg PO BID, Imdur 20 mg PO TID, Clonidine patch Q Fri, Lisinopril 40 mg daily, amlodipine 5 mg daily, toprol 50 PO daily. Her hypertension was likely related to volume overload, on HD. Her BP medications were titrated up (isosorbide and ACE I) for better control. She refuses to take amlodipine since it makes her dizzy. 2) IDDM: DKA resolved, gap closed. [**Last Name (un) **] team recommended an increase in lantus to 10 U QHS. Her sliding scale was also titrated up for better control. In terms of etiology of DKA, this was presumed secondary to missed insuline dose. Infection was ruled out given WBC elevation to 16 with PMN 92. Blood and urine cultures were sent. She had no sign of infection on feet. 3) ESRD: Ms. [**Known lastname 4553**] is getting [**Known lastname 2286**] currently. Her Nephrocaps and Sevelamer were continued. 4) Ms [**Known lastname 4553**] has anemia with recent hct as high as 38, but appears that baseline around 30. She was likely hemoconcentrated on admission and hct drop to 30 likely dilutional. However, per [**Known lastname **], the patient is markedly epogen resistant. Iron studies were consistent with anemia of chronic disease and her hct remained stable. 5) Ms. [**Known lastname 4553**] has CAD s/p CABG. She was ruled out for MI and her daily [**Known lastname **] 325, statin, BB, and ACE-I were continued. For the COPD, Ms. [**Known lastname 4553**] was continued on PRN albuterol. She was no wheezy on exam. The bupropion 150 mg [**Hospital1 **] was continued for depression. She was sent home in fair condition without services, although the physical therapy team thought she could benefit from home PT. She has no insurance that will pay for home sevices and she refused a volunteer visitor. Medications on Admission: [**Hospital1 **] 81 mg daily Renagel 800 TID Isosorbide mononitrate 10 mg TID Nephrocaps Protonix 40 mg daily Lipitor 10 mg daily Toprol 50 mg daily Clonidine 0.2 mg Friday Hydralazine 25 mg [**Hospital1 **] Colace 100 mg [**Hospital1 **] Glargine 8 U QHS Humalog SS Lasix 40 mg PO daily Norvasc 5 mg daily Ventolin PRN Zestril 30 mg daily Wellbutrin 150 mg [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap 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. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Clonidine HCl 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every Friday). 8. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 10. Insulin Glargine 100 unit/mL Solution Sig: One (1) 10 Subcutaneous at bedtime. 11. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 12. Humalog 100 unit/mL Solution Sig: One (1) sliding scale Subcutaneous four times a day. 13. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Lisinopril 40 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: end stage [**Hospital1 **] disease on HD T TH S DM I Diabetic ketoacidosis congestive heart failure hypertension COPD PVD s/p left CEA hypercholesterolemia, not on statin secondary to abnormal LFTs duodenitis, gastritis, esophageal candidiasis & [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear by EGD [**8-29**] history of MRSA UTI Discharge Condition: fair Discharge Instructions: Please take all your medications as listed on the next page. Please note, there have been some changes. Continue your hemodialysis treatments as usual. Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 5162**], chills, dizzyness, shortness of breath, chest pain, head ache, visual changes, confusion, or any other concerns. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 540**], MD Where: [**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2112-3-30**] 4:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2112-3-18**] 10:00. He may want to restart your statin in the future.

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

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332, 346

12792, 12798

4171, 7584

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3081, 3300

11083, 12364

12414, 12771

10684, 11060

12822, 13171

3315, 4152

276, 294

374, 2098

2120, 2808

2824, 3065

15,293

145,013

26368

Discharge summary

report

Admission Date: [**2112-1-27**] Discharge Date: [**2112-2-1**] Date of Birth: [**2056-6-21**] Sex: F Service: SURGERY Allergies: Propofol / Kefzol / Versed / Singulair Attending:[**First Name3 (LF) 371**] Chief Complaint: PLEASE SEE DC SUMMARY [**2-1**] (same hospital admission) sp submersion Major Surgical or Invasive Procedure: sp CVL placement sp Arterial line placement History of Present Illness: 56 year-old woman with a history of obesity and hypertension who was an unrestrained driver where the motor vehicle slid on ice down a driveway, rolled down an embankment, and flipped over into a creek. By report she was submerged for at least 20 minutes. After a lengthy extrication, she was found to be apnic and have pulseless electrical activity. She was intubated and ATLS protocol restored a pulse and blood pressure. She was transferred via [**Location (un) 7622**] to the [**Hospital1 18**] for further evaluation. Of note, [**Location (un) 7622**] personnel reported spontaneous eye opening en route. Past Medical History: morbid obesity, HTN, COPD, asthma, psychiatric Social History: depression Family History: NC Physical Exam: temp 33 C, HR 60, bp 105/60 sat 98% on ventilator ?posturing no response to verbal eyes fixed upgaze pupils intermittently reactive? neg corneals no grimace to sternal rub toes bilat down no response to noxious stimuli to limbs, no spont mvmt. ? startle reflex Pertinent Results: [**2112-1-27**] 06:20PM BLOOD WBC-10.5 RBC-4.57 Hgb-13.8 Hct-39.6 MCV-87 MCH-30.3 MCHC-34.9 RDW-14.4 Plt Ct-143* [**2112-1-28**] 03:07PM BLOOD WBC-11.2* RBC-4.15* Hgb-12.4 Hct-34.0* MCV-82 MCH-29.7 MCHC-36.4* RDW-14.6 Plt Ct-187 [**2112-2-1**] 06:25PM BLOOD WBC-11.1* RBC-4.08* Hgb-11.8* Hct-35.1* MCV-86 MCH-28.8 MCHC-33.5 RDW-15.2 Plt Ct-254 [**2112-1-27**] 06:20PM BLOOD UreaN-21* Creat-0.9 [**2112-1-28**] 03:07PM BLOOD Glucose-134* UreaN-12 Creat-0.8 Na-138 K-3.3 Cl-105 HCO3-22 AnGap-14 [**2112-1-31**] 04:32AM BLOOD Glucose-136* UreaN-13 Creat-0.8 Na-139 K-4.6 Cl-108 HCO3-22 AnGap-14 [**2112-2-1**] 06:25PM BLOOD Glucose-104 UreaN-18 Creat-0.8 Na-144 K-4.7 Cl-112* HCO3-23 AnGap-14 [**2112-1-28**] 02:08AM BLOOD ALT-65* AST-57* CK(CPK)-297* AlkPhos-88 Amylase-102* [**2112-2-1**] 06:25PM BLOOD ALT-329* AST-383* LD(LDH)-656* AlkPhos-84 Amylase-71 TotBili-0.3 [**2112-2-1**] 06:25PM BLOOD Albumin-2.2* Calcium-7.2* Phos-3.4 Mg-1.9 [**2112-1-30**] 02:07AM BLOOD Phenoba-8.9* Phenyto-14.3 [**2112-1-30**] 07:53AM BLOOD Phenoba-8.3* [**2112-1-31**] 04:32AM BLOOD Phenoba-12.2 Phenyto-13.4 [**2112-2-1**] 02:35AM BLOOD Phenoba-16.6 Phenyto-11.0 [**2112-1-27**] 06:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2112-1-27**] 08:58PM BLOOD Type-ART pO2-410* pCO2-58* pH-7.15* calHCO3-21 Base XS--9 [**2112-1-28**] 09:53AM BLOOD Type-ART pO2-161* pCO2-31* pH-7.49* calHCO3-24 Base XS-2 [**2112-1-30**] 02:26AM BLOOD Type-ART Temp-37.5 Rates-28/ Tidal V-500 PEEP-5 FiO2-40 pO2-76* pCO2-38 pH-7.40 calHCO3-24 Base XS-0 -ASSIST/CON Intubat-INTUBATED [**2112-2-1**] 02:52AM BLOOD Type-ART pO2-159* pCO2-34* pH-7.41 calHCO3-22 Base XS--1 [**2112-1-30**] 07:53AM BLOOD PENTOBARBITAL- TE [**2112-1-30**] head CT: Persistent indistinctness of the great/white matter differentiation, unchanged compared to the previous exam. No acute hemorrhage. Patent basal cisterns. [**2112-1-27**]: CT abd: 1. Patchy bilateral pulmonary parenchymal opacities and atelectases. 2. No other evidence of acute traumatic injury. [**2112-1-27**]: CT cspine: Technically limited study. No evidence of cervical spine fracture or dislocation. Scattered densities at the lung apices, likely related to history of drowning. [**1-30**] EEG: This is an abnormal discontinous 24-hour bedside EEG telemetry from [**1-29**] due to bursts of generalized spike and slow wave discharges with intermittent brief bursts of suppressed background. Under pentobarbital, the duration of the depressed background increased and the bursts of generalized spike and slow wave discharges decreased during burst suppression pattern. This finding represents a severe encephalopathy from this medication-induced burst suppression coma. Brief Hospital Course: On arrival to [**Hospital1 18**], the pt was hypothermic (33 degrees Celsius) and hemodynamically normal. Her pupils were equal bilaterally and very sluggish to respond to light. She was unresponsive to verbal and noxious stimuli. There were occasional muscle twitches but no gross motor movements. The remainder of her exam was unremarkable. Head CT shows mildly indistinct grey-white matter differentiation but no obvious injuries. The chest CT was remarkable for patchy bilateral opacities of the lungs. She was transferred to the trauma ICU warmed and resuscitated. Neurosurgery placed an intracranial bolt and the opening intracranial pressure was documented as 70 mmHg but soon after settled at around 25-30 mmHg. On follow up she developed more muscle twitching and an upward gaze suggestive of seizure activity. Dilantin was started and the neurology service was consulted. A continuous EEG was performed at the bedside and was consistent with anoxic encephalopathy with developing continuous epileptiform discharges. There was no evidence of any typical electrical brain activity. Given the history, the devastating neurologic insult, and the lack of any meaningful recovery her prognosis was dismal. After several family meetings the decision was made to withdraw support and it was the patient??????s expressed wish to be an organ donor. On hospital day 6 support was withdrawn, comfort measures were instituted, and she was taken for a DCD harvest by the transplant team. Medications on Admission: accolalate 20", serevent", flovent 220", lipitor 20', topamax 100", fluoxetine 20"', trazodone 50", asa 81', albuterol, risperdal 0.5"', hydroxychloroquine 200", hyoscyamine 0.375" Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: sp submersion/anoxic brain injury Discharge Condition: NA Discharge Instructions: NA Followup Instructions: NA Completed by:[**2112-3-8**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

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5966, 5975

4221, 5708

368, 413

6052, 6056

1468, 3208

6107, 6139

1167, 1171

5939, 5943

5996, 6031

5734, 5916

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1186, 1449

257, 330

441, 1052

3217, 4198

1074, 1123

1139, 1151

13,559

107,672

49140+59153+59155

Discharge summary

report+addendum+addendum

Admission Date: [**2177-7-3**] Discharge Date: [**2177-8-1**] Date of Birth: [**2107-11-9**] Sex: F HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 59 year old woman who presented with a chief complaint of shortness of breath. She has a past medical history of breast cancer, DCIS, diagnosed in [**2175-6-10**]. She is status post total positive, Stage II, N0 M0 with no radiation therapy, previously on Tamoxifen. She also has a history of hypertension, chronic obstructive pulmonary disease, diabetes mellitus type 2 on oral hypoglycemics, chronic renal insufficiency secondary to diabetes mellitus with nephrotic proteinuria. She has a history of increased creatinine on ACE inhibitors. She also has a history of thalassemia trait, ALLERGIES: She has no known drug allergies. SOCIAL HISTORY: She has remote tobacco use. No alcohol consumption. She lives with her son. Nine days prior to her admission to [**Hospital1 190**] she was discharged from [**Hospital1 190**] where she was admitted for a chronic obstructive pulmonary disease flare and bilateral pleural effusions and a pericardial effusion with tamponade which was tapped under ultrasound there, showing an exudative effusion and cytologies were negative. Serum [**Doctor First Name **] was positive for 1:160; a 2D echocardiogram there also showed right ventricular wall clot/tumor, but a normal ejection fraction of 60%. She was treated with Levofloxacin at the time. Upon arriving to the Emergency Department at [**Hospital1 346**] she was short of breath. PHYSICAL EXAMINATION: On examination, she was tachypneic with respirations of 25 to 35, saturating at 65% on room air. She remained hypoxic on 100% face mask and arterial blood gas showed a respiratory acidosis of 7.32/66/55. Her left eye is blind, abducted. Her right eye has equal and reactive pupil. Oropharynx is clear. Neck was supple with no jugular venous pressure. Lungs were dull at the left base with decreased breath sounds on the left, fine crackles, bibasilar. There was no wheezing but was rhonchorous. Cardiovascular: She had regular tachycardic rhythm with a faint pericardial rub. Abdomen was unremarkable. LABORATORY: Her labs on presentation were significant for a white blood cell count of 19.4, with left shift, neutrophils of 93%. Her hematocrit was 40.8 with an MCV of 77. Her hemoglobin A1C was 7.6% and her blood gas revealed a pH of 7.32, a pO2 of 66 and a pCO2 of 55 on Bi-PAP 5/5 with an FIO2 of 35%. Her EKG showed normal sinus rhythm. ST elevation of 1 mm in the anterior V1 through V3 leads; no change from [**2175-6-10**]. HOSPITAL COURSE: The patient was initially thought to have a chronic obstructive pulmonary disease flare and was treated with nebs, Lasix and Solu-Medrol. The patient was found to have tamponade physiology on PTE. She was taken for a balloon pericardiotomy and required intubation for airway protection at that time. She also received an ultrasound guided thoracentesis on [**7-4**] for a left pleural effusion which turned out to be a transudative effusion. She was successfully intubated after this procedure. Unfortunately, pulmonary and pericardial effusions reaccumulated. The patient had respiratory failure requiring re-intubation on [**7-9**], at which time she was taken to the Operating Room for a pericardial window, a left chest tube placement and a left pleurodesis. Post-procedure extubation attempts were unsuccessful and the patient was transferred to the Medical Intensive Care Unit. In the Medical Intensive Care Unit, the patient was failing to wean from the ventilator due to many factors. Most notably, the patient was found to have diaphragmatic weakness with poor negative inspiratory pressures, gastric balloon studies were nonrevealing and diaphragm ultrasound was suggestive of a diaphragmatic weakness. She was also found to have critical care polyneuropathy and myopathy as well which probably contributed significantly to her failure from weaning. She also has a component of bronchoconstriction on top of a restrictive lung disease which responds to Albuterol nebulizers. Due to the failure to wean, the patient was trached on [**2177-7-17**]. From a cardiovascular standpoint, the patient was diuresed for congestive heart failure, titrated on afterload reducing medications for systolic hypertension including Metoprolol and Lisinopril. Her initial serial PTE's showed reaccumulation of pericardial fluid which was loculated but did not show any signs of tamponade. The patient required treatment for a Candiduria and was given Diflucan for five days and then Foley catheter was changed. She was also treated with Levofloxacin for five days for a urinary tract infection between [**7-19**] and [**7-24**]. The patient had increasing white blood counts starting [**7-21**] with no determined source until [**7-27**] when her urine cultures grew out Vancomycin resistant enterococcus. She was previously given a course of Vancomycin for Gram positive cocci in one out of four bottles of blood culture, but was discontinued when the urine cultures revealed Vancomycin resistant enterococcus. She was started on Linezolid. Her hospital course was also complicated by a contrast induced nephropathy which is resolving. As mentioned previously, the patient had an EMG which showed evidence of critical care neuromyopathy. Since starting the Linezolid, the patient has had decrease in fever spikes and falling white blood cell counts. She has responded accordingly from a Pulmonary standpoint where she is able to tolerate a T-piece. The patient had a PEG tube placed on [**2177-7-28**]. CONDITION AT DISCHARGE: The patient's cause of recurrent pericardial and pleural effusions are still unknown to date. Her pleural effusions are transudative in nature. Rheumatology has evaluated her and determined that this is not a rheumatologic cause since her [**Doctor First Name **] was negative at the time of admission. Repeated pleural and pericardial effusion cytologies never showed any evidence of malignant cells nor did the pericardial biopsy from the pericardial window procedure. The patient's current Pulmonary status is improving, progressing from a ventilatory support of 25/7.5 at an FIO2 of 0.4 and tidal volumes of 200 to 400 cc, has diminished to tolerating T-piece during the day. She continues to require Albuterol and Atrovent nebulizers to help with her reactive airway disease. Her pulmonary effusions are also decreasing and her pericardial effusions appear to be stable. No repeat of the pericardial effusion echocardiogram is required unless clinically indicated. Other cardiovascular issues include her blood pressure which has stabilized as well on Metoprolol and Lisinopril. Her renal function contrast induced nephropathy is also resolving and her creatinine is returning to baseline. From an Infectious Disease standpoint, the patient has a Vancomycin resistant enterococcus in her urine being treated with Linezolid requiring a seven day course. She is currently on day number four at time of discharge on [**2177-7-30**]. From an Endocrine perspective, the patient is on insulin sliding scale and 8 units of NPH a day, split 4 units in the morning and 4 units before dinner. From a hemodynamic standpoint, the patient has required several units of blood, but the hematocrit is stable at 28 on [**7-29**] and is currently on Epogen 3 times a week to maintain her reticulocyte count. The patient may require other units of packed red blood cells to keep her hematocrit above 27. She was also found to have an SPEP with 2% gamma band. This result is not significant for myeloma; most likely consistent with MGUS. Her urinary PEP is still pending. From a gastrointestinal standpoint, she currently has a PEG tube in place requiring tube feeds of ProMod with fiber. She is still a full code and communications are with her son. The patient is ready for discharge to a Vent Core Unit to wean her off of her tracheostomy. DISCHARGE MEDICATIONS: 1. Calcium carbonate 500 mg p.o. three times a day for phosphate binding. 2. Linezolid 600 mg p.o. q. 12 hours for her VRE infection which is to be continued for another three days for a full course of seven days. 3. Lisinopril 20 mg p.o. twice a day. 4. Metoprolol 50 mg p.o. three times a day. 5. Ipratropium bromide nebulizer, one to two nebs q. four hours. 6. Insulin sliding scale that begins at a glucose value of 120 mg per deciliter giving 2 units for each increment of 40 mg per deciliter. The starting point is also 2 units. 7. Insulin NPH 4 units twice a day. 8. Epoetin alpha 5000 units subcutaneously three times a week. 9. Furosemide 80 mg p.o. twice a day. 10. Ranitidine 150 mg p.o. q. day elixir. 11. Folic acid 1 mg p.o. q. day. 12. Aspirin 325 mg p.o. q. day. 13. Lorazepam 1 mg p.o. three times a day. 14. Docusate sodium 100 mg p.o. twice a day. 15. Amlodipine 10 mg p.o. q. day. 16. Three ophthalmic solutions: First one, Latanoprost 0.005% ophthalmic solution, one drop in the right eye q. day; Dorzolamide 2% ophthalmic solution one drop in the right eye three times a day; and Brimonidine tartrate 0.2% one drop in the right eye three times a day. DISCHARGE DIAGNOSES: 1. Recurrent pleural pericardial effusions of unknown etiology. 2. Restrictive lung disease with reactive airway disease. 3. Critical care neuromyopathy. 4. Urinary tract infection. 5. Hypertension. 6. Contrast induced nephropathy. 7. Anemia. 8. Thalassemia trait. 9. Osteogenesis imperfecta. 10. Diabetes mellitus type 2. 11. Chronic renal insufficiency with nephrotic range proteinuria. 12. Status post breast cancer DCIS with total mastectomy. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-426 Dictated By:[**Name8 (MD) 1020**] MEDQUIST36 D: [**2177-7-29**] 15:48 T: [**2177-7-29**] 16:08 JOB#: [**Job Number 12115**] Name: [**Known lastname **], [**Known firstname 1194**] Unit No: [**Numeric Identifier 16681**] Admission Date: [**2177-7-3**] Discharge Date: [**2177-8-1**] Date of Birth: [**2107-11-9**] Sex: F Service: NOTE: This is an addendum to the discharge summary report date of [**2177-7-30**]. The patient is to be discharged tomorrow on [**2177-8-1**]. The patient's clinical status has basically been unchanged. currently has lower white blood cell counts and decreasing fever. Of note, please add albuterol 8 to 12 puffs q4h inhalers to the discharge medicine regimen. Also, as an addendum, her Lasix dose is currently at 80 mg po bid and will need to be reassessed at the ventilator facility. She was previously on an outpatient dose of 80 mg q day. She has required a higher dose because of her pleural effusion and She will also need to have her electrolytes, particularly potassium and magnesium, checked frequently. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-664 Dictated By:[**Doctor Last Name 16682**] MEDQUIST36 D: [**2177-7-31**] 13:52 T: [**2177-7-31**] 13:58 JOB#: [**Job Number 16683**] Name: [**Known lastname **], [**Known firstname 1194**] Unit No: [**Numeric Identifier 16681**] Admission Date: [**2177-7-3**] Discharge Date: [**2177-8-1**] Date of Birth: [**2107-11-9**] Sex: F Service: Addendum: The patient will be discharged tomorrow, new discharge date of [**2177-8-1**] to a Ventcor facility. Her clinical course since the last summary has improved. Her status is improved with infection. Of note, to add to the discharge medications is albuterol 12 puffs q4h. The last issue to also convey to the Ventilator facility is that the patient was previously on an outpatient medication of Lasix 80 mg q day, but since being in hospital, she has required 80 mg po bid for her pleural and pericardial require a downward titration of this dose as needed. She will also require frequent electrolyte monitoring specifically for her potassium and her magnesium. Otherwise, the patient is doing well and is ready for discharge. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-664 Dictated By:[**Doctor Last Name 16682**] MEDQUIST36 D: [**2177-7-31**] 13:56 T: [**2177-8-4**] 14:30 JOB#: [**Job Number 16688**]

[ "250.40", "423.9", "599.0", "401.9", "276.2", "428.0", "583.81", "518.81", "491.21" ]

icd9cm

[ [ [] ] ]

[ "34.91", "37.12", "31.1", "43.11", "37.0", "34.04", "96.71", "96.04", "34.92", "96.6" ]

icd9pcs

[ [ [] ] ]

9281, 12362

8075, 9260

2661, 5691

1596, 2643

5707, 8052

149, 821

838, 1573

19,541

170,174

23598+57361+57362+57363

Discharge summary

report+addendum+addendum+addendum

Admission Date: [**2143-2-16**] Discharge Date: [**2143-2-27**] Date of Birth: [**2071-9-13**] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 618**] Chief Complaint: L sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 71 year old R handed male with HTN and cardiomyopathy of unclear origin who presents from [**Hospital6 **] with L sided weakness and dysarthria. He was well until today around 10:30 am [**2-16**] when he suddenly felt nauseous and dizzy. He says he slumped over to the ground and need to go to the bathroom but could not get up to do so. He lost continence on the ground. He says he noticed then that his L arm and leg were weak. No LOC. His landlord found his confused, on the floor of his house, 1 hour later and called EMS. Pt was taken to [**Hospital3 4298**] hosptial where a head CT showed R MCA infarct. He then was sent to [**Hospital1 18**] for further management. He arrived in our ED at 5:30 pm, 7 hours after onset of symptoms. ROS: negative for recent illness, head or neck trauma, travel, change in mental status, headache, focal neuro deficits. Of note, pt had laparascopic polypectomy last tuesday for benign polyps, and since then has had diarrhea. Past Medical History: HTN cardiomyopathy, per pt recent ECHO and EKG were "stable" s/p L nephrectomy for renal tumor, pt did not know it's identity Social History: Lives on [**Hospital3 **] with a significant other, has 4 children, works as a police officer Denies Tobacco or drugs, occasional ETOH Family History: noncontributory Physical Exam: VS: T afeb HR 66 BP 156/83 RR18 Sat 95% on room air PE: sleepy but arousable, no acute distress HEENT AT/NC, MMM no lesions Neck Supple, no thyromegaly, no [**Doctor First Name **], no bruits Chest CTA B CVS RRR w/o MGR ABD soft, NTND, + BS EXT no C/C/E, distal pulses full, no rashes or petechiae Neuro MS: Awake, dysarthric, oriented x3. Speech: fluent w/o paraphasic error, repetition, high frequency naming intact. writing not tested. Neglects L side intermittently CN: I--not tested; II,III-- PERRLA, VFF by confrontation, seems to neglect L visual field. optic discs sharp; III,IV,VI-EOMI w/o nystagmus, no ptosis; V-- sensation intact to LT/PP, masseters strong symmetrically; VII-- L facial weakness; VIII--hears finger rub bilaterally; IX,X-- voice normal, palate elevates symmetrically, gag intact; [**Doctor First Name 81**]-- SCM/trapezii [**5-2**]; XII--tongue protrudes midline, no atrophy or fasciculation. Motor: normal bulk and tone, no tremor, dense hemiparesis of L rm with minimal mvmt even on deep painful stimulation. Able to ift L leg above bed for 2-3 seconds, then drops it. Wiggles toes n L. Cannot overcome resistence on L leg. R side full strength. Coord: rapid alternating and point-to-point (FNF, HTS, TTF)movements intact on R, cannot perform on L given hemiparesis. Refl: |[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] |toe | L | 2+ | 2+ | 2+ | 2+ | 2+ | up | R | 2 | 2 | 2 | 2 | 2 | dn | [**Last Name (un) **]: Decreased sensation to all modalities on L, a bit difficult to assess b/c of neglect. Extinguishes on L to double stimulation consistently. Pertinent Results: [**2-22**] CT of Chest/Abdomen/Pelvis RESULTS PENDING [**2-16**] CT and CTA HEAD W&W/O C & RECONS; CT NECK W/CONTRAST IMPRESSION 1. Large right MCA infarct involving almost the entire territory supplied by this artery. 2. Almost total thrombosis of the origin of the right M2 segment with reconstitution of the distal branches. A filling defect is noted in the right M2 segment. [**2-17**] CT HEAD W/O CONTRAST [**2143-2-17**] 7:49 AM IMPRESSION 1. Evolving large right MCA distribution infarct. 2. No acute intracranial hemorrhage identified. 3. These results were called to Dr [**First Name (STitle) **] [**Name (STitle) **] of Neurology at the time of interpretation (10:30 a.m.). [**2-21**] CT HEAD W/O CONTRAST IMPRESSION: Again seen is a right MCA infarct, without evidence of new infarction or hemorrhage. CAROTID SERIES COMPLETE [**2143-2-18**] IMPRESSION: No evidence of stenosis in either carotid artery. [**2-18**] TTE IMPRESSION: Moderate inducible mid-ventricular cavity gradient. Mild aortic regurgitation with normal valve morphology. Mild mitral regurgitation. No definite cardiac source of embolism identified. Based on [**2134**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [**2-22**] TEE Conclusions: The left atrium is dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the left atrial appendage. The right atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is probably systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No cardiac source of embolism identified. [**2-17**] CXR IMPRESSION: Left subclavian central venous catheter with its tip in the superior vena cava. No pneumothorax. Cardiomegaly without evidence of congestive failure. [**2-22**] CEA, PSA, ESR, Fibrinogen all pending. [**2143-2-16**] WBC-12.4* Hct-44.3 Plt Ct-178 [**2143-2-22**] WBC-8.3 Hct-39.2* Plt Ct-139* [**2143-2-16**] Neuts-87.6* Lymphs-8.7* Monos-3.3 Eos-0.3 Baso-0 [**2143-2-16**] PT-14.0* PTT-26.8 INR(PT)-1.2 [**2143-2-21**] PT-13.5 PTT-49.5* INR(PT)-1.1 [**2143-2-21**] PT-13.2 PTT-38.1* INR(PT)-1.1 [**2143-2-17**] ESR-5 [**2143-2-16**] Glucose-121* UreaN-22* Creat-1.0 Na-137 K-4.2 Cl-103 HCO3-24 [**2143-2-22**] Glucose-103 UreaN-20 Creat-1.1 Na-136 K-4.6 Cl-103 HCO3-29 [**2143-2-16**] ALT-21 AST-22 CK(CPK)-292* AlkPhos-59 Amylase-87 TotBili-0.8 [**2143-2-16**] 06:20PM BLOOD CK-MB-3 cTropnT-<0.01 [**2143-2-17**] 02:27AM BLOOD CK-MB-2 cTropnT-<0.01 [**2143-2-17**] 10:00AM BLOOD CK-MB-2 cTropnT-<0.01 [**2143-2-16**] Calcium-8.9 Phos-2.9 Mg-1.8 [**2143-2-19**] Calcium-7.5* Phos-2.0* Mg-1.9 [**2143-2-22**] Calcium-8.4 Phos-3.2 Mg-1.8 [**2143-2-17**] Triglyc-46 HDL-50 CHOL/HD-2.9 LDLcalc-87 [**2143-2-16**] 09:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2143-2-16**] 09:10PM URINE RBC-[**3-2**]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0 [**2143-2-16**] 06:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Brief Hospital Course: 71 y.o. male presented w L hemiplegia and neglect of injury admitted for R MCA stroke. A summary of his pertinent hospital course by system follows: NEURO Pt presented from [**Hospital6 **] w L hemiplegia, dysarthria and neglect of injury. Inital CT/CTA on [**2-16**] showed a large right MCA infarct involving almost the entire territory supplied by this artery as well as almost total thrombosis of the origin of the right M2 segment with reconstitution of the distal branches. The patient was not a candidate for tPA because of time elapsed since onset of symptoms. Follow-up head CT on [**2-17**] showed evolving large right MCA distribution infarct, but no acute intracranial hemorrhage. Because of a persistent headache, pt was reimaged on [**2-21**] and the head CT showed no evidence of new infarction or hemorrhage. The patient's stroke is currently of unknown etiology -- workup included carotid u/s, TTE, and TEE all of which were unrevealing for source of thrombus. With no known etiology as of [**2-22**], an oncologic w/u was initiated. ESR, CEA, Fibrinogen, PSA and a CT of the chest/abd/pelv were ordered and were pending as of [**2-22**] 5PM. Patient's L hemiplegia and L facial droop persisted through his entire hospital course. He did show improved understanding that he was not moving his L side, though he still maintained that he was capable of moving them. CARDIAC Patient ruled out for MI. Patient developed tachycardia and an irregular rhyhtm on [**2-18**]. A cardiology consult was called that concluded the patient was demonstrating PVCs and SVT likely secondary to effects of the stroke in the context of preexisting heart disease/cardiomyopathy. They recommended reinitiating BB and long term ACEi,as well as making sure Ca/K/Mg were properly repleted, and these recs were followed. Pt continued to have intermittent PVCs through his hospital course. FEN Swallowing eval cleared the patient for soft solids and thin liquids. PROPH Patient was initially given heparin 5000 U sc tid, pneumoboots, PPI. Pt had isolated PTT rise from normal range to 49.5. Heparin sc was d/c'd, PTT fell started to trend downward, ? causation. DISPO PT/OT evaluated patient. Pt was d/c'd to rehab facility. Medications on Admission: 1. Atenolol 75 mg po qd 2. ASA 325 mg qd 3. Lipitor 20 mg qd Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day: Please start taking lisinopril on [**2143-2-28**]. Disp:*60 Tablet(s)* Refills:*0* 5. Pantoprazole Sodium 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: [**Hospital 17435**] Rehab at [**Hospital 60400**] Med CTR Discharge Diagnosis: 1. Right MCA territory infarction 2. Hypertension 3. Cardiomyopathy Discharge Condition: Stable. Patient has L facial droop, unable to move L arm or L leg, L leg has postural response to noxious stimulus, patient exstinguishes to double simultaneous stimulation at LLE and LUE. Patient has some neglect of injury: thinks he is capable of moving his L arm and L leg, does realize that he has not moved them. Discharge Instructions: Patient may need ACE inhibitor in about a week or so after BP stabilizes. Keep all appointments. Take all medications as prescribed. Please call your doctor and return to emergency department for increased weakness, visual changes, or worsening confusion. Followup Instructions: Please follow-up with your PCP 1 week after discharge from the hospital. Patient will need to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the [**Hospital 4038**] Clinic after discharge from rehab. Call [**Telephone/Fax (1) 44**] for an appointment. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Name: [**Known lastname 497**] JR,[**Known firstname **] W Unit No: [**Numeric Identifier 11028**] Admission Date: [**2143-2-16**] Discharge Date: [**2143-2-27**] Date of Birth: [**2071-9-13**] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 608**] Addendum: Addendum to hospital course: Pt's chest/abd/pelvic CT showed multilobar PE's, R perirenal stranding, and R renal cysts and calculi. No masses were noted. PSA and CEA were wnl. ESR was wnl x2, then mildly elevated. Fibrinogen was mildly elevated, and CRP was elevated. The pt's facial droop improved during his course; his left hemiplegia remained (with a question of trace L index finger movement on [**2143-2-26**]). The pt also appeared to have an episode of gout, with inflammation of the R 1st MTP appearing and extending over a 24-hour period; this was treated first with indomethacin and then colchicine, with significant improvement. Heme/Onc was consulted re: possible oncologic etiology of CVA and PE's; no clear source was identified, and anticardiolipin, homocysteine, and Factor VIII were ordered. Records regarding the pt's recent polypectomy at [**Hospital 11029**] Hospital were were requested repeatedly; at the time of this writing they had not been obtained. Pt's PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] notes that pt did have a rectal polyp with high grade dysplasia removed within the last few months. After discussions btwn neuro and heme/onc, pt was bridged to Coumadin from heparin. Pt remained stable and was planned for discharge to acute rehab [**2143-2-27**]. If INR is subtherapeutic at time of d/c, pt will continue w/Lovenox until INR>2.0. Discharge Disposition: Extended Care Facility: [**Hospital **] Rehab at [**Hospital 11030**] Med CTR [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**] Completed by:[**2143-2-26**] Name: [**Known lastname 497**] JR,[**Known firstname **] W Unit No: [**Numeric Identifier 11028**] Admission Date: [**2143-2-16**] Discharge Date: [**2143-2-27**] Date of Birth: [**2071-9-13**] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 608**] Addendum: Pt has regained some antigravity movement in his R leg and had a flicker of finger movemnt in his left arm on [**2-26**]. Pending labs: Factor 7 and homocysteine, hypercoag labs. Daughter is now helping to obtain records regarding his colonic polyps / partial resection??? and his kidney resection / ?? recnal cell carcinoma. With his hypercoag state, bilat pulm emboli and gout, we feel he likely has a malignancy yet unfound. Discharge Disposition: Extended Care Facility: [**Hospital **] Rehab at [**Hospital 11030**] Med CTR [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**] Completed by:[**2143-2-27**] Name: [**Known lastname 497**] JR,[**Known firstname **] W Unit No: [**Numeric Identifier 11028**] Admission Date: [**2143-2-16**] Discharge Date: [**2143-2-27**] Date of Birth: [**2071-9-13**] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 608**] Addendum: We would also recommend starting him on allopurinol on top of colchicine for his gout management, but his uric acid is currently low and we therefore are not starting him at this time. Discharge Disposition: Extended Care Facility: [**Hospital **] Rehab at [**Hospital 11030**] Med CTR [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**] Completed by:[**2143-2-27**]

[ "438.83", "402.90", "274.9", "415.19", "427.89", "425.4", "V10.52", "342.82", "434.01" ]

icd9cm

[ [ [] ] ]

[ "38.93", "88.72" ]

icd9pcs

[ [ [] ] ]

15037, 15238

7398, 9622

289, 296

10470, 10790

3343, 7375

11096, 11840

1620, 1638

9733, 10250

10379, 10449

9648, 9710

11857, 13262

10814, 11073

1653, 3324

233, 251

324, 1301

1323, 1451

1467, 1604

28,016

163,118

152

Discharge summary

report

Admission Date: [**2110-5-20**] Discharge Date: [**2110-6-3**] Date of Birth: [**2032-8-21**] Sex: M Service: MEDICINE Allergies: Penicillins / Sulfonamides / Hytrin Attending:[**First Name3 (LF) 898**] Chief Complaint: "can't catch my breath after walking 20 feet or even button my pants!" Major Surgical or Invasive Procedure: Paracentesis x2 History of Present Illness: 77yo M w/ COPD with interstitial lung disease, pulm HTN, severe cor pulmonale, and chronic renal disease who p/w worsening SOB, increasing abdominal girth, and 20 lb wt gain for 2 weeks. Pt reports feeling exhausted and "terrible." He is becoming short of breath after walking ~20-25 feet from the bathroom to the living room, having stop and catch his breath, which is unusual for him. At the same time, he was noted to have increasing weight--a gain of 20 lbs over 2 wks (198 -> 218 lbs). Accordingly, he then developed "belly pain" and began having trouble buttoning his pants over his growing abd. Because of these increasing symptoms, he was brought to the ED for further evaluation. Of note, the pt has had a precipitous decline in his functional status since [**10-26**] primarily due to symptoms of end-stage cor pulmonale from his severe pulm disease. In [**11-26**], pt developed similar symptoms of SOB, abd distension, and wt gain and was hospitalized at [**Hospital1 18**] for a total of 12 days. Pt otherwise denies fever/chills, chest pain, palpitations, nausea/vomiting/diarrhea, headache/dizziness, or incontinence. Past Medical History: -- Hypertension -- Hyperlipidemia -- BPH; s/p turp x2 -- Gout -- Impaired glucose tolerance -- Interstitial lung disease with diminished DLCO (thought [**12-21**] to pulmonary fibrosis and emphysema as per Pulmonary). B/L pleural thickening and honeycombing on CT. pt needs 2-3L, occasionally 4L, of continuous supp O2 at baseline, pt is able to ambulate independently w/o walker, cane, or assistance. -- End-stage Cor pulmonale -- Left ventricular diastolic dysfunction/heart failure -- Obesity -- Diabetes mellitus 2, diet controlled -- hiatal hernia -- sleep apnea -- R sided renal lesion -- CKD - baseline creatinine is 1.6-1.7 -- Abdominal aortic aneurysm. -- Constipation. -- Hypothyroidism Social History: Lives at home with his wife of 50 years. Stays on the [**Location (un) 453**] of the house (can't climb stairs [**12-21**] SOB). Has 6 children and 15 grandchildren-all healthy. Was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1573**] high school teacher for 7 yrs, elementary school principal for 12 yrs, and superintendent for 19 yrs. Retired in [**2091**] and became a lobbyist for the retirees until 1/[**2109**]. Quit smoking 20 yrs ago (1ppd x 20 yrs), rare ETOH, no drug use. Family History: Non-Contributory Physical Exam: Tm 98.3, Tc 96.3, HR 88 (50-80s), BP 100/67 (90-110s/40-60s), RR 20, 02 96% 4L (92-100%) Admission wt 99.3kg, I/O: Length of stay in MICU -5.5L Constitutional: Pleasant elderly man sitting up in chair waiting for transfer. HEENT: NC/AT. PERRL. Oral pharynx benign. CV: Regular rate, irregular rhythm. Loud P2. No M/R/G. PULM: B/l crackles up to mid lung fields. No wheezes. ABD: Severely distended, protuberant abd w/ significant fluid wave. Soft yet slightly taut. NT. +BS EXTREM: Mild clubbing present throughout b/l finger nails. Mild R hand tremor at rest. B/l LE 1+ pitting edema. SKIN: 2 scabs -- 1.5cm x 0.5cm and 0.5cm x 0.5cm at R inner leg. 1 broken blister w/ dried blood at L shin. L inner leg dried broken blister. Dry, scaly skin w/ hyperpigmentation below mid-leg b/l. NEURO: Alert and oriented x 3. CN II-XII intact. Motor strength full ([**3-24**]) throughout b/l UE and LE. Mild R hand tremor at rest. Only b/l biceps reflexes elicited, unable to elicit patellar, ankle, or triceps reflexes. Downgoing toes b/l. Proprioception intact at b/l toes. Narrow-based gait. Pertinent Results: **********LABORATORY RESULTS********** [**2110-5-20**] 03:10PM BLOOD WBC-7.4 RBC-4.50* Hgb-11.8* Hct-37.6* MCV-84 MCH-Plt Ct-292 [**2110-6-3**] 07:10AM BLOOD WBC-5.8 RBC-3.75* Hgb-10.1* Hct-31.3* MCV-84 MCH-27.0 MCHC-32.2 RDW-21.1* Plt Ct-274 [**2110-5-20**] 03:10PM BLOOD PT-16.5* PTT-26.7 INR(PT)-1.5* [**2110-5-20**] 03:10PM BLOOD Glucose-145* UreaN-44* Creat-2.0* Na-134 K-4.7 Cl-[**2110-6-3**] 07:10AM BLOOD Glucose-100 UreaN-36* Creat-1.8* Na-136 K-4.1 Cl-94* HCO3-30 [**2110-5-20**] 03:10PM BLOOD proBNP-[**Numeric Identifier 1574**]* [**2110-5-20**] 07:26PM BLOOD Digoxin-0.6* [**2110-5-20**] 03:13PM BLOOD Lactate-3.1* [**2110-5-20**] 07:46PM BLOOD Lactate-2.7* [**2110-5-21**] 4:11 pm PERITONEAL FLUID. GRAM STAIN (Final [**2110-5-21**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2110-5-24**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2110-5-27**]): NO GROWTH. [**2110-5-20**] 3:10 pm BLOOD CULTURE VENIPUNCTURE #1. Blood Culture, Routine (Final [**2110-5-26**]): NO GROWTH. [**2110-5-20**] 3:25 pm BLOOD CULTURE VENIPUNCTURE #2. Blood Culture, Routine (Final [**2110-5-26**]): NO GROWTH. [**2110-5-28**] 11:38 am URINE Source: Catheter. URINE CULTURE (Final [**2110-5-30**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. _______________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=1 S Echocardiography [**2110-5-27**] at 2:01:13 PM The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-20mmHg. Normal left ventricular systolic function. The right ventricular cavity is dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There is no mass/thrombus in the right ventricle. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. Significant pulmonic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Severe right ventricular dilation and hypokinesis with severe tricuspid regurgitation. Right ventricular pressure/volume overload. Severe pulmonary hypertension. No evidence of intracardiac shunt. SINGLE AP UPRIGHT RADIOGRAPH OF THE CHEST: There is a right lower lobe opacity in comparison with multiple prior studies, likely represents epicardial fat exaggerated by lordotic technique and patient rotation. With the exception of this, there are no focal consolidations. There is no pulmonary edema. There is no pleural effusion or pneumothorax. Heart size is enlarged, stable. IMPRESSION: No acute cardiopulmonary process. Study Date of [**2110-5-22**] 9:00 AM RIGHT UPPER QUADRANT ULTRASOUND: The liver echotexture is normal. There is no focal liver lesion or intrahepatic biliary ductal dilatation. The main portal vein is patent with the appropriate direction of flow, though flow is noted to be pulsatile. The heparic veins are also dilated. The gallbladder is normal without evidence of stones. The common duct is not dilated, measuring 2 mm. The pancreas is not visualized. The spleen is normal in size, measuring 8.5 cm. A moderate to large amount of ascites is seen in all quadrants. IMPRESSION: Probable passive hepatic congestion related to right-sided heart failure, particularly in light of relatively pulsatile blood flow in the portal vein. Normal liver echotexture and spleen size. Large amount of ascites. Brief Hospital Course: Mr. [**Known lastname **] is a 77 year-old male with COPD/interstitial lung disease, pulmonary hypertension, severe cor pulmonale, and chronic kidney disease who presented with exacerbation of cor pulmonale, worsening SOB and 20 lb wt gain. In the [**Name (NI) **], pt experienced hematemesis x 2. O2 sat of 80s on 4L NC and then 94-96% on NRB. Pt was placed on Bipap 10/5 and received 40 mg IV Lasix x 2. Lactate was 3.1 on admission, BNP [**Numeric Identifier 1574**], Trop slightly above baseline of 0.02 to 0.04. Pt was initially admitted to Medicine [**Hospital1 **] for further treatment of his R-sided HF. On arrival to the medical [**Hospital1 **], the patient was hypoxic w/ O2 sats in low 70s, BP 131/86, dyspneic at RR 44, tachy w/ HR of 92, as well as vomited 50cc of bloody contents upon arrival to the floor. He transferred to the MICU for further monitoring and management. In the MICU, pt was gently diuresed w/ IV Lasix. A 4L paracentesis was performed. He became hypotensive (BP into the 70s-80s systolic) following the paracentesis. For this, he received total of 75g albumin over 2 days. Once patient's vitals stabilized, he was transferred to the floor for further management. On the General Medicine floor, the following issues were managed as described below. ## Pulmonary fibrosis: Pt has severe interstitial pulmonary disease refractory to treatment. It has led to severe pulmonary hypertension and end-stage cor-pulmonale. He requires Given prior side effects of hypotension, tachycardia, and dizziness with a trial of sildenafil in the past ([**11/2109**]), no sildenafil was attempted during this hospital stay. Patient was maintained on prn inhalers and continued on oxygen regimen increased from home dose of 4L. Patient was also placed on CPAP overnight. Continued outpatient pulmonary follow-up with Dr. [**Last Name (STitle) 575**] will be needed. ## Cor pulmonale: Chronic. Echo shows severe right ventricular dilation and hypokenesis w/ severe tricuspid regurgitation, as well as right ventricular pressure/volume overload. This is thought to be secondary to severe pulmonary fibrosis/pulmonary hypertension. There is no evidence of intracardiac shunt on echo. His right ventricular failure has led to hepatic congestion -> ascites -> b/l LE edema. He was treated with aggressive diuresis as well as paracentesis x2. Net total weight/fluid loss at the end of the hospital stay was approximately 20 lbs. Discharge weight 87kg (day prior had been 92kg, before 2L paracentesis). Patient was discharged with Lasix 80 mg PO BID with increased oxygen requirement at 5L NC satting between 90-94%. He goal 02 sat is >93%. ## Hypotension: Pt is relatively hypotensive at baseline with SBP typically 90-110. However, following his first paracentesis of 4L his BP did drop into the 70s-80s. He remained asymptomatic despite this drop in blood pressure. His blood pressure responded to albumin. Of note, he underwent a 2nd therapeutic paracentesis of 2L and his blood pressure tolerated the lower volume tap. ## Chylous ascites: The fluid was chylous in nature w/ high TG's. The cause of ascites secondary to hepatic congestion related to RH failure. Abdomen remained significantly protuberant with dramatic fluid wave on exam despite paracentesis. Patient received therapeutic paracentesis x 2. ## Hematemesis: Patient had episode of hematemesis on admission, though no subsequent episodes. He was evaluated by the GI service. EGD was discussed but the patient preferred to hold on the procedure since there was no recurrence of following admission. His HCT remained relatively stable in the low to mid-30s. Given no further evidence of bleend and the patient's request to decrease the number of pills taken daily, Protonix was discontinued during the latter half of the hospitalization. ## LV diastolic HF: Echo showed 55% LV systolic function. ## Insomnia: Patient initially complained of insomnia, which was treated with home dose of 10 mg PO Ambien. ## Hypothyroidism: Clinically stable with complaints of cold intolerance but no other symptoms or signs of hypothyroidism. Patient was maintained on home dose of levothyroxine. ## CODE: DNR/DNI Medications on Admission: Allopurinol 100 mg PO qd Lipitor 10 mg PO qd BIPAP - 11cm inspiratory and 7 cm expiratory along with 4 L/min 02 Cyclosporine 0.05 % 1 Dropperette in the R eye [**Hospital1 **] Fluoxetine 10 mg PO qd Lasix 80 mg PO tiw, 60 mg qiw Lactulose 10 gram qd or [**Hospital1 **] PRN constipation Levothyroxine 12.5 mcg PO qd Metoprolol tartrate 12.5 mg PO bid Prilosec 20 mg PO qd PRN gastric upset Oxygen 4 Liters/min continuously (recently increased from 3L NC) Spironolactone 25 mg PO qod Digoxin 125 mcg QOD (started [**5-13**]) Verapamil recently discontinued ([**5-13**]) Discharge Medications: 1. Oximeter Please provide a pulse oximeter for use at home. Goal oxygen saturations >95%. 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 4. Levothyroxine 50 mcg Tablet Sig: 0.25 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-20**] Puffs Inhalation Q6H (every 6 hours). 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: primary: pulmonary fibrosis, pulmonary hypertension, cor pulmonale, hypotension secondary: hypothyroidism, hematemesis, hepatic congestion, left ventricular diastolic heart failure, possible urinary tract infection, chylous ascites, insomnia Discharge Condition: Stable. Discharge weight 87kg (day prior had been 92kg, before 2L paracentesis) Discharge Instructions: You were admitted with shortness of breath, worsening edema, and weight gain of 20 lbs. This was due to your severe lung disease, which has caused heart failure. During your hospital stay, fluid was drained from your abdomen twice and you received Lasix to removed additional fluid from your body. -You should take Lasix 80 mg twice daily at home. This dose may need to be increased if you start gaining weight again. -You have also been prescribed potassium pills because your potassium levels have been low. -You should no longer take metoprolol, verapamil, spironolactone or digoxin. -You have been given a pulse oximeter. It is important that you check your oxygen levels when you are walking or exerting yourself to be sure that your oxygen level is above 90%. Otherwise, while resting, you should monitor your oxygen saturation every 6 hours. -Please keep your supplemental oxygen on at all times with a goal oxygen saturation > 93%. Please use BiPAP every night. -Weigh yourself every morning, call your primary care provider or pulmonary specialist, Dr. [**Last Name (STitle) 575**], if weight > 3 lbs. Please adhere to a diet of < 2 grams of sodium per day as well as fluid restriction of < 1.5 L per day. -Please take all of your medications as prescribed. If you develop any shortness of breath, weight increase, ascites, chest pain, increased abdominal girth, worsened edema, severely low blood pressure, dizziness, blood in your stool, or any other symptoms of concern, please call your primary care physician or pulmonary specialist or proceed to the nearest emergency department. Followup Instructions: Please follow-up with your physicians after discharge. The following appointments have been scheduled. PROVIDER: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD on [**2110-6-12**] at 11:50am PHONE: ([**Telephone/Fax (1) 1577**] FAX: ([**Telephone/Fax (1) 1578**] PROVIDER: [**Name10 (NameIs) 1571**] FUNCTION LAB PHONE: [**Telephone/Fax (1) 609**] DATE/TIME: [**2110-7-17**] 8:40 PLACE: [**Hospital Ward Name 516**], [**Hospital1 18**] ***Please arrive at 8:30am to undergo pulmonary function tests. . PROVIDER: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. PHONE: [**Telephone/Fax (1) 612**] DATE/TIME: [**2110-7-17**] 9:00 PLACE: [**Hospital Ward Name 516**], [**Hospital1 18**]

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icd9cm

[ [ [] ] ]

[ "54.91" ]

icd9pcs

[ [ [] ] ]

13835, 13892

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365, 383

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149,607

18519

Discharge summary

report

Admission Date: [**2157-11-11**] Discharge Date: [**2157-11-16**] Date of Birth: [**2093-10-20**] Sex: F Service: MEDICINE Allergies: Penicillins / Levofloxacin Attending:[**First Name3 (LF) 2297**] Chief Complaint: transfer for possible intervention/bronch for tracheal stenosis Major Surgical or Invasive Procedure: bronchoscopy History of Present Illness: 64 yo F w/ h/o COPD s/p trach in [**2155**], CAD s/p CABG in [**2145**], CHF (LVEF 60%), who on [**2157-11-8**] had a #10 T-tube placed by Dr. [**First Name (STitle) **] [**Name (STitle) **]. However, due to significant supraglottic redundant tissue stenosis was not amenable to dilation. Since the time of procedure, the patient has had persistent dyspnea and on the day of transfer was referred to [**Hospital3 2737**] ED by her VNA due to increased work of breathing. The patient in [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] had wheezing, respiratory distress, SpO2 89%. Patient reports increased production of white sputum. Denies fevers or chills. No chest pain, nausea, vomiting, diarrhea, constipation any other complaints. Past Medical History: 1. DMII - on insulin 2. CAD s/p CABG for 3-V disease approximately 12 years ago at [**Hospital 4415**]. 3. [**Name (NI) 3672**] Pt had a severe COPD exacerbation and question PNA approximately two years ago. She was on a ventilator at that time which was eventually converted to a trach. She has never been able to come off of the trach. 4. CHF - EF 25% in [**7-/2157**] 5. GERD 6. Depression 7. PVD Social History: Patient lives at home with her daughter, her daughter's family as well as sister and much of extended family. Patient reports a 47 pack-year history of smoking (quit 2 years ago s/p trach placement), denies any use of ETOH, IVDU or other illicit drug use. Family History: Patient's parents with heart disease, lung CA. Physical Exam: Vitals: T 95.7; HR 77; BP 103/46; RR 26; O2 sat 98% on FiO2 50% General: obese hispanic female, somnolent, sitting upright in bed with humidified O2 mask over trachea, increased work of breathing, mild respiratory distress. HEENT: NCAT, EOMI. Neck: obese, no palpable LAD Chest: course inspiratory and expiratory breath sounds diffusely. Cor: Difficult exam given patient's body habitus and course breath sounds. Normal S1and S2, no M appreciated Abdomen: Obese, soft, non-tender, non-distended. +NABS Extrem: No cyanosis, clubbing. Venous stasis changes are present bilaterally. Pertinent Results: [**2157-11-16**] 04:15AM BLOOD WBC-14.2* RBC-4.08* Hgb-10.6* Hct-32.2* MCV-79* MCH-25.9* MCHC-32.9 RDW-14.6 Plt Ct-305 [**2157-11-11**] 11:28PM BLOOD WBC-14.5* RBC-3.92* Hgb-10.7* Hct-31.1* MCV-79* MCH-27.3 MCHC-34.4 RDW-14.9 Plt Ct-240 [**2157-11-16**] 04:15AM BLOOD Plt Ct-305 [**2157-11-14**] 03:11AM BLOOD PT-13.6* PTT-25.1 INR(PT)-1.2 [**2157-11-16**] 04:15AM BLOOD Glucose-104 UreaN-18 Creat-0.8 Na-138 K-3.8 Cl-98 HCO3-29 AnGap-15 [**2157-11-11**] 11:28PM BLOOD Glucose-50* UreaN-9 Creat-0.7 Na-138 K-4.4 Cl-101 HCO3-27 AnGap-14 [**2157-11-16**] 04:15AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.9 [**2157-11-11**] 11:28PM BLOOD Calcium-8.3* Phos-3.5 Mg-1.7 [**2157-11-12**] 11:47AM BLOOD calTIBC-281 Ferritn-22 TRF-216 [**2157-11-16**] 12:59PM BLOOD Type-ART pO2-113* pCO2-57* pH-7.33* calHCO3-31* Base XS-2 [**2157-11-15**] 07:51AM BLOOD Type-ART Temp-36.1 pO2-101 pCO2-52* pH-7.39 calHCO3-33* Base XS-4 [**2157-11-14**] 03:56PM BLOOD Type-ART Temp-36.8 Rates-/24 FiO2-35 O2 Flow-15 pO2-88 pCO2-58* pH-7.42 calHCO3-39* Base XS-10 Intubat-NOT INTUBA [**2157-11-13**] 10:36PM BLOOD Type-ART Temp-36.7 FiO2-50 pO2-90 pCO2-56* pH-7.39 calHCO3-35* Base XS-6 Intubat-NOT INTUBA [**2157-11-12**] 12:49PM BLOOD Type-ART Temp-36.6 Rates-[**12-29**] Tidal V-300 PEEP-5 FiO2-30 pO2-56* pCO2-56* pH-7.40 calHCO3-36* Base XS-7 Intubat-INTUBATED Vent-SPONTANEOU [**2157-11-11**] 10:15PM BLOOD Type-ART pO2-138* pCO2-61* pH-7.32* calHCO3-33* Base XS-3 . CXR [**2157-11-13**]: The cardiac silhouette and pulmonary vascularity appear slightly more prominent compared to previous studies, but could potentially be accentuated by extreme apical lordotic projection. However, it is difficult to exclude mild volume overload as a cause for these findings. There are no confluent areas of consolidation within the lungs or significant atelectasis. . CXR [**2158-1-13**]: Tracheostomy tube has a longer than standard intrathoracic component, presumably treatment for the tracheal stricture demonstrated on [**11-7**] chest CT scan. Lungs are clear. There is no atelectasis and no pneumothorax or pleural effusion. Moderate cardiomegaly is stable. Dilated right pulmonary artery may be due to pulmonary arterial hypertension or adenopathy. The patient has had median sternotomy and coronary bypass grafting. . CXR [**2157-11-11**]: No evidence of pneumonia on a limited study. Followup views should be obtained if there is persistent concern. Brief Hospital Course: A 64 year-old female with COPD, CAD, CHF with h/o tracheal stenosis who is s/p #10 T tube placement (on [**2157-11-8**]) who presented with increased work of breathing and dyspnea. . 1. Dyspnea: Etiology: COPD exacerbation vs. CHF exacerbation vs. pneumonia (had elevated WBC on admission) or T tube obstruction. Initially on CMV ventilation at 300x12/35%/5, and at the time of discharge was on 15L/m FiO2 35% via facemask. The Pt. required frequent suctioning of upper airway mucus/secretions. Pt. bronched and evaluated by interventional pulmonology, recommended leaving T-Tube in place with continued suctioning PRN and encouragement to cough on her own to clear mucus/secretions. Continue albuterol and Ipratropium nebs. Plan to continue prednisone taper (for COPD exacerbation) post-discharge (today [**2157-11-16**] is day 2 of 3 of 20mg/day). Pt. was switched to IV lasix during hospitalization, and was switched back to PO in preparation for discharge. Her daily weights and strict Is/Os were monitored. Due to rising bicarbonate, she was also given diamox 500mg IV q12 for two days. . 2. CAD s/p CABG. Home doses of ASA, carvedilol, lisinopril, lipitor and Zetia were continued during hospitalization. Telemetry monitoring was continued throughout the entire hospitalization. . 3. PVD. Continued Trental. . 4. GERD. Continued Protonix. . 5. DM. Patient was found to be hypoglycemic on admission. She was maintained on an ISS, and her home dose of NPH insulin (60U QAM) was restarted prior to d/c. Her NPH dose was adjusted during hospitalization based on her PO intake. Fingersticks were monitored routinely. . 6. CHF EF 25% ([**7-26**]). Patient appeared to be mildly volume overloaded. IV Lasix (and diamox) were used for diuresis. The patient was diuresed with a goal of >500cc negative per day. . 7. UTI: The patients admission urinalysis was consistent with a UTI. She was treated with a three day course of Bactrim (today [**2157-11-16**] is day 2). . 8. Depression: Continued fluoxetine. . 9. FEN: Cardiac diet. Repleted electrolytes as per routine. . 10. Prophylaxis: Bowel regimen. Heparin SQ. PPI. . 11. Code: Full. . 12. Communication: Patient & her daughter. Medications on Admission: Ranitidine 150mg PO qd Trental 400mg tid Lisinopril 10mg po qd Zetia 10mg po qd ASA 81 mg po qd Senokot 2 tabs po bid Nitropatch 0.4mg q am Protonix 40mg po qd Mucinex 1200mg po bid Prozac 40 mg po qd KCl 20 mEq po bid Albuterol nebs qid prn Regular insulin sliding scale NPH 60 units sq Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO TID (3 times a day). 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. Carvedilol 3.125 mg Tablet Sig: One (1) 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. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. 11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: please start after final dose of 20mg prednisone. 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours). 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q2H (every 2 hours). 14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 15. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 days: please give this dose in am on [**11-17**]. 19. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 20. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 22. Lorazepam 0.5-1 mg IV Q4H:PRN anxiety hold for RR<10 23. NPH 60U QAM 24. Insulin sliding scale in addition to NPH to cover for hyperglycemia. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Hospital - [**Location (un) 701**] Discharge Diagnosis: Primary: COPD Secondary: CAD CHF PVD GERD UTI depression Discharge Condition: stable. Discharge Instructions: Please continue to take all medications as prescribed. You will be going to a rehabilitation hospital so that your breathing and lung function can heal and improve. You will receive special care there including suctioning of your trach tube as necessary. Followup Instructions: Please continue to follow up with your PCP [**Last Name (NamePattern4) **]: [**Hospital 22163**] MEDICAL, P.C. [**Telephone/Fax (1) 22166**] Completed by:[**2157-11-17**]

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icd9cm

[ [ [] ] ]

[ "96.71", "33.22" ]

icd9pcs

[ [ [] ] ]

9541, 9619

4977, 7175

355, 370

9720, 9730

2533, 4954

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28,456

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33134

Discharge summary

report

Admission Date: [**2186-11-21**] Discharge Date: [**2186-11-22**] Date of Birth: [**2171-9-20**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: Gunshot wound to abdomen Major Surgical or Invasive Procedure: Exploratory laparotomy Abdominal Washout Right lower extremity fasciotomy Placement of Swann-Ganz catheter Placement of central venous catheters History of Present Illness: Mr. [**Known lastname 18937**] is a 15-year-old male who was shot in the right lower quadrant at approximately 0300 on [**2186-11-21**]. He was taken to [**Hospital 40576**] by EMS where he evidently had a GCS of 15, positive FAST, and hemorrhagic shock. He was taken to the operating room and I (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) have discussed the details of this with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] of [**Hospital3 **]. He evidently had a stapled repair of a cecal injury as well as ligation of the right iliac vein. He also had a segmental loss of external iliac artery for which he had an external iliac to common femoral artery inter-position graft. The bullet was reported to remain in the right iliac fossa. He was then transferred here due to blood bank depletion and need for critical care. During transfer (helicopter), he evidently had a systolic pressure between 30 and 90 mmHg. . On arrival, his pressure was 50 systolic. He had had approximately 30 units of packed cells, 2 units of platelets, 23 liters of crystalloid, and 6 units of plasma prior to arrival. His blood loss had been estimated at 18 liters and his urine output had been 100 mL. He was hypothermic (initial temperature here was 88 degrees Fahrenheit), profoundly acidotic (pH of 6.7, Base deficit of 29, Lactate of 20), and profoundly coagulopathic (INR reported at 7, would later increase to 22). CXR from referring hospital demonstrates no pneumothorax or effusion by attending surgeon read. . Upon his arrival to the TSICU, massive transfusion protocol was initiated and the patient was taken emergently to the operating room for exploration of his open (covered) abdominal wound. Past Medical History: Reportedly in good health prior to admission . Past Surgical History: Appendectomy, date unspecified. Social History: Per report from his mother, the patient has been a "runaway" since [**2186-11-14**]. Parents are divorced. Mother lives locally, Father lives in [**State 108**]. No other social history obtained. Family History: Noncontributory Physical Exam: Pt expired. Pertinent Results: [**2186-11-22**] CXR: FINDINGS: In comparison with the study of [**11-21**], there is probable progression of the diffuse bilateral alveolar opacifications presenting a bat-[**Doctor First Name 362**] pattern. Although most consistent with noncardiogenic pulmonary edema, the possibility of diffuse hemorrhage or even infection or ARDS must be considered. Swan-Ganz catheter has been pulled back to the tip of the pulmonary outflow tract. Endotracheal tube remains in place, as does the nasogastric tube. . [**2186-11-21**] XR PELVIS: Tubing and a balloon device overlies the pelvis. Multiple other iatrogenic devices are seen. Skin staples are present. Of note, there is a bullet overlying the soft tissues of the medial proximal right thigh. Although bony detail on this image is quite limited, no obvious fracture is identified. . [**2186-11-21**] KUB PORTABLE: HISTORY: Critical gunshot. No other clinical indication available to me at this time. Single AP portable view obtained in the OR of the abdomen. An NG tube is present, tip over stomach. Two drains are present. Additional surgical instrumentation and skin staples and overlying artifact are present. Assessment of fine detail in the abdomen is limited -- ? fluid in abdomen. No bullet is detected in the abdomen on this film. At the periphery of these films, there are findings raising the question of increased density at the lung bases. . [**2186-11-22**] 12:00AM GLUCOSE-47* UREA N-12 CREAT-1.8* SODIUM-145 POTASSIUM-6.4* CHLORIDE-110* TOTAL CO2-19* ANION GAP-22* [**2186-11-22**] 12:00AM CALCIUM-10.1 PHOSPHATE-6.8* MAGNESIUM-2.2 [**2186-11-22**] 12:00AM WBC-1.6* RBC-3.01* HGB-9.8* HCT-26.7* MCV-89 MCH-32.5* MCHC-36.5* RDW-14.2 [**2186-11-22**] 12:00AM PLT COUNT-96* [**2186-11-22**] 12:00AM PT-18.8* PTT-48.6* INR(PT)-1.7* [**2186-11-21**] 10:11PM TYPE-ART PO2-143* PCO2-44 PH-7.24* TOTAL CO2-20* BASE XS--8 [**2186-11-21**] 10:01PM WBC-1.5* RBC-3.26* HGB-10.2* HCT-28.9* MCV-89 MCH-31.4 MCHC-35.4* RDW-14.0 [**2186-11-21**] 10:01PM PT-22.0* PTT-67.5* INR(PT)-2.1* [**2186-11-21**] 08:13PM ALT(SGPT)-446* AST(SGOT)-783* LD(LDH)-1099* ALK PHOS-49 AMYLASE-143* TOT BILI-0.7 [**2186-11-21**] 08:13PM LIPASE-89* [**2186-11-21**] 08:13PM ALBUMIN-2.4* CALCIUM-10.5 PHOSPHATE-5.3* MAGNESIUM-1.7 Brief Hospital Course: Upon his arrival to the TSICU, massive transfusion protocol was initiated and the patient was taken emergently to the operating room for exploration of his open (covered) abdominal wound by Dr. [**Last Name (STitle) **]. (see op note for detail) After leaving the operating room, Pt arrived to TSICU with tenuous blood pressure. Pt arrested multiple times and was resuscitated with blood/platelets/plasma and pressor support. Pt received 90+ units of blood products, was on vasopressor support throughout, multiple amps of bicarb, Factor 7. On postoperative day 1, the patient was hyperkalemic, continued to be acidotic, coded multiple time for bradycardic arrest, ventricular fibrillation, asystole, profound hypotension. Right lower extremity fasciotomies were performed by the Vascular Surgery team. Muscle appeared to be somewhat viable but did not bleed well. Pt. again arrest approximately at 515 PM and expired. Medications on Admission: None Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Gunshot wound to abdomen Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None - Patient Expired

[ "276.7", "902.53", "958.2", "958.92", "728.88", "286.9", "863.99", "991.6", "902.54", "E965.0", "285.1", "958.4", "868.10" ]

icd9cm

[ [ [] ] ]

[ "96.71", "54.12", "99.77", "99.04", "99.07", "39.95", "93.59", "83.14", "99.05", "54.11", "99.06" ]

icd9pcs

[ [ [] ] ]

5998, 6007

4991, 5914

341, 488

6076, 6086

2677, 4968

6139, 6165

2613, 2630

5969, 5975

6028, 6055

5940, 5946

6110, 6116

2348, 2381

2645, 2658

277, 303

516, 2256

2278, 2325

2397, 2597

76,562

109,750

39849

Discharge summary

report

Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-26**] Date of Birth: [**2089-5-1**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: Critical aortic stenosis with a bicuspid valve Major Surgical or Invasive Procedure: [**2141-12-21**]: 1. Aortic valve replacement with a size 23 St. [**Male First Name (un) 923**] Regent mechanical valve. 2. Ascending aortic aneurysm resection and replacement with ascending aortic tube graft, size 24 Gelweave History of Present Illness: 52 y/o female with known heart murmur presented to [**Hospital 1474**] Hospital after she had an episode of syncope. She walked up two flights of stairs and felt dizziness and had a loss of consciousness for approximately five minutes. Family member (nursing student) performed CPR. Patient recovered from her syncoipe and absolutely refused to go to hospital at that time. She went to see the Rocketters in [**Location (un) 86**] and then went home. Family members then convinced her to go to ER for evaluation. MI was ruled out. ECHO EF of 55-60%. [**Location (un) 109**] 0.6 cm2. Cardiac cath at [**Hospital1 1474**] showed normal coronary arteries. Patient is referred for AVR. Cardiac Catheterization: Date: [**12-15**] - normal coronaries Place: [**Hospital 1474**] Hospital Past Medical History: Heart Murmur Social History: Married lives with family. Denies Tobacco and ETOH Family History: non-contributory Physical Exam: Admission: Pulse:80 (SR) Resp:16 O2 sat: 98% RA B/P Right: Left: Height: Weight: General:NAD, alert, cooperative 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 [] II/VI SEM across precordium Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None []+2 edema bilaterally with varicosities Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right/Left: murmur radiates to both carotids Pertinent Results: Echo [**2141-12-21**]: PRE-CPB: The aortic valve is bicuspid with apparent fusion of the left and non-coronary cusps. . The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The ascending aorta is mildly dilated. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left atrium is moderately dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. POST-CPB: A mechanical aortic valve prosthesis is present. The aortic valve prosthesis leaflets appear to move normally. The peak gradient across the aortic valve is 18mmHg, the mean gradient is 8mmHg. There is no apparent paravalvular leak. A graft is seen in the ascending aorta. In the posterior aspect of the graft-to-root anastamosis, there appears to be a small area of turbulent flow which can be seen in multiple views. There is no obvious flow across the suture line, and there is no evidence of fluid collection outside of the aortic root. No thoracic aortic dissection is seen. Chest CT [**2141-12-19**]: 1. Ascending thoracic aorta aneurysm, measuring up to 4.7cm in diameter at the mid ascending aorta. 2. Aneurysmal outpouching of the inferior wall of the aorta at the level of the distal arch. The aorta measures 3 cm in diameter at this level. 3. 6 mm right middle lobe pulmonary nodule. Chest CT in 12 months is recommended for further evaluation, provided the patient has no risk factors for malignancy (e.g. nonsmoker, no history of malignancy). 4. Extensive calcifications of the aortic valve. Carotid Dopper [**2141-12-19**]: On the right side, peak systolic velocities are 53 cm/sec, 66 cm/sec and 74 cm/sec in the internal, common and external carotid arteries respectively. The right ICA to CCA ratio is 0.8. On the left side, peak systolic velocities are 81 cm/sec, 96 cm/sec and 82 cm/sec in the internal, common and external carotid arteries respectively. The left ICA to CCA ratio is 0.84. Both vertebral arteries presented antegrade flow. IMPRESSION: There is no evidence of significant stenosis within the internal carotid arteries bilaterally. Brief Hospital Course: On [**2141-12-21**] she was brought to the operating room and underwent Aortic valve replacement with a [**Street Address(2) 11688**]. [**Male First Name (un) 923**] Regent mechanical valve; Ascending aortic aneurysm resection and replacement with ascending aortic tube graft, size 24 Gelweave (see operative report for further details). In the first twenty four hours she was weaned from sedation, awoke neurologically intact, and was extubated without complications. She continued to progress on post operative day one and was started on diuretics and beta blockers. She was transferred to the floor and was started on Coumadin that evening for her [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical valve. Respiratory: aggressive pulmonary toilet, nebs, and incentive spirometer she titrated off oxygen. Chest tubes: mediastinal and pericardial chest tubes were removed on POD2. Cardiac: She remained hemodynamically stable in sinus rhythm on low dose beta-blockers and aspirin were started. Pacing wires were removed [**2141-12-24**] GI: H2 Blockers and bowel regime Nutrition: cardiac healthy diet Renal: she was gentley diuresed, renal function normal with good urine output. Heme: Coumadin 5 mg was started [**2141-12-23**] [**Male First Name (un) 923**] Mechanical Valve. INR Goal 2.0-3.0. Her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17887**] will manage her Coumadin as an outpatient. ID: Amoxicillin was continued for her in-complete root canal. Pain: Well controlled with narcotics. Disposition: she was seen by physical therapy who deemed her safe for home. She was discharged on [**2141-12-26**] and will follow-up with Dr. [**Last Name (STitle) **], her cardiologist and PCP as an outpatient. Medications on Admission: Amoxicillin 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 10 days. Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 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). 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. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 6. amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*90 Capsule(s)* Refills:*2* 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:*20 Tablet(s)* Refills:*0* 9. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR goal 2.0-3.0 Coumadin dose to be determined by Dr. [**Last Name (STitle) 17887**]. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Critical Aortic Stenosis with a bicuspid valve Syncope s/p AVR (#23 regent mech AVR), ascending aortic aneurysm repair Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Discharge Instructions: -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 -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 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** Your Coumadin will be followed by Dr. [**Last Name (STitle) 17887**] [**Telephone/Fax (1) 6699**] Goal INR 2.0-3.0 for mech aortic valve Your first INR will be drawn on [**2141-12-27**] and the results called to Dr. [**Last Name (STitle) 17887**] at [**Telephone/Fax (1) 6699**] for coumadin dosing. You will need a follow up chest CT scan in 6 -12 months for a right middle lobe nodule. You will need to stay on amoxicillin until you have your root canal. Followup Instructions: You are scheduled for the following appointments Surgeon: [**Doctor Last Name **] [**Telephone/Fax (1) 170**] on [**2142-1-17**] at 1pm Cardiologist: to be determined by PCP Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 17887**] [**Telephone/Fax (1) 6699**] next week for Coumadin management **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 [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**] Mechanical Aortic Valve Goal INR 2.0-3.0 First draw [**2141-12-27**] Results to Phone: [**Telephone/Fax (1) 6699**] Fax: [**Telephone/Fax (1) 69014**] You will need a follow up chest CT scan in 6 -12 months for a right middle lobe nodule. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2142-1-3**]

[ "785.2", "424.1", "746.4", "780.2", "441.2" ]

icd9cm

[ [ [] ] ]

[ "35.22", "39.61", "38.45" ]

icd9pcs

[ [ [] ] ]

7755, 7810

4729, 6496

357, 594

7973, 8122

2310, 4706

9428, 10399

1536, 1554

6558, 7732

7831, 7952

6522, 6535

8146, 9405

1569, 2291

271, 319

622, 1415

1437, 1451

1467, 1520

2,619

168,468

21638

Discharge summary

report

Unit No: [**Numeric Identifier 56893**] Admission Date: [**2102-4-22**] Discharge Date: [**2102-5-3**] Date of Birth: [**2053-7-16**] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This 48-year-old white female had a history of severe mitral regurgitation prior to mitral valve repair in [**2101-8-3**]. She now presents with increasing mitral regurgitation and has felt fatigued since surgery. She denies significant shortness of breath, palpitations, or dyspnea on exertion. Her most recent echocardiogram revealed 2+ MR and an EF of 25%. She had a cardiac catheterization which showed normal coronaries. An echocardiogram in [**2102-1-31**] showed moderate LAE, 2+ MR, 1+ TR, 1+ [**Last Name (LF) **], [**First Name3 (LF) **] EF of 20% to 25%, borderline pulmonary hypertension, and a normal ascending aorta. She is now admitted for redo sternotomy, AVR, and MVR. PAST MEDICAL HISTORY: Significant for a history of mitral regurgitation, history of CHF, history of hypercholesterolemia, history of cardiomyopathy, history of left arm tendinitis, status post pneumonia in [**Month (only) **], status post mitral valve repair with a St. [**Male First Name (un) 923**] ring in [**2101-8-3**], status post bone spur removal, status post vaginal cyst removal, and status post tubal ligation. Her last dental exam was [**3-6**], and she was cleared by dental. MEDICATIONS ON ADMISSION: Levbid 0.375 mg p.o. b.i.d., [**Doctor First Name **] 180 mg p.o. daily, lisinopril 2.5 mg p.o. daily, aspirin 325 mg p.o. daily, amiodarone 200 mg p.o. daily, Wellbutrin 150 mg p.o. daily, Coreg 12.5 mg p.o. daily, Lipitor 20 mg p.o. daily, vitamin E 200 international units p.o. daily, flaxseed oil, calcium plus D, Ambien 10 mg p.o. p.r.n., oxycodone p.r.n., ibuprofen p.r.n. ALLERGIES: She is allergic to PENICILLIN (she gets hives), SULFA (she gets hives), and PERCOCET (she gets GI upset, nausea, and vomiting). FAMILY HISTORY: Significant for coronary artery disease. SOCIAL HISTORY: She lives with her husband and 2 children and works as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] for an ambulance company. She has a 45- pack-year history of smoking and quit in [**2101-8-3**]. She drinks alcohol minimally. REVIEW OF SYSTEMS: Her review of systems is remarkable for tendinitis in the left arm and shoulder and occasional pedal edema. PHYSICAL EXAMINATION ON ADMISSION: She is a well-developed white female in no apparent distress. Vital signs were stable, afebrile. HEENT exam was normocephalic and atraumatic. Extraocular movements were intact. The oropharynx was benign. The neck was supple. Full range of motion. No lymphadenopathy or thyromegaly. The carotids were 2+ and equal bilaterally without bruits. The lungs were clear to auscultation and percussion. She had a well-healed sternotomy scar. Cardiovascular exam revealed a regular rate and rhythm with a [**2-5**] holosystolic murmur. The abdomen was soft and nontender with positive bowel sounds. No masses or hepatosplenomegaly. The extremities were without clubbing or cyanosis. She had trace bilateral lower extremity edema. Neurologic exam was nonfocal. HOSPITAL COURSE: She was admitted, and on [**4-24**] she underwent a redo sternotomy with an aortic valve replacement with a 21-mm St. [**Male First Name (un) 923**] Regent supraannular aortic valve and a mitral valve replacement with a 27-mm St. Jude valve. Cross- clamp time was 115 minutes. Total bypass time was 150 minutes. She was transferred to the CSRU on milrinone, Levophed, and propofol in stable condition. She was extubated on her postoperative night. On postoperative day 1, she had her milrinone weaned. On postoperative day 2, she had her chest tubes discontinued and had her neck line changed over a wire, and she was transferred to the floor in stable condition. She was started on anticoagulation with Coumadin. She also went into AFib on postoperative day #3. Her Coreg was restarted. She was increased on this slowly but continued to be in AFib and would slow to a rapid rate upon ambulation. Her epicardial pacing wires were discontinued on postoperative day #3, and on postoperative day #7 EP was consulted. On postoperative day 9, they cardioverted her, and she converted to a sinus rhythm. DISCHARGE STATUS: She was discharged to home in stable condition. MEDICATIONS ON DISCHARGE: Potassium 20 mEq p.o. b.i.d. (for 7 days); Colace 100 mg p.o. b.i.d.; aspirin 81 mg p.o. daily; Wellbutrin 150 mg p.o. daily; Levbid 0.375 mg p.o. t.i.d., Darvocet-N 100 1 to 2 p.o. q.4-6h. p.r.n. (for pain), ibuprofen 600 mg p.o. q.6h. p.r.n. (for pain), Lipitor 20 mg p.o. daily, amiodarone 400 mg p.o. daily for 1 month and then decrease to 200 mg p.o. daily, carvedilol 12.5 mg p.o. b.i.d., lisinopril 2.5 mg p.o. daily, and Coumadin 4 mg p.o. tonight and tomorrow night and then as directed by Dr. [**Last Name (STitle) 31**]. She will have her coag's run every Monday, Wednesday, and Friday and call to his office. His office has been notified of this. LABORATORY DATA ON DISCHARGE: Hematocrit of 30.9, white count of 8.4, hemoglobin of 10.5, PT of 18.6, INR of 2.3, sodium of 140, potassium of 4.6, chloride of 102, CO2 of 29, BUN of 21, creatinine of 1.2, blood sugar of 99. DI[**Last Name (STitle) 408**]E FOLLOWUP: She will be followed by Dr. [**Last Name (STitle) 31**] in 1 to 2 weeks, by Dr. [**First Name (STitle) 2031**] in 2 to 3 weeks, by Dr. [**Last Name (Prefixes) **] in 4 weeks, and by Dr. [**Last Name (STitle) 73**] in 4 weeks. DISCHARGE DIAGNOSES: Aortic regurgitation, mitral regurgitation, congestive heart failure, atrial fibrillation, hypercholesterolemia. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2102-5-3**] 17:18:36 T: [**2102-5-3**] 17:58:54 Job#: [**Job Number 56944**]

[ "V17.3", "244.9", "V15.82", "425.4", "996.71", "423.1", "746.4", "427.31", "726.10", "428.0" ]

icd9cm

[ [ [] ] ]

[ "35.22", "99.04", "35.24", "37.12", "39.61", "88.72", "99.62" ]

icd9pcs

[ [ [] ] ]

1932, 1974

5544, 5911

4366, 5042

1394, 1915

3171, 4339

5057, 5522

2257, 2387

189, 876

2402, 3153

899, 1367

1991, 2237

27,162

181,175

8723

Discharge summary

report

Admission Date: [**2171-8-15**] Discharge Date: [**2171-9-3**] Date of Birth: [**2109-11-1**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Codeine / Benadryl Decongestant Attending:[**First Name3 (LF) 5018**] Chief Complaint: Transfer from Neurosurgery service (Dr. [**Last Name (STitle) **] for management of right basal ganglia hemorrhage with intraventricular extension, s/p EVD placement Major Surgical or Invasive Procedure: [**2171-8-15**]: R EVD placement History of Present Illness: Ms. [**Known lastname **] is a 61 yo F with h/o poorly-controlled HTN, HLD, ESRD on HD, CAD s/p CABG x4 who initially presented to [**Hospital1 **] ED with headache, vomiting, altered mental status and elevated BPs at home (300mmHg systolic per records). She was taken to her nephrologist's office where she was found to be hypertensive. Nitropaste was applied to her chest and she was given clonidine (of note, has h/o lethargy with clonidine). She was then transferred by car to [**Hospital3 **] where she was found to have SBP >190 (for which she received 20 mg IV Labetolol), lethargic and difficult to arouse. CT head showed right likely caudate hemorrhage with IVH to right lateral ventricle as well as extending into 3rd and 4th ventricles. She was subsequently intubated and received 25g Mannitol. Right femoral line was placed. Right IJ was attempted but was misplaced in subclavian vein, also resulted in apical pneumothorax. She was noted to have old, chronic abdominal distension (baseline per family). She was transferred to [**Hospital1 18**] for further management. Her initial exam here (on Propofol)revealed PERRLA 2mm and moving right leg. She received another 50g of Mannitol, was started on nicardipine drip for blood pressure control, as well as transfused 1 unit platelet. She had right EVD placed in the ED, and transferred to T-SICU. General ROS (obtained from notes): Last HD yesterday. Prior to intubation, patient states she was compliant with all her medications. Right IJ placement was attempted but ended in subclavian vein. It was subsequently removed with apical pneumothorax on OSH CXR. A right femoral central line was placed. She has abdominal distension that is old, and chronic constipation. Past Medical History: -HTN -Hyperlipidemia -ESRD ([**12-20**] PCKD) on MWF HD -CAD s/p CABG x4 ([**2166**]) -Paroxysmal AFib (not on anticoag) -Tobacco abuse -Anxiety -Gout -Tonsillectomy -Tubal ligation -[**Doctor First Name **] tumor removal Social History: Works as stay at home mom + tobacco - 1.5 ppd x 30 years Denies etoh Lives with husband and son Family History: Mother deceased from MI at 44 Physical Exam: Physical Exam on Admission: VS: T: 99, HR: 50-60/ SR, B.P- NBP- 110-156/ 50-60 (MAP 70-80s), ABP- 150-170/ 60-70 (MAP 80-90s), )2 sats- 100% CPAP, ICP= 14-20, CPP 46-89 (calcuated using ABP), EVD at 10, drain output 54 GPE: moderately built and nourished elderly female in NAD HEENT: R EVD placement CVS: RRR, no m/r/g Pulm: CTAB Abdomen: distended, firm mass palpated bilateral lower quadrant R>L, BS +, no shifting dullness Extremities: no c/c/e Neurological: eye opening to loud verbal stimuli but closes eyes quickly, does not follow any commands. Cranial nerves: PERRLA 2-1 mm bilaterally, extraocular movements intact oculocephalics, blink to threat bilaterally, corneal reflex + bilaterally, unable to comment re: facial assymetry due to ETT. Cough and gag reflex + Chewing at the ETT+ Motor: high frequency rhythmic twitching noted in right hand, especially thumb that was intermittent. Withdrew hand more briskly on the left side than on the right. Withdrew bilateral lower extrenties to noxious stimuli. Reflexes: intact throughout, bilaterally upgoing toes. Physical Exam on Discharge: Afebrile, SBPs 130s-150s. somewhat somnolent but easily arousable to voice, oriented to full name, hospital, [**Month (only) 359**]. Following simple commands. Moves RUE spontaneously but difficult to assesss full motor strength. Moves RLE but less briskly. in LUE, only has some movement in her digits and anti gravity in triceps and biceps. No movement in LLE. Pertinent Results: LABS ON ADMISSION: -WBC-6.9 RBC-3.59* Hgb-11.0* Hct-34.5* MCV-96 MCH-30.7 MCHC-31.9 RDW-15.2 Plt Ct-166 -Neuts-92.7* Lymphs-4.1* Monos-2.7 Eos-0.2 Baso-0.3 -PT-11.6 PTT-30.5 INR(PT)-1.1 -Glucose-170* UreaN-27* Creat-6.2* Na-135 K-3.8 Cl-91* HCO3-27 AnGap-21* -Calcium-8.6 Phos-6.9*# Mg-2.3 -BLOOD Type-ART Rates-16/ Tidal V-400 PEEP-5 FiO2-100 pO2-226* pCO2-43 pH-7.44 calTCO2-30 Base XS-5 AADO2-444 REQ O2-76 Intubat-INTUBATED Studies: EEG ([**8-16**]): This is an abnormal continuous ICU monitoring study because of focal slowing with increased amplitude and accentuation of faster frequencies over the left central region, consistent with focal cerebral dysfunction and breach artifact. There is mild to moderate diffuse background slowing and slow alpha rhythm. These findings are indicative of mild to moderate diffuse cerebral dysfunction, which is etiologically nonspecific. No electrographic seizures are present. EEG ([**8-17**]): This is an abnormal continuous ICU monitoring study because of focal slowing with increased amplitude and accentuation of faster frequencies over the left central region, consistent with focal cerebral dysfunction and breach artifact. There is mild to moderate diffuse background slowing and slow alpha rhythm. These findings are indicative of mild to moderate diffuse cerebral dysfunction, which is etiologically nonspecific. No electrographic seizures are present. Compared to the prior day's study, there is no significant change. NCHCT ([**8-17**]): No significant change since prior study, stable right caudate and intraventricular bleed. CXR ([**8-16**]): There is no evident pneumothorax. Moderate-to-severe cardiomegaly is stable. ET tube tip is in the right main stem bronchus. NG tube tip is out of view below the diaphragm. There is mild vascular congestion. Sternal wires are aligned. NCHCT ([**8-16**]): 1. Slight increase of the right intraparenchymal hemorrhage at the right caudate head with overlying edema, with possible redistribution in the subarachnoid region at the right frontoparietal area. No evidence of worsening mass effect or central herniation. No evidence of acute infarction or new hemorrhage. 2. No change in ventricular size suggestive of obstructive hydrocephalus. NCHCT ([**8-18**]): No interval change in right intraparenchymal caudate hemorrhage. Continued evolution of blood products in the lateral ventricles and subarachnoid spaces. No new area of hemorrhage. NCHCT ([**8-22**]): 1. Stable right caudate parenchymal hemorrhage. 2. Stable position of right frontal approach EVD without hydrocephalus. Resolved pneumocephalus. NCHCT ([**8-25**]): No significant change in right caudate intraparenchymal hemorrhage. No new hemorrhage or mass effect. Interval removal of right frontal approach EVD. ARTERIAL DUPLEX UPPER EXTREMITY FINDINGS: Duplex evaluation was performed of both subclavian arteries. The waveforms and velocities are normal. There is no evidence of pseudoaneurysm or aneurysm. IMPRESSION: Normal duplex of the subclavian arteries. Of note, the whole subclavian artery cannot be evaluated via ultrasound but in the area of concern, there were no abnormal findings. Brief Hospital Course: 61 yo F with h/o HTN, CAD, ESRD on HD who presented on [**8-15**] to OSH ED with HA, N/V and found to have right caudate hemorrhage with intraventricular extension, likely hypertensive in etiology. # NEURO: Patient was intubated at OSH and transferred to [**Hospital1 18**] Neurosurgery service for further management. In the TSICU she received 75g IV mannitol. Her BP was controlled with Labetalol and started on Nicardepime gtt. Right EVD was placed for drainage of IVH. A CT was performed in the AM [**8-16**] which was stable. On [**8-16**] her care was transferred to the Neurology service. She was noted to have rhythymic twitching of her right hand on initial evaluation so she was started on Keppra for seizure prophylaxis (risk given EVD placement). Serial EEGs showed no electrographic seizures. Her home blood pressure medications were restarted and she was gradually weaned off the Nicardepime gtt. Her exam was notable for left-sided hemiplegia, felt likely due to right cerebral peduncle compression caused by IVH. Serial head CTs showed stable right caudate hemorrhage and gradual resoluation of intraventricular bleeding. On HD #9 her EVD was removed. She was transferred to the neurology floor where she remained stable. Blood pressure was controlled as below (see cardiac). Keppra was weaned and then discontinued, which patient tolerated well. Will continue aspirin 81mg daily. (held initially then re-started). Of note, her atorvastatin was discontinued in the setting of hemorrhage and re-starting it can be re-addressed as outpatient. On dsicharge, she was somewhat somnolent but easily arousable to voice, oriented to full name, hospital, [**Month (only) 359**]. Following simple commands. Moves RUE spontaneously but difficult to assesss full motor strength. Moves RLE but less briskly. in LUE, only has some movement in her digits and anti gravity in triceps and biceps. No movement in LLE. # CARDIAC: EKG showed demand ischemia. Echo with LVH, EF 50-55%. In the ICU she was kept within goal SBP range 120-150 with amlodipine, captopril, labetalol and PRN hydralazine, and initially nicardepime gtt as above. Blood pressures were quite elevated on the floor. Anti-hypertensives were uptitrated gradually and she was stabilized on captopril 75mg tid, labetalol 700mg tid and amlodipine 10mg daily. Her home ASA 81mg daily was initially held in setting of ICH, then restarted once >1 week out from hemorrhage. # PULM: intubated for airway protection at OSH. Extubated on HD#7 in ICU s/p EVD removal. # ID: Patient febrile with leukocytosis while in ICU. Initially started broad spectrum coverage for HCAP with Vanc/Cefepime; DC'd Vanc once sputum grew out pan-sensitive Enterobacter (day 14 Cefepime = [**2171-9-3**]). Pt also developed profuse watery stool, +C diff amplification assay, so started Vancomycin 125mg PO QID (day 14 Vancomycin = [**2171-9-3**]) and later Flagyl (day 1 = [**8-25**], day 12 = [**9-8**]). In ICU she was also initially started on Tobramycin 110mg IV qHS per SICU; however, fiinal culture grew out 10-100,000 yeast, likely colonization, so Tobramycin was discontinued. # Renal: ESRD [**12-20**] PCKD, on MWF HD. She was followed by Nephrology throughout hospitalization and dialyzed per home schedule. #GI: Had distended abdomen with h/o [**Doctor First Name 1946**] tumor and chronic constipation. KUB without e/o SBO/megacolon x2. No pain, soft, just monitored. TRANSITION OF CARE: - will follow up with Dr. [**Last Name (STitle) **] in stroke clinic - Consider MRI at outpatient follow-up to rule out underlying mass/AVM/bleed - Determine when to re-start atorvastatin Medications on Admission: ASA 81mg daily Metoprolol 100 mg [**Hospital1 **] Captopril 50 mg PO TID Amlodipine 10 mg PO QOD Hydralazine 25 mg PO daily Sevelamer 800 mg [**Hospital1 **] Colace 100 mg daily Super B complex q day Cacarb 1000 mg PO BID Diazepam 2 mg PO daily Atorvastatin 40 mg PO daily Tums 1000 mg TID prn acid reflux Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Captopril 75 mg PO TID 4. Labetalol 700 mg PO TID 5. Lanthanum 500 mg PO TID W/MEALS 6. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 7. Calcium Carbonate 500 mg PO TID:PRN reflux Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Right caudate hemorrhage Hospital acquired pneumonia C. difficile infection Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname **], You came to the hospital with confusion, nausea, headache and inability to move your left side. A CAT scan of your head showed that you had bleeding in your brain. Your blood pressure was VERY high and this is likely the cause of the bleeding. You were intubated and spent some time in the intensive care unit. Once you became more stable, you were transferred to the floor. During the hospitalization, you had a pneumonia and a gastrointestinal infection which we treated with antibiotics. Your blood pressures were quite high and we started several new medications to control it. We have made multiple changes to your medications. An updated list is included. On discharge, please follow up with Dr. [**Last Name (STitle) **] in stroke clinic as scheduled below. It was a pleasure taking care of you, we wish you all the best! Followup Instructions: Department: NEUROLOGY When: MONDAY [**2171-10-14**] at 4:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2171-9-3**]

[ "285.21", "348.4", "753.13", "431", "564.09", "008.45", "342.92", "585.6", "305.1", "411.89", "272.4", "403.91", "V45.81", "482.83" ]

icd9cm

[ [ [] ] ]

[ "38.91", "38.97", "96.6", "02.21", "33.24", "96.72", "39.95" ]

icd9pcs

[ [ [] ] ]

11635, 11717

7383, 11024

473, 507

11837, 11837

4178, 4183

12910, 13406

2642, 2673

11381, 11612

11738, 11816

11050, 11358

12017, 12887

2688, 2702

3790, 4159

267, 435

535, 2267

3258, 3762

4197, 7360

11852, 11993

2289, 2512

2528, 2626

5,056

156,002

30186

Discharge summary

report

Admission Date: [**2171-5-1**] Discharge Date: [**2171-5-21**] Date of Birth: [**2131-10-4**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 330**] Chief Complaint: Confusion Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 39 yo male with history of EtOH cirrhosis presented to [**Hospital1 **] on [**2171-4-18**] with increased agitation and confussion. According to OSH he had used increased EtOH use over weeks prior to admission and was fired from his job. He stated that he was feeling well with no complaints prior to admission to [**Hospital1 **]. At OSH a head CT was performed which was negative. However he had labs and symptoms consistent with EtOH hepatitis. While there he had an episode of hematemesis and was admitted to the ICU. He had an EGD there which showed no varices but did show gastritis. The lowest his HCT went was 24, he was transfused and has remained stable at 29-30. They had some trouble with access so a femoral line was placed. He had no withdrawal symptoms while there. For his EtOH hepatitis he was treated with Vitamin K for elevated INR, also got FFP at the time of femoral line removal. At the OSH he appeared stable initially but then worsened. He was transferred to [**Hospital1 **] for further care given his elevated INR, elevated bili, and elevated creatinine. . He reports that he currently feels well. He does note increased leg swelling and abominal swelling although he states his belly has been big like that for years. He is currently hungry although he says he gets full rapidly. He denies fevers, chills, shortness of breath, chest pain, or abdominal pain. Past Medical History: 1. EtOH cirrhosis/hepatic encephalopathy 2. type 2 DM 3. EtOH abuse 4. GERD Social History: Lives with family, currently not working, smokes 1 pack/4 days, drinks 1 pint plus several beers a day, no drugs, no IVDU. Family History: No liver disease Physical Exam: VS: Temp 98.5, Pulse 60,, BP 120/64, RR 18, Sat 100% on RA Gen: alert, oriented, cooperative male in NAD HEENT: MMM, OP clear, sclera and bucal mucosa icteric Neck: no lymphadenopathy, no thyromegally Lungs: clear to auscultation bilaterally CV: RRR, nl S1S2, 2/6 SEM at LLSB Abd: distended with ascites, positive fluid line, positive BS, soft, non-tender, non-distended. Ext: 3+ edema to his sacrum Neuro: + asterixis on exam Pertinent Results: Studies from OSH: EKG: sinus at 96, nl axis, nl intervals, no ST/T wave changes [**2171-4-27**] Lower extremity ultrasound: no DVT [**2171-4-25**] Abdominal U/S: Hepatosplenomegaly, Ascites Labs: from [**2171-5-1**]: WBC 6.7, HCT 29.5 (lowest during admission to [**Hospital1 **] 24.7), PLT 42, INR 5.53 Na 132, K 3.8, Cl 112, CO2 15, Gl 124, BUN 12, creat 1.7, Alb <1.0, t.protein 7.3, tbili 20.5, dbili 10.3, Ca 7.8, alkphos 101, ALT 59, AST 137, NH3 122 AFP 3.7, HepBSAg non-reactive, HepBSAb <5, HepCAb non-reactiveprocess. Labs on admission: [**2171-5-1**] 10:05PM BLOOD WBC-7.7 RBC-3.12* Hgb-10.6* Hct-30.6* MCV-98 MCH-33.9* MCHC-34.5 RDW-18.2* Plt Ct-78* [**2171-5-6**] 03:45PM BLOOD Neuts-87.2* Lymphs-6.5* Monos-5.4 Eos-0.8 Baso-0.2 [**2171-5-1**] 10:05PM BLOOD PT-30.0* PTT-71.4* INR(PT)-3.2* [**2171-5-1**] 10:05PM BLOOD Glucose-114* UreaN-14 Creat-1.2 Na-131* K-3.7 Cl-108 HCO3-14* AnGap-13 [**2171-5-1**] 10:05PM BLOOD ALT-66* AST-148* LD(LDH)-225 AlkPhos-139* TotBili-23.6* [**2171-5-3**] 05:37AM BLOOD Lipase-59 [**2171-5-1**] 10:05PM BLOOD Albumin-2.0* Calcium-8.0* Phos-2.9 Mg-2.1 Labs prior to expiration: [**2171-5-21**] 07:36AM BLOOD WBC-25.2* Hct-21.2* Plt Ct-31* [**2171-5-18**] 02:54AM BLOOD Neuts-76* Bands-7* Lymphs-12* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-9* [**2171-5-21**] 07:36AM BLOOD PT-38.8* PTT-85.5* INR(PT)-4.3* [**2171-5-21**] 07:36AM BLOOD FDP-80-160* [**2171-5-21**] 07:36AM BLOOD Fibrino-92* [**2171-5-21**] 07:36AM BLOOD Glucose-100 UreaN-26* Creat-2.4* Na-133 K-3.5 Cl-89* HCO3-31 AnGap-17 [**2171-5-21**] 07:36AM BLOOD ALT-192* AST-358* LD(LDH)-588* AlkPhos-125* Amylase-249* TotBili-34.3* [**2171-5-21**] 07:36AM BLOOD Lipase-214* [**2171-5-20**] 03:19PM BLOOD Lactate-6.3* Other labs: [**2171-5-21**] 07:36AM BLOOD Albumin-2.4* Calcium-9.2 Phos-3.1 Mg-1.8 [**2171-5-20**] 03:02AM BLOOD Hapto-<20* [**2171-5-7**] 05:50AM BLOOD TSH-<0.02* [**2171-5-7**] 05:50AM BLOOD T4-3.8* T3-89 Free T4-1.4 [**2171-5-18**] 04:20PM BLOOD Cortsol-21.3* [**2171-5-18**] 04:18PM BLOOD Cortsol-27.1* [**2171-5-18**] 11:48AM BLOOD Cortsol-25.6* Brief Hospital Course: 39 yo male with history of EtOH cirrhosis presenting with EtOH hepatitis and renal failure. He was treated on the medicine floor for MSSA bacteremia with nafcillin. On [**2171-5-7**] pt had increasingly worsening mental status on the floor. He was given lactulose with no improvement. He had abdominal distention and worsening renal failure (creatinine to 4.4) He was intubated as he was found to have abdominal compartment syndrome, was not able to maintain his airway. Over the course of the ensuing days, Mr. [**Known lastname 3646**] was bleeding from line sites, paracentesis sites and an upper GI source grossly. An EGD was done which showed gastropathy and friable mucosa but no varices. CVVH was initiated for worsening renal failure and to help the abdominal compartment syndrome. As this was going on, pt also had septic shock, source unclear. [**Name2 (NI) **] was started on broad spectrum antibiotics and daptomycin was added when urine grew VRE. Pressor requirements kept increasing and pt was maxed out on three pressors. It became quite clear that he had an irreversible process. Pt was made CMO and passed away on [**2171-5-21**] in the presence of his family. Medications on Admission: Medications prior to admission at OSH: 1. Campral 333 mg 2 tabs PO TID 2. Chromagen Forte 1mg PO daily 3. Folate 1mg PO daily 4. Protonix 40mg daily 5. Lactulose 10gm PO daily . No clear list of transfer meds from OSH Discharge Disposition: Expired Discharge Diagnosis: Acute liver failure acute renal failure respiratory failure coagulopathy Sepsis Coagulopathy Discharge Condition: NA Discharge Instructions: NA Followup Instructions: NA

[ "785.52", "305.1", "518.81", "287.4", "572.2", "530.81", "995.92", "428.0", "571.1", "250.00", "790.94", "557.0", "303.00", "E934.2", "572.3", "535.01", "570", "572.4", "286.6", "038.11", "599.0", "571.2", "729.73", "584.5" ]

icd9cm

[ [ [] ] ]

[ "99.06", "99.04", "96.6", "38.95", "99.07", "39.95", "54.91", "00.17", "99.11", "38.93", "88.72", "38.91", "45.13", "99.05" ]

icd9pcs

[ [ [] ] ]

6030, 6039

4582, 5762

283, 305

6176, 6180

2471, 3005

6231, 6236

1990, 2008

6060, 6155

5788, 6007

6204, 6208

2023, 2452

234, 245

333, 1733

3019, 4206

1755, 1833

1849, 1974

4218, 4559

2,950

112,775

5496+55678

Discharge summary

report+addendum

Admission Date: [**2137-12-1**] Discharge Date: [**2137-12-19**] Date of Birth: [**2074-3-4**] Sex: F Service: GOLD-GENSU HISTORY OF PRESENT ILLNESS: The patient is a 63 year old white female with a history of bipolar disorder, sexual abuse, borderline hypertension, atypical chest pain and hypercholesterolemia, who was admitted to the hospital on [**12-1**], with complaints by sister of mental status changes and confusion. The patient had recently undergone medications changes; Topamax was increased to 200 and Trazodone was started. Her symptoms were initially attributed to her medicines. Three days prior to admission, she was noticed to have increased somnolence, fatigue, incoherent speech, disorientation, unsteady gait, as well as decreased appetite. Due to her symptoms, she had fallen three days ago but without apparent ill-effect. The patient denied nausea, vomiting, diarrhea, cough, dysuria. Upon surgical consultation, the patient revealed a three day history of nausea, vomiting, and cramping abdominal pain. PHYSICAL EXAMINATION: Temperature was 102.0 F., blood pressure 145/90; heart rate was 120; respiratory rate 20, O2 saturation was 94% on room air. The patient was ill appearing, lethargic but arousable. Regular rate and rhythm; no murmurs, rubs or gallops. Lungs showed decreased breath sounds at bilateral bases. Abdomen was soft, nontender, nondistended, no edema. No focal deficits on neurological examination. LABORATORY: White blood cell count 22,900, bands 5, neucleocytes 79, lymphocytes 8, hematocrit 38.8. Sodium 134, potassium 3.7, BUN 19, creatinine 0.9. Urinalysis is 6 to 10 white blood cells, few bacteria, zero to 2 epithelial cells. Serum toxicology was negative. Chest x-ray was normal. EKG sinus rhythm [**Company 22213**] wave inversion in V1 through V6. HOSPITAL COURSE: The patient was put on Levaquin prophylactically for possible urinary tract infection. The same day, the patient was re-evaluated and was found to have mild to moderate diffuse abdominal tenderness which later localized to her right lower quadrant. Her antibiotic coverage changed to Ceftriaxone and Flagyl. A lumbar puncture was performed at that time which was negative. The patient underwent a CT scan of the abdomen and pelvis on day one which demonstrated circumferential thickening with surrounding inflammatory changes of the terminal ileum suggesting acute ileitis and partial small bowel obstruction. The appendix was unremarkable at the time. GI was consulted and felt that terminal ileitis was more likely due to infection than IBD or ischemia. The patient was put on Levofloxacin and Flagyl. NG tube was placed and surgical consult was made. The patient refused the NG tube. Her white blood cell count fluctuated between 13 and 20. Abdominal pain, nausea and vomiting resolved, however the diarrhea was persistent. All stool cultures were negative. On hospital day five, the patient complained of increasing shortness of breath, wheezing, with crackles on examination. Wheezes were unresponsive to nebulizer treatment. Chest x-ray revealed no evidence of congestive heart failure. It revealed a distended thoracic esophagus, marked gastric distention with pleural effusions, right greater than left which are new. A CT angiogram was performed to rule out pulmonary embolism. A KUB was obtained which again showed an unresolved small bowel obstruction. An NG tube was later passed that day which resolved her wheezing, probably due to esophagus distention and compression of her trachea. She became hypotensive in the 80s. She responded to fluids, but her respiratory status was tenuous. She was transferred to the Medical Intensive Care Unit for concern of respiratory fatigue and more intensive management. A GTE demonstrated hyperdynamic ejection fraction of 75%. A thoracentesis removed 500 cc of fluid in the right lung, which was not infected. Cytology later demonstrated no malignancy. A repeat CT scan on [**12-11**], showed multiple small loculated collections in the pelvis, not amenable to CT guided drainage. There was a small air fluid collection in the right hemipelvis. There were multiple distended small bowel loops, bilateral basilar atelectasis and pleural effusions. On hospital day seven, she was sent back to the Floor. On hospital day 12, a repeat CT scan was done which showed ruptured appendicitis. The patient was hypotensive overnight requiring two liters of intravenous fluids. Surgery was consulted on hospital day 12. On [**12-12**], the patient was taken to the Operating Room by the surgical team, Dr. [**Last Name (STitle) 519**] and Dr. [**Last Name (STitle) 22214**]. Please see Operative Note for further details. An appendectomy and fecaliths were sent to Pathology. They found right lower quadrant phlegmon, abscessed cavities, and the perforated appendix. The procedure went without complications. Postoperatively, the [**Hospital 228**] hospital stay was unremarkable. The patient was put on Zosyn, however, due to a rash the patient was switched to Levofloxacin and Flagyl. On [**12-16**], the NG tube was removed. She was started on sips and tolerated well on [**12-17**]. She experienced flatus and was kept on sips and on [**12-18**], she was started on clears, a pureed regular diet. TPN was no longer needed. She had used TPN throughout most of her hospital stay. Physical Therapy was consulted due to limited mobility and patient's family requesting rehabilitation. The patient was discharged to Rehabilitation on: DISCHARGE MEDICATIONS: 1. Depakote for mood stabilizer, 250 mg p.o. q. h.s. 2. Zantac 150 mg p.o. twice a day. 3. Miconazole Powder to perineum p.r.n. 4. Levofloxacin 500 mg p.o. q. day. 5. Flagyl 500 mg p.o. q. eight. 6. Atenolol 25 mg p.o. q. day. 7. Benadryl 25 to 50 mg p.o. q. h.s. p.r.n. 8. Percocet one to two tablets p.o. q. four to six p.r.n. for pain. DISCHARGE DIAGNOSES: The patient is status post appendectomy for perforated appendicitis, initially hospitalized for a terminal ileitis. She has a history of bipolar disorder. ALLERGIES: Her allergies include Lithium, Seroquel, MAO inhibitors, sulfa drugs. CONDITION ON DISCHARGE: She is in stable condition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**] Dictated By:[**Name8 (MD) 6908**] MEDQUIST36 D: [**2137-12-18**] 13:49 T: [**2137-12-18**] 13:54 JOB#: [**Job Number 22215**] Name: [**Known lastname **], [**Known firstname 3709**] Unit No: [**Numeric Identifier 3710**] Admission Date: [**2137-12-1**] Discharge Date: [**2137-12-20**] Date of Birth: [**2074-3-4**] Sex: F Service: ADDENDUM: The patient tolerated po well, will be taking Levofloxacin 500 mg po q d and Flagyl 500 mg po q 8 hours for 10 more days, end date [**2137-12-29**]. The patient is in stable condition. Please see prior dictation summary for further information. [**First Name11 (Name Pattern1) 1080**] [**Last Name (NamePattern4) 3711**], M.D. [**MD Number(1) 3712**] Dictated By:[**Name8 (MD) 3713**] MEDQUIST36 D: [**2137-12-20**] 09:37 T: [**2137-12-20**] 09:49 JOB#: [**Job Number 3714**]

[ "286.9", "511.9", "V64.4", "555.0", "560.9", "272.0", "276.2", "540.0", "296.7" ]

icd9cm

[ [ [] ] ]

[ "47.09", "38.93", "34.91", "99.15" ]

icd9pcs

[ [ [] ] ]

5974, 6213

5601, 5953

1862, 5578

1080, 1844

172, 1057

6238, 7308

3,456

162,329

6706

Discharge summary

report

Admission Date: [**2135-1-22**] Discharge Date: [**2135-1-28**] Date of Birth: [**2082-11-29**] Sex: F Service: MEDICINE Allergies: Remicade Attending:[**First Name3 (LF) 30**] Chief Complaint: Blocked picc line and fever Major Surgical or Invasive Procedure: R Midline access placement History of Present Illness: HPI: The patient is a 52 year old female with a history of Crohn's disease and multiple abdominal surgeries, now with short gut syndrome on chronic TPN. The patient also has a history of difficulty with chronic venous access. She reports that for the past few weeks, she has noted that one of the lumens of her PICC is "clogged." Earlier today, the patient went to [**Hospital **] Hospital for further evaluation. The patient states that she was informed that the other lumen of her PICC was "blocked." The patient has undergone previous recanalization of her veins by IR in the past, so she was transferred to the [**Hospital1 18**] ED. On presentation, she was noted to have a SBP in the 60s. She reported having a T=104 at home earlier in the day. She also reported feeling "weak" over the past few days. Multiple attempts were made to obtain L subclavian access, yet these attempts were unsuccessful, so a L femoral line was placed and the patient was given aggressive IVFs (5 L total in ED). She was also placed on Levophed. Her BPs improved to 90s/50s. Of note, the patient states that her baseline SBP is around 90. The patient's labs were notable for a leukocytosis and a positive UA. The patient was administered doses of Vanco, Levo, and Flagyl. She has been transferred to the [**Hospital Unit Name 153**] for further management. Past Medical History: PMH: Crohn's disease Sarcoidosis Avascular necrosis of the R hip, complicated by chronic pain TPN dependent S/p C-section X 2 S/p hysterectomy, oopherectomy, and lysis of adhesions, which was complicated by colon perforation ([**2120**]) S/p multiple abdominal surgeries (18 in total), including a colostomy in [**2125**], after which she developed a fistulous tract Depression Anxiety HTN "Irregular heart beat" H/o SVC occlusion secondary to chronic central access, s/p superior vena cava recanalization by IR ([**4-10**]) Chronic diarrhea . ALL: Remicade-> anaphylaxis Social History: SH: The patinet lives with her ex-husband. She has 2 sons. She is not working at this time. She denies use of tobacco or illicit drugs. She notes occasional ETOH use. Family History: FH: Noncontributory Physical Exam: [**Hospital Unit Name 25564**] NOTE . CC:[**CC Contact Info 25565**]. HPI: The patient is a 52 year old female with a history of Crohn's disease and multiple abdominal surgeries, now with short gut syndrome on chronic TPN. The patient also has a history of difficulty with chronic venous access. She reports that for the past few weeks, she has noted that one of the lumens of her PICC is "clogged." Earlier today, the patient went to [**Hospital **] Hospital for further evaluation. The patient states that she was informed that the other lumen of her PICC was "blocked." The patient has undergone previous recanalization of her veins by IR in the past, so she was transferred to the [**Hospital1 18**] ED. On presentation, she was noted to have a SBP in the 60s. She reported having a T=104 at home earlier in the day. She also reported feeling "weak" over the past few days. Multiple attempts were made to obtain L subclavian access, yet these attempts were unsuccessful, so a L femoral line was placed and the patient was given aggressive IVFs (5 L total in ED). She was also placed on Levophed. Her BPs improved to 90s/50s. Of note, the patient states that her baseline SBP is around 90. The patient's labs were notable for a leukocytosis and a positive UA. The patient was administered doses of Vanco, Levo, and Flagyl. She has been transferred to the [**Hospital Unit Name 153**] for further management. . PMH: Crohn's disease Sarcoidosis Avascular necrosis of the R hip, complicated by chronic pain TPN dependent S/p C-section X 2 S/p hysterectomy, oopherectomy, and lysis of adhesions, which was complicated by colon perforation ([**2120**]) S/p multiple abdominal surgeries (18 in total), including a colostomy in [**2125**], after which she developed a fistulous tract Depression Anxiety HTN "Irregular heart beat" H/o SVC occlusion secondary to chronic central access, s/p superior vena cava recanalization by IR ([**4-10**]) Chronic diarrhea . ALL: Remicade-> anaphylaxis . OUTPT MEDS: BusPIRone 30 mg PO TID Clopidogrel Bisulfate 75 mg PO Metoclopramide 10 mg PO QIDACHS Diphenoxylate-Atropine 4 TAB PO QID Ferrous Sulfate 325 mg PO BID Oxycodone 30 mg PO Q8H:PRN Fluoxetine HCl 40 mg PO BID Pantoprazole 40 mg PO TID Promethazine HCl 25 mg PO Q6H:PRN Loperamide HCl 2 mg PO TID . SH: The patinet lives with her ex-husband. She has 2 sons. She is not working at this time. She denies use of tobacco or illicit drugs. She notes occasional ETOH use. . FH: N/C . ROS: The patient notes a low grade temp yesterday, and she states that she had a temp = 104 earlier today. She denies any chills, cough, rhinorrhea, SOB, CP, abd pain, rash, or change in her bowel/bladder habits. She reports that she has chronic diarrhea. She has felt "weak" for the past few days. . PHYSICAL EXAMINATION: Gen: Patient is lying in bed in NAD. VS: 97.1 100/54 with MAP 70 (on Levophed 0.05) 84 17 100% RA Heent: NC/AT. PERRL. EOMI. MMM. OP clear. Cards: RRR. S1, S2. No m/r/g. Lungs: CTAB. Abd: Soft, NT. Patient has a ventral hernia. She has multiple scars from previous abdominal surgeries, including a skin graft. Ext: No c/c/e. Warm. PICC site in R arm w/o erythema or tenderness. L femoral line in place. Skin: No rashes. . LABORATORY DATA: . [**2135-1-22**] 12:21a . Venous gas pH 7.26 pCO2 60 pO2 42 HCO3 28 BaseXS -1 Type:Mix Lactate:1.0 O2Sat: 71 . [**2135-1-21**] 10:26p Lactate:1.1 . [**2135-1-21**] 10:25p . 131 95 21 87 AGap=14 3.7 26 0.8 . Color Yellow Appear Clear SpecGr 1.015 pH 5.0 Urobil Neg Bili Neg Leuk Sm Bld Tr Nitr Neg Prot Neg Glu Neg Ket Tr RBC 0-2 WBC [**7-16**] Bact Many Yeast None Epi 0 . [**2135-1-21**] 9:22p Lactate:2.1 . [**2135-1-21**] 9:15p 129 94 21 86 AGap=15 3.8 24 0.9 . 95 21.4 9.8 271 28.5 N:92.6 Band:0 L:3.8 M:3.0 E:0.3 Bas:0.3 . PT: 12.5 PTT: 28.0 INR: 1.0 . RADIOLOGY DATA: CXR: ? retrocardiac opacity. . A/P: The patient is a 52 year old female with a h/o Crohn's disease and multiple abdominal surgeries, with short gut syndrome and chronic venous access issues. She has been admitted to the [**Hospital Unit Name 153**] for management of sepsis. . #Sepsis: Likely due to line infection, though there is also the possibility of an early LLL pneumonia. Patient cites a h/o chronic diarrhea, but would also consider possibility of C diff colitis. Will continue empiric coverage with Vanco, Flagyl, and Levaquin and f/u blood cx data. Will also obtain fungal cx given h/o chronic TPN use and risk of fungemia. At present, pt's hypotension is responding to IVF resuscitation, so will wean Levophed with goal to keep SBP>90 (pt's baseline) and UO>30 cc/hr. , #Access: Pt currently has L femoral line due to difficulty obtaining L subclavian vein access. Will need to contact IR re: venous access issues. PICC will need to be removed and tip sent for culture. , #Chronic diarrhea: Will send sample for C diff, though suspect her diarrhea is related to her short gut syndrome. Will continue patient's antidiarrheal medications. Patient is on empiric Flagyl. . #Anxiety/depression: Will continue outpt Psych meds. . #Chronic pain: Confirmed pain medication dosages with patient. Will continue her methadone and oxycodone. . #Anemia: Patient has h/o anemia with baselne HCT 26-29 w/ MCV 95. Anemia likely related to her chronic illness, but possible nutritional deficiency. Will continue Fe supplement. Will check B12/folate levels. . #Metabolic acidosis: VBG notable for CO2=60, possibly related to pt's somnolence. Will obtain repeat VBG. . #Prophylaxis: PPI and SQ Heparin. . #Dispo: ICU. . #Code status: Full. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] pager [**Numeric Identifier 25566**] Pertinent Results: CXR: Retrocardiac opacification concerning for early consolidation. No evidence of CHF, or pleural effusion bilaterally. . EKG: NSR, nl axis, nl intervals . CT abdomen: 1. Very short GI tract, with dilated loops of small bowel and remaining colon with air fluid levels present. The findings suggest partial obstruction vs. ileus, but there is fluid down through the rectum. No discrete transition point is identified. 2. Mild intrahepatic biliary ductal dilatation. In addition, the common bile duct is large measuring 11 mm at the pancreatic head. 3. Single gallstone. 4. Posterior/superior dislocation of the right hip, with formation of a pseudoacetabulum in the right ilium. 5. Compression fractures of T8, T11, and T12. . RIJ central line placement: 1. Successful placement of a right internal jugular tunneled central venous catheter with tip in the superior vena cava just above the junction with the right atrium. The catheter can be used immediately. Catheter is a 10-French double-lumen catheter. 2. Angioplasty of a tight stenosis of the right subclavian vein, with good angiographic result. 3. Removal of the right upper extremity PICC. . Echo: Conclusions: 1. The left atrium is mildly dilated. 2. 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 normal (LVEF>55%). 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The ascending aorta is mildly dilated. 5.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. No mass or vegetation is seen on the aortic valve. 6.The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. No mitral regurgitation is seen. 7.There is moderate pulmonary artery systolic hypertension. 8.There is no pericardial effusion. IMPRESSION: No echocardiographic evidence of endocarditis seen. . [**2135-1-22**] 11:20PM IRON-24* [**2135-1-22**] 11:20PM calTIBC-95* FERRITIN-1079* TRF-73* [**2135-1-22**] 11:20PM CORTISOL-21.0* [**2135-1-22**] 06:08PM POTASSIUM-3.3 [**2135-1-22**] 06:08PM CORTISOL-4.5 [**2135-1-22**] 04:55AM TYPE-[**Last Name (un) **] PO2-39* PCO2-55* PH-7.26* TOTAL CO2-26 BASE XS--2 [**2135-1-22**] 04:55AM LACTATE-0.7 [**2135-1-22**] 04:28AM GLUCOSE-84 UREA N-14 CREAT-0.6 SODIUM-136 POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-20* ANION GAP-14 [**2135-1-22**] 04:28AM ALBUMIN-2.1* CALCIUM-6.9* PHOSPHATE-3.2 MAGNESIUM-1.5* [**2135-1-22**] 04:28AM VIT B12-953* FOLATE-19.9 [**2135-1-22**] 04:28AM WBC-10.1# RBC-2.54* HGB-7.8* HCT-24.5* MCV-96 MCH-30.5 MCHC-31.7 RDW-13.7 [**2135-1-22**] 04:28AM NEUTS-90.0* BANDS-0 LYMPHS-7.3* MONOS-2.3 EOS-0.3 BASOS-0.2 [**2135-1-22**] 04:28AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL TARGET-OCCASIONAL [**2135-1-22**] 04:28AM PLT SMR-NORMAL PLT COUNT-224 [**2135-1-22**] 02:36AM TYPE-MIX [**2135-1-22**] 02:36AM LACTATE-0.8 [**2135-1-22**] 02:36AM O2 SAT-55 [**2135-1-22**] 01:32AM TYPE-MIX [**2135-1-22**] 01:32AM LACTATE-0.8 [**2135-1-22**] 01:32AM O2 SAT-69 [**2135-1-22**] 12:21AM TYPE-MIX PO2-42* PCO2-60* PH-7.26* TOTAL CO2-28 BASE XS--1 [**2135-1-22**] 12:21AM LACTATE-1.0 [**2135-1-22**] 12:21AM O2 SAT-71 [**2135-1-22**] 12:15AM GLUCOSE-108* UREA N-18 CREAT-0.7 SODIUM-137 POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-23 ANION GAP-11 [**2135-1-21**] 10:25PM GLUCOSE-87 UREA N-21* CREAT-0.8 SODIUM-131* POTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-26 ANION GAP-14 [**2135-1-21**] 10:26PM LACTATE-1.1 [**2135-1-21**] 10:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2135-1-21**] 10:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2135-1-21**] 10:25PM URINE RBC-0-2 WBC-[**7-16**]* BACTERIA-MANY YEAST-NONE EPI-0 [**2135-1-21**] 09:22PM LACTATE-2.1* [**2135-1-21**] 09:15PM GLUCOSE-86 UREA N-21* CREAT-0.9 SODIUM-129* POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-24 ANION GAP-15 [**2135-1-21**] 09:15PM WBC-21.4*# RBC-3.00* HGB-9.8* HCT-28.5* MCV-95 MCH-32.6* MCHC-34.3 RDW-14.1 [**2135-1-21**] 09:15PM NEUTS-92.6* BANDS-0 LYMPHS-3.8* MONOS-3.0 EOS-0.3 BASOS-0.3 [**2135-1-21**] 09:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ STIPPLED-OCCASIONAL [**2135-1-21**] 09:15PM PLT SMR-NORMAL PLT COUNT-271 [**2135-1-21**] 09:15PM PT-12.5 PTT-28.0 INR(PT)-1.0 Brief Hospital Course: Hospital Course: 52 year old female with a h/o Crohn's disease and multiple abdominal surgeries, with short gut syndrome, on chronic TPN, and with chronic venous access issues. She was admitted to the [**Hospital Unit Name 153**] for management of sepsis. . # Sepsis: Initial blood cultures were positive for MRSE. Sepsis was likely due to a R picc line infection. The R picc line was removed, and cath tip culture was positive for oxacillin-sensitive coag neg Staph. There was also the possibility of an early LLL pneumonia. Patient cites a h/o chronic diarrhea, but would also consider possibility of C diff colitis. Patient was empirically covered with Vanco, Flagyl, and Levaquin. Given h/o chronic TPN use, risk of fungemia was high, but fungal cultures were negative. In the [**Hospital Unit Name 153**], patient's hypotension responded to IVF resuscitation, so Levophed was weaned. Pt had a L femoral line placed due to difficulty in obtaining L subclavian vein access, followed by a R midline placed by IR. Followup blood cultures were negative, hypotension stopped, and patient improved. . # Chronic diarrhea: Was likely associated with patient's short gut syndrome, and was C diff negative. Patient was continued on antidiarrheal medications, and empiric Flagyl was stopped. . # Anxiety/depression: Outpatient Psych meds were continued. . #Chronic pain: Patient was continued on her home regimen of methadone and oxycodone. . #Anemia: Patient has h/o anemia with baselne HCT 26-29 w/ MCV 95. Anemia likely related to her chronic illness, but also nutritional deficiency due to short gut syndrome. Patient was continued on her Fe supplement. . #Prophylaxis: Patient was maintained on PPI and sc heparin. . #Code status: Full. Medications on Admission: OUTPT MEDS: BusPIRone 30 mg PO TID Clopidogrel Bisulfate 75 mg PO Metoclopramide 10 mg PO QIDACHS Diphenoxylate-Atropine 4 TAB PO QID Ferrous Sulfate 325 mg PO BID Oxycodone 30 mg PO Q8H:PRN Fluoxetine HCl 40 mg PO BID Pantoprazole 40 mg PO TID Promethazine HCl 25 mg PO Q6H:PRN Loperamide HCl 2 mg PO TID Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 2. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: Four (4) Tablet PO QID (4 times a day). 3. Buspirone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 4. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 5. Methadone 10 mg Tablet Sig: Seven (7) Tablet PO QID (4 times a day). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 8. Oxycodone 5 mg Tablet Sig: Six (6) Tablet PO Q8H (every 8 hours) as needed. 9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID: prn. Disp:*120 Tablet, Chewable(s)* Refills:*2* 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 11. Vancomycin in Dextrose 1 g/250 mL Solution Sig: One (1) Intravenous once a day for 5 weeks. Disp:*qs qs* Refills:*0* 12. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H:prn. 13. Loperamide 2 mg Tablet Sig: One (1) Tablet PO three times a day. 14. Line care Hickman care per protocol 15. Outpatient Lab Work For the next 5 weeks, please check CBC, Chem 7, vancomycin trough weekly satrting [**1-31**] - please send results to PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 1356**] # [**Telephone/Fax (1) 25567**] Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Therapies Discharge Diagnosis: Principal Diagnoses: 1. Line Sepsis - MRSE Bactermia. 2. Partial Small Bowel Obstruction. Secondary: 1. Crohn's Disease. 2. TPN Dependent Short Gut Syndrome. 3. Multiple Bowel Resection. 4. S/P TAH/BSO/LOA c/b colon perforation and colostomy and fistula. 5. Sarcoidosis. 6. Chronic Diarrhea. 7. Chronic SVC occlusion secondary to central access, s/p IR Recanalization. 8. Hypertension. 9. Anxiety/Depression. 10. Iron Deficiency Anemia. 11. Vertebral Compression Fractures. 12. Avascular Necrosis of Right Hip w/ superior/posterior dislocation and iliac pseudoacetabulum. Discharge Condition: good Discharge Instructions: Please take all of your medications as prescribed. ** Please call your doctor or return to the emergency department if you develop feveres/chills, nausea/vomiting, if you develop shortness of breath, chest pain, dizzness, if you pass out or other symptoms that are concerning to you. Followup Instructions: Follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 1356**] [**Telephone/Fax (1) 25567**] Call to schedule appointment in one week. ** Please make sure your PCP checks your blood sugar when you see her. Completed by:[**2135-2-28**]

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Discharge summary

report+report

Admission Date: [**2113-4-28**] Discharge Date: [**2113-5-3**] Date of Birth: [**2040-12-26**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1271**] Chief Complaint: Sycope fall Major Surgical or Invasive Procedure: None History of Present Illness: This is a 72 year old female on aspirin who fell [**2113-4-28**] at home. She states that she felt lightheaded and then next remembers being on the tiled floor in the kitchen. The fall was unwitnessed with reported loss of consciousness and the patient does not know how long she was down for. She reports 4 episodes of vomiting since her fall. She complains of numbness and tingling sensation in her hands, weakness in her hands and legs. She denies bowel or urine incontinence, hearing or visual deficit.She denies use of assistive devices to ambulate at home. She reports 4 episodes of lightheadedness in the past. Past Medical History: CVA [**2105**] Social History: The patient lives at home with her husband Physical Exam: On admission: PHYSICAL EXAM: O: T:96.5 BP: 100/50 HR:54 R: 16 O2Sats: 100% Gen: comfortable, NAD. HEENT: 2 cm occipital lac Pupils: 2.5-2mm EOMs: intact Neck: hard cervical 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. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2.5 to 2 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 Motor: D B T WE WF IP Q H AT [**Last Name (un) 938**] G R 5 5 5 4 4 3 3 4 2 2 2 L 5 5 5 4 3 3 3 5 4+ 4+ 4+ GRIP [**1-6**] bilat No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements rectal tone- flacid Upon Discharge: D B T WE Grasp IP Q H AT [**Last Name (un) 938**] G R 3 5 2 4 3 3 3 3 3 3 3 L 3 5 2 4- 3 3 3 3 3 3 3 Lower extremity exam is antigravity but effort dependent. Moves spontaneously, but not always to command. No clonus Sensation reduced below C7 to light touch At discharge she had an episode of hypotension which resolved when in bed to 140/55. According to daughter in law the patient is always hypotensive baseline. Pertinent Results: MR C/T/L spine [**2113-4-28**]: IMPRESSION: 1. Edema within the spinal cord at C5-C7, likely due to contusion secondary to spinal stenosis and trauma with blood products within the cord consistent with hemorrhagic contusion. 2. Posterior disc bulge and osteophyte complex at multiple levels, most severe at C5-C6 with moderate neural foraminal narrowing bilaterally at C5-C6 as well as moderate posterior disc bulge and osteophyte formation at C4-C5 and C6-C7 level with mild neural foraminal stenosis bilaterally at these levels. 3. Multilevel degenerative changes within the lumbar spine, most prominent at C4-C5 with disc bulge and facet degenerative changes causing minimal narrowing of the spinal cord and indentation of the thecal sac. 4. Posterior soft tissue swelling with no obvious disruption of the ligamentum flavum, anterior, posterior spinous ligaments within the cervical region.Increased signal in interspinous region without widening of interspinous distance indicates trauma without disruption. ECHO [**2113-4-29**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. Head CT [**2113-4-29**]: No evidence of SAH. EEG [**2113-4-30**]: Normal Carotid Ultrasound [**2113-5-2**]: Findings: Duplex evaluation was performed of bilateral carotid arteries. On the right there is moderate heterogeneous plaque in the bulb/ICA. On the left there is moderate heterogeneous plaque seen in the bulb/ICA. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 76/21, 56/10, 79/17 cm/sec. CCA peak systolic velocity is 52 cm/sec. ECA peak systolic velocity is 100 cm/sec. The ICA/CCA ratio is 1.5. These findings are consistent with <40% stenosis. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 75/20, 85/18, 72/16 cm/sec. CCA peak systolic velocity is 54 cm/sec. ECA peak systolic velocity is 67 cm/sec. The ICA/CCA ratio is 1.6. These findings are consistent with <40% stenosis. Right antegrade vertebral artery flow. Left antegrade vertebral artery flow. Impression: Right ICA stenosis <40%. Left ICA stenosis <40%. Brief Hospital Course: Ms [**Known lastname 931**] was admitted on [**2113-4-28**] after sustaining a C5-6 cord contusion and SAH after a syncope fall at home. She was admitted to the ICU for close observation where her blood pressure was kept to a MAP of 85 for perfusion. She was placed in a hard cervical collar. On [**2113-4-29**] the trauma service cleared her T and L spine. Repeat head CT was stable and she was transferred to the floor. Syncope workup: ECHO was negative Carotid ultrasound (see report) EEG was normal Hgb A1c 5.9 PT/OT worked with the patient and recommended rehab placement. On [**2113-5-3**] she was discharged to [**Hospital 38**] Rehab Medications on Admission: ASA 81mg Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane TID (3 times a day) as needed for mouth care. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain. 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed for constipation. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): Titrate if needed. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Spinal stenosis C [**4-6**]/C [**5-8**] C5-6 cord contusion Central Cord Syndrome Nondisplaced occipital fracture Subarachnoid hemorrhage Syncope 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: ?????? No pulling up, lifting more than 15 lbs., or excessive bending or twisting until your follow-up appointment ?????? Limit your use of stairs to 2-3 times per day. ?????? If you are required to wear one, wear your cervical collar or back brace as instructed. ?????? Please shower with the cervical collar on. You may remove the brace off briefly to provide skin care. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? You [**Month (only) **] NOT drive as you are required to wear a cervical collar. Return to work recommendations will be discussed at your office visit. ?????? Exercise should be limited to walking; no straining, or excessive bending. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin prior to your injury, please refrain from taking until cleared by your Neurosurgeon- this will occur at your follow-up appointment Followup Instructions: Please have your occipital sutures removed on [**2113-5-8**]. You may have this done with your PCP or with our clinic. Please call [**Telephone/Fax (1) 1272**] to make this appointment. Please follow-up with Dr [**Last Name (STitle) 739**] in [**1-5**] weeks. You will not need spinal imaging at that time, but you will need a Head CT to reassess your head bleed. Please call Paresa to make this appointment [**Telephone/Fax (1) 1272**]. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2113-5-3**] Admission Date: [**2113-5-3**] Discharge Date: [**2113-5-25**] Date of Birth: [**2040-12-26**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1271**] Chief Complaint: " I can't move my legs" Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 931**] is a 72 yo woman who returns from [**Hospital 38**] rehabilitation center following a change in exam from her discharge earlier today. To review, Ms. [**Known lastname 931**] was admitted on [**4-28**] after sustaining an unwitnessed fall at home. Upon admission, the patient was found to have a frontal and temporal subarachnoid hemorrhage and a non displaced occipital fracture. The patient is experiencing significant weakness in her hands and legs upon exam. MRI demonstrated edema within the spinal cord at C5-C7, felt to be secondary to a hemorrhagic contusion. The patient's exam was reportedly slightly decreased from admission, but overall stable. She was discharged to rehab this AM ([**5-3**]). Upon arrival to rehabilitation this afternoon, there was concern that the patient was no longer able to move her legs. In addition, he was reporting pain in her arms (right worse than left). Given this, Dr. [**Last Name (STitle) 739**] (her prior attending) was contact[**Name (NI) **] and the patient was referred back to the emergency room for further evaluation. The patient currently endorces [**3-11**] pain in her right arm (between her shoulder and her elbow). She reports being numb in her legs and states she has been unable to move her legs since this morning. She endorces a feeling of vibration moving across her mid section which is uncomfortable but not painful She has not had a bowel movement in the last 24-48 hours. She has a foley that was in place since her transfer so she is unsure of her urinary control. She denies any headache, changes in vision, chills or nausea. She denies difficulty breathing; she has no chest pain. All other ROS where negative. Past Medical History: CVA [**2105**], no residual deficit Hypothyroidism Remote history of syncope Social History: The patient lives at home with her husband and she has many children in the area. Family History: non- contributory Physical Exam: T: 97.6 BP: 142/55 HR: 50 R 16 100O2Sats Gen: resting in C collar, appears anxious HEENT: MMM Lungs: CTA bilaterally Cardiac: RRR. S1/S2. Abd: Soft, mildly distended, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, diminsihed affect. Oriented to person, place, and date. CN: Pupils 2.5-2mm bilaterally, EOMI, Face symmetric, tongue midline. Motor: D B T WE WF FE FL IP Q H AT [**Last Name (un) 938**] G R 4 5 3 3 3 0 0 0 0 0 0 0 0 L 4 5 3 3 3 0 0 0 0 0 0 0 0 Sensation: Diminished light touch, pinprick, temperature bilaterally, L>R with lower extremities worse than upper extremities. Pinprick sensory level to T1 right, T2 on left. Symmetric loss of vibratory sense in the lower extremities. Diminished proprioception in left toe. Withdraws to noxious on right, not on left. Reflexes: B T Br Pa Ac Right 2+ 2+ 2+ 2+ 2beats clonus Left 2+ 2+ 3 2+ 2beats clonus Toes downgoing bilaterally Present but diminished rectal sphincter tone *** Physical Exam upon discharge *** Motor: D B T WE WF FE FL IP Q H AT [**Last Name (un) 938**] G R 5 5 0 4 3 0 0 0 0 0 0 0 0 L 5 5 0 4 3 0 0 0 2 0 3 0 0 can wiggle toes and move foot slightly back and forth Sensation: Diminished light touch to stomach feels like pin and needles. Reflexes: Br Pa Ac Right 2+ 2+ Left 2+ + Pertinent Results: [**2113-5-3**] C-Spine CT: IMPRESSION: 1. No fracture. 2. Multilevel degenerative changes, worse at C4-C5, C5-C6, C6-C7, with posterior disc osteophyte complex at this level. [**2113-5-3**] C-Spine MRI: IMPRESSION: 1. Progression of the cord signal abnormality suggestive of progressive edema, now extending caudally to the T2 level. While this can relate to trauma, consider follow up and clinical/lab correlation to exclude non-traumatic causes. 2. Findings suggestive of a nondisplaced fracture involving the T2 vertebral body. Further evaluation with CT/PXR can be considered for better assessment of fractures. 3. Extensive abnormal STIR signal in the posterior soft tissues, the interspinous ligament, prevertebral fluid, and high signal along the ligamentum nuchae are all suggestive of traumatic injury with/without associated ligamentous injury. Small amount of facet joint fluid at the C3-4 level and the T2-3 level. Correlate with CT. 4. High grade canal stenosis at the levels above. [**2113-5-10**] Cspine MRI: IMPRESSION: 1. Interval improvement in residual cord signal abnormality when compared with the prior study of [**2113-5-3**]. Subtle enhancement in the cord can be seen after contusion. 2. Marked interval improvement in edema and fluid within the prevertebral soft tissues, interspinous ligaments, and ligamentum nuchae when compared with the prior study. 3. Please see report of MRI performed [**2113-5-3**] for evaluation of stable severe degenerative changes of the cervical spine. [**2113-5-13**] CTA Chest: IMPRESSION: 1. Large bilateral pulmonary emboli with extension into multiple subsegmental branches as described above. 2. Aberrant right subclavian artery causing mass effect on the esophagus. [**2113-5-13**] Head CT: IMPRESSION: Ill-defined focus of hyperintensity within the left frontal lobe, not identified on the prior study and could represent a small amount of acute subarachnoid hemorrhage. Hyperdense focus within the posterior [**Doctor Last Name 534**] of the left lateral ventricle also not identified on the prior study, could represent a tiny amount of intraventricular blood. Given the patient's history of recent heparinization, an MRI or serial CT scans may be obtained for further characterization. [**2113-5-14**] Bilateral Upper/Lower extremity veins ultrasound: No DVTs. [**2113-5-14**] MRI Cspine: IMPRESSION: Stable appearance of Cspine. [**2113-5-14**] Head: 1. No change. 2. Hyperdense foci in the left frontal lobe and left occipital [**Doctor Last Name 534**] of the lateral ventricles are unchanged in size and density. Brief Hospital Course: Pt was seen in the emergency room and evaluated by the neurosurgery team. She was admitted to Neurosurgery in the SICU for q1 hour neuro checks. Her goal MAP >85 to ensure cord perfusion (using a neosenephrine gtt as needed). She was given Decadron 10mg IV x 1. Family was updated of current situation and plan. A C-spine CT and MRI were obtained. CT revealed no changes from previous scan. MRI revealed progression of the cord signal abnormality suggestive of contusion/edema previously noted, now extending caudally to the T2 level and a nondisplaced fracture involving the T2 vertebral body. On [**5-4**] upon examination the patient had stable strengths of her UE's, no movement of her left LE and reflexive vs extension of her R LE to stimulation. No clonus was appreciated and patellar reflexes were 3+ b/l. Sensation was intact to light touch. At this time her neuro check were changed to q2hrs, but she remained in the ICU for close neuro exams and BP control. On [**5-5**] her neurological exam remained stable. Her SBP was liberalized to >120 and her Neo-Synephrine gtt was weaned. She continued on midodrine and her decadron was changed to a taper over 5 days. On [**5-8**] she continued to be in the ICU her neurologic exam was improving with her right leg now with strength of at least 4 in all muscle groups except her IP which was 2+. On [**5-9**] she was placed on neosynephrine and she had bradycardia to the 20's. Her LLE was moving less and her SBP goal was raised to >120. On [**5-10**] she was continued on neosynephrine for BP control in order to keep her SBP>120 but was unable to so her SBP goal was made >100. Also on [**5-10**] she had an MRI of the cervical spine which showed interval improvement. On [**5-11**] her WBC count was 12 UA and Ucx were sent which were both negative. Also on the 10th her SBP goal was changed to >90. On [**5-12**] given her cnetral cord symptoms she was seen by Dr. [**Last Name (STitle) 1274**] for eval fo autonomic dysreflexia. He recommended added florinef and fluid challenging. he also recommended eval by electrophysiology for pacer. She was also seen by Pt and OT. On [**5-13**] she developed shortness of breath, tachypnea, tachycardia, and hypoxia and was found to have bilateral PE's. A heparin gtt was initiated and a CT head and neck were obtained after the heparin was initiated. The CT head showed a question of a small area of SAH and the CT Neck was negative. On [**5-14**] she was stable in the ICU and was being evaluated for potential IVC filter placement. Also on [**5-14**] she had a CT head which was unchanged and a MRI of the cervical spine which showed mild increase in the pattern of spinal cord edema, extending from C5 through C7 levels, unchanged spinal cord expansion at C6. No IVC filter was placed in the setting that anticoagulation was not contraindicated. She was given Coumadin and on [**5-18**] her INR was 3.4 and her Heparin gtt was discontinued. On [**5-19**] the neosynephrine drip was discontinued. Her blood pressure remained stable on Midodrine and floricef. On [**5-22**] she was transferred to the Step Down Unit. Her INR on discharge was 3.8 we would recommend holding a dose for [**5-25**]. She was discharged to [**Hospital 38**] Rehab on [**5-25**] see physical exam section for discharge exam. Medications on Admission: Medications on Discharge [**2113-5-3**] 1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane TID (3 times a day) as needed for mouth care. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain. 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed for constipation. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): Titrate if needed. Home Medications: Pravastatin 10mg daily Levothyroxine 137mcg daily Aspirin 81mg daily Folic Acid 1mg daily Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: SAH Central Cord Contusion Cspine hematoma Occipital fracture Pulmonary Embolism Hypotension Bradycardia Urinary Retention Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: ?????? Do not smoke. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? You must wear a cervical collar at all times If you are required to wear one, wear your cervical collar or back brace as instructed. WE RECOMMEND SBP REMAIN BETWEEN 80-180. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. Followup Instructions: You will need to follow-up with Dr [**Last Name (STitle) 739**] 4 weeks from discharge. No imaging is needed at this appointment. Please call Paresa to make this appointment [**Telephone/Fax (1) 1272**]. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2113-5-25**]

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icd9cm

[ [ [] ] ]

[ "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

20894, 20991

16444, 19755

10301, 10308

21169, 21169

13826, 15575

22146, 22476

12283, 12302

6559, 7498

21012, 21148

19781, 20761

21304, 22123

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10238, 10263

2551, 3072

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1564, 2529

15584, 16421

1116, 1116

21184, 21280

12088, 12167

12183, 12267

15,041

189,077

10810

Discharge summary

report

Admission Date: [**2177-11-4**] Discharge Date: [**2177-11-13**] Date of Birth: [**2135-5-5**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7141**] Chief Complaint: Pelvic mass Major Surgical or Invasive Procedure: Exploratory laparotomy, radical resection of pelvic mass, supracervical hysterectomy, bilateral salpingo-oophorectomy, ileocecectomy with ileal ascending colostomy anastomosis, rectal resection with end sigmoid colostomy and Hartmann pouch, infracolic omentectomy, extensive tumor debulking. History of Present Illness: Ms. [**Known lastname 35274**] is a 42 yo woman who initially presented in [**Month (only) 205**] with LUQ discomfort. Due to her h/o nephrolithiasis, a CT urogram was done on [**8-11**] which showed non-obstructing stones and a bulky heterogenous uterus consistent with fibroids. Pt then had gradual onset of pelvic discomfort, constipation, and bloating. Pelvic ultrasound on [**10-16**] showed a large complex vascular left adnexal mass. Past Medical History: PMH: Brain aneurysm, nephrolithiasis PSH: Coiling of brain aneurysm in [**2170**], lithotripsy [**2173**] OB HISTORY: Vaginal delivery x1. GYN HISTORY: Last Pap smear and mammogram were both recently normal. Social History: The patient does not smoke or drink. She is an accountant. Family History: Significant for mother with liver cancer. Physical Exam: GENERAL APPEARANCE: Well developed, well nourished. HEENT: Sclerae anicteric. LYMPHATICS: Lymph node survey was negative. LUNGS: Clear to auscultation. HEART: Regular without murmurs. BREASTS: Without masses. ABDOMEN: Soft and distended with a palpable mass extending from the left lower quadrant to the left upper quadrant. This mass was nontender. It felt quite firm. There was also a palpable mass in the mid lower abdomen, which was also quite firm. EXTREMITIES: Without edema. PELVIC: The vulva and vagina were normal. The cervix was not visualized. Bimanual and rectovaginal examination revealed that the cervix was small and displaced anteriorly. There was a large smooth mass that was palpable both through the anterior vaginal wall and through the posterior fornix. By rectal examination, the posterior mass was filling the cul-de-sac. The rectal was intrinsically normal. Bimanual examination revealed that the mass seemed to be contiguous with the mass in the left upper quadrant. There was no parametrial disease. Pertinent Results: [**2177-11-5**] 04:14AM BLOOD WBC-6.6 RBC-4.02* Hgb-10.6* Hct-32.0* MCV-80* MCH-26.3* MCHC-33.0 RDW-14.5 Plt Ct-278 [**2177-11-4**] 10:17PM BLOOD Neuts-81* Bands-6* Lymphs-8* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2177-11-4**] 10:17PM BLOOD PT-14.5* PTT-25.7 INR(PT)-1.3* [**2177-11-5**] 04:14AM BLOOD Glucose-163* UreaN-13 Creat-1.2* Na-141 K-4.2 Cl-108 HCO3-21* AnGap-16 [**2177-11-5**] 04:14AM BLOOD Calcium-7.1* Phos-5.1* Mg-1.6 [**2177-11-4**] 04:56PM BLOOD Type-ART pO2-223* pCO2-35 pH-7.42 calTCO2-23 Base XS-0 Intubat-INTUBATED [**2177-11-4**] 04:56PM BLOOD Glucose-134* Lactate-1.0 Na-138 K-3.9 Cl-103 . Starting hct 33 -> 1000 EBL, 1 U PRBC intra-op->38->32->28->26-> 22.3-> 2u pRBC [**11-7**] -> 30 -> 34.1 -> 26.3 ->27->26.8 -->26.1 -->25.9-->26.1-->27.6 Pre coumadin INR-->1.8, after starting 5mg INR-->2.5-->4.7 coumadin held-->3.7 ECG [**11-6**]: Sinus tachycardia. Delayed R wave transition. No previous tracing available for comparison. . Chest X-ray [**11-6**]: COMPARISON: [**2177-10-28**]. FINDINGS: As compared to the previous radiograph, the lung volumes have markedly decreased. There is a marked retrocardiac atelectasis, associated with a small left-sided pleural effusion. Small areas of atelectasis are also seen at the right lung base. The size of the cardiac silhouette has mildly increased. There are no features suggesting pulmonary edema. No evidence of pneumothorax. . CTA Chest [**11-6**]: REASON FOR THIS EXAMINATION: R/o PE IMPRESSION: 1. Acute pulmonary emboli, right upper lobe pulmonary artery and segmental divisions. 2. Severe bibasilar atelectasis and small airways obstruction probably also contributory to respiratory insufficiency. 3. Small bilateral pleural effusions reflect recent abdominal surgery. No evidence of intrathoracic malignancy. . Surgical Tissue Pathology [**11-4**]: DIAGNOSIS: 1. Pelvic mass, biopsy (A-G): Poorly differentiated carcinoma consistent with papillary serous carcinoma. 2. Pelvic tumor, resection (C-G): Papillary serous carcinoma. 3. "Ovary", left (H-Q): Papillary serous carcinoma, see synoptic report. 4. Uterus, right ovary and tube, left ovary and tube, small intestine, large intestine and rectum: Papillary serous carcinoma, see synoptic report. a. Uterus, right ovary and tube, left ovary and tube (AA-AI): -Uterine serosal implant of serous carcinoma. -Resected supracervical margin is negative. -Ovaries (left and right) with serous carcinoma. -Right fallopian tube free of tumor. -No left fallopian tube recognized. b. Small intestine (R-U): Multiple serosal implants of serous carcinoma c. Large intestine and rectum, partial resection (V-Z): Diffusely encased with serous carcinoma. 5. Cecum (AJ-AK): No malignancy identified. 6. Sigmoid tumor ([**Doctor Last Name **]-AP): Papillary serous carcinoma. 7. Left colon tumor (AQ): Papillary serous carcinoma. 8. Omentum (AR-AU): Papillary serous carcinoma. 9. Abdominal wall (AV-AX): Papillary serous carcinoma. EXTENT OF INVASION Primary Tumor TNM (FIGO): pT3c and/or N1 (IIIC): Peritoneal metastasis beyond pelvis more than 2 cm in greatest dimension and/or regional lymph node metastasis. Regional Lymph Nodes: pNX: Cannot be assessed. Lymph Nodes: None submitted. Distant metastasis: pMX: Cannot be assessed. Venous/lymphatic vessel invasion (V/L): Present. Brief Hospital Course: 42 yo P1 admitted to the gyn oncology service s/p suboptimal cytoreductive surgery for advanced ovarian cancer. She had an exploratory laparotomy, SCH/BSO, small bowel resection and re-anastimosis, and sigmoid rection with colostomy. The surgery was uncomplicated; please see operative note for full details. . She was monitored in the ICU overnight given her extensive surgery, and was transferred to the regular floor on POD 1. Her post-operative course is summarized below and was complicated by the following: . *) Pulmonary embolus: On POD 1, she had shortness of breath, tachycardia, and tachypnea. A CTA was performed which showed a right upper lobe PE. Heparin drip was started for anticoagulation and she was transitioned to Coumadin when tolerating a regular diet. She was given Coumadin 5 mg PO QHS and her INR was monitored daily. INR was supra-therapeutic at 4.7 on [**11-12**]. Coumadin was held that night, and INR was 3.7 on [**11-13**]. Since she was stable for discharge at that time, she was discharged home with plans to have her INR monitored by [**Month/Year (2) 269**] and her Coumadin adjusted by her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 35275**]. . *) Blood loss anemia: Her starting hct was 33, and EBL was 1000cc. She received 1 U PRBC intra-op and another 2 U PRBC on [**11-7**]. Her hct was stable at 26-27 for many days prior to discharge. . *) Chest pain: She had one episode of chest pain on POD 2 which resolved spontaneously. Her EKG showed sinus tachycardia and her cardiac enzymes were cycled for 3 sets and found to be normal. . *) Colostomy: Her ostomy started functioning on POD3. She was seen by the ostomy nurse and learned to independently care for her ostomy. She was discharged home POD #9 in good condition. She was ambulating, voiding, and tolerating a full diet without problems. [**Name (NI) 269**] was arranged for stoma care and to check her INRs. Medications on Admission: None Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 2. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 3. Outpatient Lab Work Please draw INR every morning and report results to patient's primary Care: Dr. [**Last Name (STitle) 35275**] - Office [**Telephone/Fax (1) 35276**] - Pager [**Telephone/Fax (1) 35277**] (#[**Numeric Identifier 35278**]) - Cell [**Telephone/Fax (1) 35279**] 4. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime: As instructed by Dr. [**Last Name (STitle) 35275**]. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Ovarian cancer Pulmonary embolus Discharge Condition: Good Discharge Instructions: No heavy lifting or strenuos activity for 6 weeks. No driving while taking the Percocet. Take care of your ostomy as instructed. You will need your INR checked every day and your Coumadin dose will be adjusted by Dr. [**Last Name (STitle) 35275**]. Call if you have increasing pain, nausea or vomiting, redness or drainage from your incision, chest pain, shortness of breath, or any other problems. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7613**], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2177-12-11**] 1:00 . The medical oncologist will call you to arrange an appointment. . Please call Dr.[**Name (NI) 35280**] office to schedule an appointment. Completed by:[**2177-11-14**]

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icd9cm

[ [ [] ] ]

[ "40.3", "68.39", "45.93", "45.75", "65.61", "59.02", "46.13", "45.62", "54.4", "48.69" ]

icd9pcs

[ [ [] ] ]

8629, 8678

5935, 7873

340, 633

8755, 8762

2554, 3992

9209, 9521

1430, 1473

7928, 8606

8699, 8734

7899, 7905

8786, 9186

1488, 2535

289, 302

4024, 5912

661, 1104

1126, 1336

1352, 1414

64,911

103,718

11072

Discharge summary

report

Admission Date: [**2106-10-3**] Discharge Date: [**2106-10-12**] Date of Birth: [**2049-6-29**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 348**] Chief Complaint: Abdominal Pain, Nausea, Vomiting Major Surgical or Invasive Procedure: Arthrocentesis Right Knee [**2106-10-11**] History of Present Illness: Mr. [**Known lastname **] is a 57 y/oM with h/o HCV HTN Hypercholesterolemia, h/o diverticulitis requiring resection, followed by [**Last Name (NamePattern4) 35772**], h/o EtOH abuse awoke with abdominal pain and nausea and vomiting starting at 6am this morning. He has a prior h/o EtOH abuse and prior h/o withdrawal per the patient. He reported drinking about one pint of vodka on Friday/[**2106-10-1**], and drinking 2 glasses of wine at dinner on Saturday (lobster/shrimp) and feeling well. He developed pain around 6am, infraumbilical, with NBNB emesis, followed by a normal NB bowel movement. Because of the severe nature of the abd pain, he requested his wife take him to the [**Name (NI) **]. At [**Hospital1 **], Temp 98.2, HR 92 BP 196/113 RR 30 Sat 100% on RA, BP as high as 218/119. Lipase was critically elevated >3000, Cr 1.2, AG 23, Gluc 246, AST 125, ALT 183, AP 85. Lactic acid reported at 46 [sic] from ED attg note. Ct showed severe stranding around the pancreas without necrosis, and without fluid collection. No mention of gallstones. He received 3L of IV NS. He received dilaudid 1mg IV and Zofran 4mg IV, later morphine. He also received 3g of Unasyn empirically. He was transferred to [**Hospital1 18**] for further management. In the [**Hospital1 18**] ED, his vitals were 96.1, HR 116, BP 161/118, RR 18, and his oxygen sat was 93% on 3L NC. Lipase was 1837, TBili 0.7, Cr 1.3, Gluc 249, ALT 169, AST 108, WBC 17.4. FAST ultrasound in the ED showed no gallstones. He received 4L of NS placed on nipride 2mcg/kg/min. His O2 sats dropped, 90% on NRB with ABG 7.26/41/70, placed on Bipap 5/5 rising to 98%. Lopressor was given without effect on blood pressure. CXR showed LLB haziness but no definite effusion or interstitial edema. He was evaluated by surgery in the ED, who reviewed his case and discussed the CT with the outside hospital radiology resident. Recommendation was made for continued medical care in the ICU. Seen in the ICU, the patient has decreased attention and no significant complaints of pain. He follows commands, and is oriented x3 but easily falls asleep. Past Medical History: 1) Hepatitis C, genotype 1, c/b cirrhosis s/p ribavirin and peg- interferon x 48 weeks without response 2) Hypertension 3) Psoriasis 4) h/o Diverticulitis c/b Colovesicular Fistula requiring resection 5) h/o Nephrolithiasis Social History: Occupation: Self-Employed Software Engineer Drugs: Former IVDU, current Marijuana Tobacco: Former Alcohol: h/o Alcoholism, drinks ~1 bottle of wine/night, h/o prior withdrawal, no seizures Other: Lives at home with wife, daughter Family History: noncontributory Physical Exam: On initial PE he was noted to be oriented x 3, but somnolent, falling asleep during interview with diffuse abdominal tenderness and distension On Transfer to floor T:95.6 ax 120/65 56 16 98%RA Gen: Pleasant, well appearing man conversant, interactive, in NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD, No JVD. No thyromegaly. CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**] LUNGS: Diminished at bases but no W/R/C ABD: NABS. Soft, NT, ND. No HSM EXT: WWP, NO CCE. 2+ DP pulses BL. Right knee with edema, erythema and minimal warmth, mildly tender to palpation. ROM limited [**1-2**] pain. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**12-2**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2106-10-3**] WBC-17.4*# RBC-5.08 Hgb-17.9 Hct-48.6 MCV-96 MCH-35.1* MCHC-36.7* RDW-13.3 Plt Ct-185 Neuts-92.6* Lymphs-3.8* Monos-3.4 Eos-0.2 Baso-0.1 [**2106-10-4**] WBC-15.2* RBC-4.25* Hgb-15.1 Hct-41.2 MCV-97 MCH-35.6* MCHC-36.7* RDW-12.9 Plt Ct-152 [**2106-10-5**] WBC-14.6* RBC-4.03* Hgb-13.7* Hct-38.7* MCV-96 MCH-34.0* MCHC-35.4* RDW-13.7 Plt Ct-115* [**2106-10-9**] WBC-16.5* RBC-3.80* Hgb-13.2* Hct-37.4* MCV-98 MCH-34.7* MCHC-35.3* RDW-12.5 Plt Ct-215 Neuts-85* Bands-3 Lymphs-5* Monos-6 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2106-10-11**] WBC-20.1* RBC-3.67* Hgb-12.5* Hct-36.2* MCV-99* MCH-34.1* MCHC-34.5 RDW-13.0 Plt Ct-277 11/11/08-17.2* RBC-3.66* Hgb-12.4* Hct-35.3* MCV-96 MCH-33.9* MCHC-35.2* RDW-12.9 Plt Ct-269 [**2106-10-3**] PT-14.3* PTT-21.7* INR(PT)-1.2* [**2106-10-11**] PT-13.8* PTT-22.8 INR(PT)-1.2* [**2106-10-3**] Glucose-249* UreaN-16 Creat-1.3* Na-142 K-4.0 Cl-109* HCO3-18* AnGap-19 [**2106-10-5**] Glucose-145* UreaN-21* Creat-1.0 Na-143 K-3.4 Cl-116* HCO3-20* AnGap-10 [**2106-10-8**] Glucose-117* UreaN-16 Creat-1.0 Na-141 K-3.5 Cl-112* HCO3-18* AnGap-15 [**2106-10-12**] Glucose-154* UreaN-20 Creat-1.1 Na-139 K-3.2* Cl-109* HCO3-19* AnGap-14 [**2106-10-3**] ALT-169* AST-108* AlkPhos-66 TotBili-0.7 [**2106-10-3**] ALT-135* AST-79* LD(LDH)-221 CK(CPK)-177* AlkPhos-49 TotBili-0.6 [**2106-10-7**] ALT-45* AST-35 LD(LDH)-535* AlkPhos-38* TotBili-1.9* [**2106-10-11**] ALT-26 AST-31 LD(LDH)-387* AlkPhos-67 TotBili-1.1 [**2106-10-3**] Lipase-1837* [**2106-10-5**] Lipase-638* [**2106-10-9**] Lipase-239* [**2106-10-11**] Lipase-192* [**2106-10-3**] Albumin-4.6 Calcium-8.4 Phos-2.5* Mg-1.4* [**2106-10-5**] Albumin-3.2* Calcium-6.6* Phos-1.9* Mg-1.9 [**2106-10-12**] Calcium-8.2* Phos-3.5 Mg-2.2 [**2106-10-5**] Ammonia-53* [**2106-10-3**] Triglyc-116 HDL-43 CHOL/HD-4.4 LDLcalc-123 [**2106-10-3**] Serum Tox ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2106-10-3**] ART pO2-70* pCO2-41 pH-7.26* calTCO2-19* Base XS--8 [**2106-10-3**] Lactate-2.1* [**2106-10-5**] Lactate-3.1* [**2106-10-7**] Lactate-0.6 [**2106-10-3**] freeCa-1.05* [**2106-10-4**] freeCa-0.99* [**2106-10-7**] freeCa-1.10* [**2106-10-11**] 03:17PM JOINT FLUID WBC-900* RBC-[**Numeric Identifier 35773**]* Polys-59* Bands-2* Lymphs-6 Monos-32 Eos-1* [**2106-10-11**] 03:17PM JOINT FLUID Crystal-NONE MICRO C diff negative x 2 Blood cx, urine cx No growth Joint fluid cx no growth Brief Hospital Course: In summary, Mr. [**Known lastname **] is a 57 year old male with h/o HCV and Alcohol abuse, admitted with acute pancreatitis likely secondary to alcohol ingestion. Course additionally notable for hypoxia requiring NIMV/BIPAP, altered mental status secondary to alcohol withdrawal, hypertension, and right knee pain. 1. Pancreatitis. Patient presented with severe pancreatitis with elevated [**Last Name (un) **] scores on admission and at 48hrs. Etiology of pancreatitis was thought to be alcohol ingestion as [**Name (NI) 5283**] sono showed cholelithiasis but no evidence of gallstone pancreatitis and alk phos was not elevated. He also was noted to have a normal triglyceride level. Patient had ongoing pain with fevers during hospital stay so abdominal CT was obtained revealing pancreatic necrosis. He was followed by surgery during hospital stay. He was initially kept NPO and given IVF and pain management, and his symptoms improved. His diet was advanced and at time of discharge he was tolerating regular diet without abdominal pain, nausea or vomiting. He should have follow up imaging (MRCP) in [**1-4**] weeks). 2. FEVER. Patient was febrile on [**10-7**] and [**10-8**] (hospital day 4 and 5). Cultures were negative, but abdominal cat scan showed necrotizing pancreatitis. He was started on vanco/zosyn on [**10-8**]. Antibiotics were stopped [**10-12**] since there was no obvious infection source and empiric antibiotics for sterile pancreatic necrosis is controversial and not neccessary. He was afebrile >48 hours prior to discharge and WBC was trending down [**10-12**]. 3. HYPOXIA. Patient was hypoxic during hospital stay requiring intermittent bipap. Etiology of hypoxia was thought to be splinting from abdominal pain, obesity, and fluid overload. Hypoxia improved with intermittent BIPAP and lasix diuresis. At time of discharge, he had been satting mid-high 90s on room air without shortness of breath and did not desat with activity with physical therapy. 4. ALCOHOL WITHDRAWAL/ABUSE. Patient developed alcohol withdrawal during hospital stay. He required large amounts of benzos and standing zyprexa. He was given multivitamins and thiamine. He no longer required benzos for withdrawal > 72 hours prior to discharge. Patient was counseled on alcohol abuse and the importance of stopping all alcohol intake. He was also seen by social work. 5. Hypertension. Patient was hypertensive during hospital stay, likely secondary to pain and alcohol withdrawal. He was intermittently on a labetolol drip. He was given benzos for alcohol withdrawal and morphine for pain, with improvement of BP. He was normotensive off medications a time of discharge. 6. Right Knee pain: Pt had right knee pain, most likely secondary to gout. He was seen by Rheumatology who recommended NSAIDs and performed arthrocentesis which was consistent with traumatic tap/inflammation. There was no evidence of infection, joint fluid culture and crystals were negative. He was given Indomethacin with good effect for a short duration for presumed gout. Medications on Admission: Tricor 145mg PO daily [**2106-9-30**] Citalopram 40mg PO daily [**2106-9-30**] Tramodol 100mg PO TID PRN [**2106-9-9**] Benicar 20mg PO daily [**2106-9-9**] Pantoprazole 40mg PO daily [**2106-9-9**] Ibuprofen PRN for headaches Discharge Medications: 1. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 2 weeks. Disp:*42 Capsule(s)* Refills:*0* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day. 4. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Benicar 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Outpatient Physical Therapy Outpatient Physical Therapy for gait and balance training 7. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis 1. Acute Necrotizing Pancreatitis 2. Alcohol Abuse/Withdrawal Secondary Diagnosis Hepatitis C c/b cirrhosis HTN Psoriasis h/o diverticulitis requiring resection Discharge Condition: Hemodynamically stable, afebrile, tolerating diet, abdominal pain improved Discharge Instructions: You were admitted to the hospital with symptoms of abdominal pain, nausea and vomiting. These symptoms were from pancreatitis (inflammation of your pancreas) which is most likely from your alcohol use. You were intially treated with antibiotics but these were discontinued since you did not have any signs or symptoms of an infection. We also treated you for alcohol withdrawal while you were in the hospital. It is extremely important that you avoid all alcohol intake to avoid recurrent episodes of pancreatitis. You also developed knee pain which is felt to be most likely from a flare of gout which you may have had in the past. Fluid from your knee was drained and was not consistent with an infection. We treated you with Indomethacin which helped control your pain. We made the following changes to your medications: 1. We added Indomethacin for your knee pain 2. We added Pantoprazole to prevent you from developing gastritis while on Indomethacin (although you were also intermittently taking this medication at home) Please return to the ER or call your primary care doctor if you develop fever >100.4, chills, nausea, vomiting, chest pain, shortness of breath or any other concerning symptoms. Followup Instructions: Please follow up with your primary care doctor, Dr. [**Last Name (STitle) 29250**]. You have an appointment on Tuesday [**10-26**] at 11:15am. You can call the office at ([**Telephone/Fax (1) 34906**] if you have any questions. You also have an appointment with Dr. [**Last Name (STitle) **] in Liver clinic to follow up your hepatitis C and cirrhosis as well as your pancreatitis. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2106-10-21**] 11:15 You will need to call your primary care doctor for a referral prior to this visit. You should have an MRCP in [**1-4**] weeks to re-image your pancreas.

[ "070.70", "V15.81", "799.02", "401.0", "303.01", "696.1", "571.2", "577.0", "291.81", "574.20" ]

icd9cm

[ [ [] ] ]

[ "94.62", "81.91", "96.6", "38.91", "93.90" ]

icd9pcs

[ [ [] ] ]

10451, 10457

6444, 9518

301, 346

10680, 10757

3983, 6421

12012, 12691

2998, 3015

9796, 10428

10478, 10659

9544, 9773

10781, 11577

3030, 3964

11606, 11989

229, 263

374, 2484

2506, 2735

2751, 2982

63,292

117,110

37375+58141

Discharge summary

report+addendum

Admission Date: [**2170-10-30**] Discharge Date: [**2170-11-5**] Date of Birth: [**2086-4-8**] Sex: F Service: SURGERY Allergies: Influenza Virus Vaccine Attending:[**First Name3 (LF) 2777**] Chief Complaint: Ruptured TAA Major Surgical or Invasive Procedure: 1. Ultrasound-guided puncture of bilateral common femoral arteries. 2. Bilateral introduction of catheter into the aorta. 3. Arch aortogram. 4. Endovascular stent graft repair of ruptured thoracic aortic aneurysm with [**Doctor Last Name 4726**] TAG 31 x 15 and [**Doctor Last Name 4726**] TAG 31 x 10 and [**Doctor Last Name 4726**] TAG 37 x 10 endoprosthesis. 5. Bilateral Perclose closure of common femoral arteriotomies. 6. Exploration of right groin. 7. Repair of common femoral arterial dissection with bovine pericardial patch angioplasty. History of Present Illness: 84 y/o female transfered from OSH with a ruptured TAA. No active extravasation but mediastinal and pleural blood noted. Patient stable at OSH. Put on nitroprusside to lower blood pressure and medflighted to [**Hospital1 18**] to the CVICU. 2wks ago noted back pain but only sought medical attn when had "ripping" back pain at 1AM at night and a syncopal episode. Past Medical History: Hypertension Hypercholesterol Sciatica Cold feet PSH: Hysterectomy Social History: Social History: lives with husband. active and independent in ADLs. no tobacco (husband was a smoker in the house). no etoh Family History: No CAD Physical Exam: Alert and oriented x3 NAD RRR CTA b/l Abd soft, nondistended LE warm and pink bilaterally. Pulses: radial Fem DP PT R/L 2+/2+ 2+/2+ 2+/2+ trip/trip Moving all extremities Pertinent Results: [**2170-11-4**] 07:00AM BLOOD WBC-10.4 RBC-3.62* Hgb-11.3* Hct-31.8* MCV-88 MCH-31.1 MCHC-35.4* RDW-14.0 Plt Ct-200 [**2170-11-2**] 06:30PM BLOOD PT-12.8 PTT-23.1 INR(PT)-1.1 [**2170-11-4**] 07:00AM BLOOD Glucose-102 UreaN-18 Creat-0.7 Na-141 K-3.8 Cl-104 HCO3-27 AnGap-14 [**2170-11-4**] 07:00AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.0 [**2170-10-30**] 10:14PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->1.050URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2170-10-30**] 10:05 pm MRSA SCREEN NASAL SWAB. MRSA SCREEN (Final [**2170-11-1**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. CXR: FINDINGS: Aortic stent graft remains in place within a right-sided aortic arch and descending thoracic aorta. Interval extubation and removal of nasogastric tube. Cardiomediastinal contours are unchanged. Increasing left effusion with adjacent left basilar atelectasis. New patchy opacity at right base which may reflect acute aspiration, atelectasis, and less likely developing infection. Small right pleural effusion has also increased. CTA: FINDINGS: Right-sided aortic arch is seen with left subclavian artery as the first branch arising from the aortic arch. At the level of the distal part of the arch, beginning of the descending thoracic aorta, there is pseudoaneurysm in the left anterior direction. Findings are accompanied by high density soft tissue in the mediastinum compatible with mediastinal hematoma. No active extravasation is seen. Bilateral pleural effusions are seen, on the right of a small amount and on the left, small to moderate amount. The effusions are of high density with the hematocrit effect. Findings are consistent with pleural hematoma. Further noted return of descending aorta to the right posterior thorax. Low trachea and bronchial tree are compressed from the hematoma to the AP diameter of 6 mm in the lower trachea and to the diameter of 4 mm at the level of the carina. Further noted linear atelectases in the right lower lobe, left lower lobe and right middle lobe. Liver of normal size and attenuation. No intrahepatic or extrahepatic bile dilatation is noted. Right adrenal is unremarkable. Left adrenal is diffusely thickened. Upper part of the right and left kidney are within normal limits. A single lymph node is seen to the right of the celiac axis measuring 0.7 cm. Pancreas is within normal limits. OSSEOUS STRUCTURES: Degenerative changes of the thoracic spine are seen. IMPRESSION: Ruptured pseudoaneurysm of a right-sided aortic arch with mediastinal hematoma and bilateral hemothoraces. No evidence of active extravasation is seen. Brief Hospital Course: [**2170-10-30**] Patient was emergently medflighted to [**Hospital1 18**] for ruptured AAA. Taken to the OR for TEVAR with Vascular and Cardiac surgery. A-line monitoring and BP control for goal SBP 100. Recieved IVF and 1 unit of PRBC intra-op. Kept intubated overnight. Groins stable without hematoma. On esmolol, propofol and fentanyl IV gtts post-op. [**2170-10-31**] Stable in ICU intubated with labile BP. NPO. ETT, OGT and foley in place. [**2170-11-1**] Extubated and resp status stable. Recieved 2 additional units of blood. Following commands. OOB, PT consult. Sips of clears and bowl regimen. Pedal pulses palpable. Transferred to VICU. [**2170-11-2**] Stable overnight. Tmax 100.3 Advanced to ADAT. Continue to diuresis. PT eval recommends Rehab at fist evaluation. Fall precautions in place. [**2170-11-3**] Stable. Afib on tele. Continue to diuresis and replete electrolytes. CXR shows small rith effusion and moderate left effusion and atelectasis. [**2170-11-4**] Stable overnight. Continue PT and diuresis. [**2170-11-5**] PT cleared for home with home physical therapy. Discharged home. Will f/u with Dr. [**Last Name (STitle) **] with CT scan in 1 month. Medications on Admission: lovastatin 10, motrin 400 tid, premarin, enalapril 10, HCTZ 25. Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) Inhalation three times a day. 4. Premarin 0.625 mg Tablet Sig: One (1) Tablet PO once a day. 5. Enalapril-Hydrochlorothiazide 10-25 mg Tablet Sig: One (1) Tablet PO once a day. 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing/sob. 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for Wheezing. Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Ruptured thoracic aortic aneurysm Plueral Efussion Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**1-30**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**4-2**] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2170-12-6**] 11:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2170-12-6**] 1:30 Completed by:[**2170-11-5**] Name: [**Known lastname **],[**Known firstname 13350**] F Unit No: [**Numeric Identifier 13351**] Admission Date: [**2170-10-30**] Discharge Date: [**2170-11-5**] Date of Birth: [**2086-4-8**] Sex: F Service: SURGERY Allergies: Influenza Virus Vaccine Attending:[**First Name3 (LF) 726**] Addendum: Simvastatin 10 mg qd Aspirin 81 mg qd Combivent 18-103 mcg/Actuation Aerosol TID Premarin 0.625 mg qd Acetaminophen 325 mg PRN Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain Labetalol 200 mg Tablet DISCHARGE MEDICATIONS AS ABOVE. VNA WILL CHECK BP AND FAX THE RESULTS TO PCP. Name: SORIAL,EHAB NASSIM Location: PRIMA CARE, P. C. Address: [**Street Address(2) 13352**], [**Location (un) **],[**Numeric Identifier 13353**] Phone: [**Telephone/Fax (1) 13354**] Fax: [**Telephone/Fax (1) 13355**] Chief Complaint: n a Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. [**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 730**] MD [**MD Number(2) 731**] Completed by:[**2170-11-5**]

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icd9cm

[ [ [] ] ]

[ "39.56", "88.42", "39.73" ]

icd9pcs

[ [ [] ] ]

10600, 10814

4452, 5633

296, 865

6750, 6759

1747, 4429

9365, 10555

1510, 1519

5748, 6576

6676, 6729

5659, 5725

6783, 8785

8811, 9342

1534, 1728

10572, 10577

893, 1260

1282, 1351

1383, 1494

23,999

113,570

26274

Discharge summary

report

Admission Date: [**2105-11-13**] Discharge Date: [**2105-11-18**] Date of Birth: [**2034-12-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Salicylates / Morphine / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 7934**] Chief Complaint: Aspiration Major Surgical or Invasive Procedure: Trach on vent. History of Present Illness: HPI: Pt is a 70 y/o F with a hx of COPD with a trach not currently being vented, who presented from a NF to [**Location (un) 745**]-Wellesly Hopsital with hypoxia and respiratory difficulty. She is well known to [**Location (un) 745**]-Wellesly with numerous previous admissions. Pt was not responsive to oxygen there and per report the patient is at high risk for aspiration, since peanuts and other food was found in her bedsheets. She is unable to provide an accurate history. The patient was transferred to [**Hospital6 **] CXR was suspicious for aspiration PNA ,R>L. In addition there was blood-tinged sputum from her trach. Patient was treated with Vancomycin and Imipenem, and transeferred to [**Hospital1 18**] as no ICU beds were available. Of note patient was noted to have a potassium of 6.0, and was given insulin, D50, and 1 amp of HCO3. . Of note, the patient was recently d/c'd from [**Location (un) 65053**] Hospital [**2105-9-18**] after fevers and RML, RLL, and LLL PNA. There was purelent material in the trach, and she was presumed to have a recurrent PNA. She was treated at that time with Linezolid, Aztreonam, and Tobramycin given her h/o PNA's with Proteus, Psuedomonas, Serratia, and MRSA. Past Medical History: PMHx: Morbid Obesity COPD CAD with old LBBB CHF Hypothroidism Paroxysmal Atrial Fibrillation Recurrent pancreatitis s/p failed cholecystectomy for gallstones h/o MRSA PNA, and MRSA bacteremia h/o complicated PNA's with Pseudomonas, Proteus, and Serratia h/o post-traumatic intubation w/ intubation requiring trach CRF (unknown baseline, was 1.4 in [**10-17**]) Chronic foley, with h/o recurrent UTI's h/o GIB h/o pseudoseizures secondary to anxiety h/o severe pustular psoriasis to certain antibiotics(amoxicillin and levofloxacin) h/o Anxeity and Depression Type II DM Catatracts Social History: Soc: Patient is resident of [**Hospital 745**] Healthcare Center; no current Etoh or tobacco hx. Primary family are nephews. Family History: FMHx: Noncontributory (per OSH records) Physical Exam: VS(on admission): T=99.5, BP=135/59, HR=74, O2 sat 100%; vent settings 500 x 18, PEEP 5, Rate 18 (breathing 20-26), FiO2 60% GEN: Pt morbidly obese, in no acute distress HEENT: nonicteric, mucosa moist; unable to assess JVP; erythema diffuse over neck bilaterally CHEST: transmitted vent sounds ant & lat CV: RRR; difficult exam ABD: obese, soft; prior surgical scars EXT: [**12-14**]+ pitting LE edema NEURO: pt alert, follows basic commands; tremor of left arm and mild tremor of right arm; complete neuro exam difficult due poor cooperation. Pertinent Results: [**2105-11-13**] 05:05PM GLUCOSE-98 UREA N-32* CREAT-1.3* SODIUM-141 POTASSIUM-5.5* CHLORIDE-110* TOTAL CO2-20* ANION GAP-17 [**2105-11-13**] 05:05PM ALT(SGPT)-14 AST(SGOT)-18 LD(LDH)-303* ALK PHOS-306* TOT BILI-0.2 [**2105-11-13**] 05:05PM LIPASE-102* [**2105-11-13**] 05:05PM ALBUMIN-3.4 CALCIUM-8.1* PHOSPHATE-3.3 MAGNESIUM-1.6 [**2105-11-13**] 05:05PM WBC-21.4* RBC-4.57 HGB-11.2* HCT-34.8* MCV-76* MCH-24.5* MCHC-32.2 RDW-18.4* [**2105-11-13**] 05:05PM TSH-1.0 [**2105-11-13**] 05:05PM NEUTS-93* BANDS-0 LYMPHS-1* MONOS-5 EOS-0 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [**2105-11-13**] 05:05PM HYPOCHROM-OCCASIONAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-OCCASIONAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-1+ TEARDROP-OCCASIONAL [**2105-11-13**] 05:05PM PLT COUNT-286 [**2105-11-13**] 05:05PM PT-15.0* PTT-21.7* INR(PT)-1.5 . Labs from outside hospital: ABG 7.28/41/162 on 50% FiO2 . UA with 11,000 WBC's, 323 RBC's, many bact, +nitrite, 12 epis . Na 136, K 6.0(hemolyzed), bicarb 20, Chl 112, BUN 27, Cr 1.2, Glu 192; Ca 7.8 (Alb 3.0), PO4 2.8, INR 1.4; negative cardiac enzymes, BNP 76.5 . WBC 24 (76N, no bands), Hct 44, Plt 326 . CXR(OSH) - read as bilateral infiltrates, R>L Brief Hospital Course: Hospital Course: 70 year old nursing home resident with multiple medical problems who presents with aspiration pneumonitis and UTI. . ## Aspiration pneumonitis: Patient was found to have a large right-sided consolidation that resolved quickly within a day. Patient was satting 98-100% trach on vent, then was taken off of the vent and continued to sat >95% on 35% FiO2. She required suctioning Q6H, and was only short of breath upon suctioning. She was maintained on Imipenem/Cilastatin for an 8 day course (to be completed after discharge) to cover for aspiration pneumonia. Sputum culture grew out minimal yeast and oropharyngeal flora, but no bacterial pathogen. She was placed on Vancomycin for 6 days to cover for MRSA, but no MRSA grew from the sputum culture, and Vanco was thus d/ced. Patient was not severely sick on admission, and gradually improved until discharge. Vitals were stable at all times. . Patient has a trach but is not vented, is not short of breath, and eats and drinks at baseline. She is known to aspirate, but "would rather die" than not be able to take food and drink by mouth. She was maintained NPO until the day before discharge. The patient is fully aware of the dangers of aspiration and possible death, but she wishes to eat and drink by mouth. The types of food that are least prone to aspiration were discussed with the patient as being safer foods for her. Upon admission, peanuts and potato chips were found in the patient's trach. Code status was discussed with the patient because of likely readmission to an ICU, and she would like to follow her nephew's wishes, and her nephew wishes her to be full code. . ## CHF: There was a component of pulmonary edema due to CHF. Patient was diuresed with a goal of -1 to -2 L per day, which was achieved with Lasix 20 mg x1/day. . ## Subglottic stenosis: Communication between Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 65054**] (pulm fellow, [**Hospital1 18**]) and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital3 1196**]. Patient does not wish to remove her trach at this time, and she would not like intervention or stent in her trachea. . ## Paroxysmal AFIB: Coumadin 4 QD (home regimen) had been held during admission, but was restarted upon discharge. Patient was in normal sinus rhythm during admission. . ## Hyperkalemia: Patient was hyperkalemic upon admission, and kayexylate was administered 1x with decrease of K to 5.0. Patient was asymptomatic. Patient was not hyperkalemic for the remainder of admission, and EKG showed NSR without hyperkalemic morphology. Cr was stable and wnl. Etiology of hyperkalemia was not established. . ## UTI: Patient has a chronic foley catheter that was changed on [**2105-11-16**]. UA showed 11,000 WBC, and urine culture was negative. Patient was covered with Imipenem/Cilastatin. . ## DM2: BG were well controlled on insulin sliding scale. . ## Pseudoseizures: Patient has a history of pseudoseizures and has been maintained on Dilantin. She was not able to take PO meds during admission, but was restarted on Dilantin on the day before discharge. No seizures were witnessed during admission. . ## Depression: Patient was discharged on Seroquel per home regimen. . ## History of gallstone pancreatitis: Right upper quadrant ultrasound was performed for RUQ pain, and was found to be negative for cholelithiasis, with no gallbladder wall thickness changes. LFTs and pancreatic enzymes were wnl. . ## Chronic pain: Patient has pain "all over" and in her right upper quadrant that is intermittent. She was on a fentanyl patch with good pain control. . ## Access: Patient has a mediport (placed on [**9-18**], clotted on [**9-24**]), which now appears to be functioning. Site of port was clean. . ## Code: FULL per nephew. . ## Primary Communication: [**First Name9 (NamePattern2) 65055**] [**Known lastname **] @ ([**Telephone/Fax (1) 65056**], ([**Telephone/Fax (1) 65057**]. Medications on Admission: Meds(at NH): Pulmicort neb [**Hospital1 **] Effexor XR 150mg QD Fentanyl patch 50mcg q72 hours Lasix 40mg QD Norvasc 5mg QD Prednisone 5mg QD Protonix 40mg QD Ursodiol 300mg QD Colace 100mg QD Oyster shell calcium w/ Vit D 500mg [**Hospital1 **] Seroquel 75mg QD Dilantin 100mg TID Neurontin 300mg HS Dilaudid 1mg QID prn pain Ativan 1mg Q6 hours prn Duoneb q4 hours prn Tylenol prn Coumadin 4mg QD Realfin 100mg QD? Metoprolol 75mg PO BID Ambien prn RISS . All: salicylates/ASA, amoxicllin, codeine, floroquinolones/levaquin, morphine, sulfa, PCN(h/o severe rxn w/ sloughing of skin; per records never had a cephalosporin), Metoclopromide Discharge Medications: 1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 9. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 10. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 12. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 13. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Imipenem-Cilastatin 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours): Last date to give: [**2105-11-20**]. 18. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 mg Intravenous Q8H (every 8 hours) as needed. 19. Warfarin 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Home regimen, restarted [**2105-11-18**]. Discharge Disposition: Extended Care Facility: [**Hospital3 1196**] - [**Location (un) 745**] Discharge Diagnosis: Primary diagnosis: Aspiration pneumonia Secondary diagnosis: UTI Discharge Condition: Good. Patient is eating and understands the associated dangers, vitals stable. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2 L Followup Instructions: 1. Primary Care: Please make an appointment to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**], [**Telephone/Fax (1) 65058**]. 2. Please follow up with a pulmonologist at [**Hospital1 16961**]. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] has seen this patient in the past. Completed by:[**2105-11-18**]

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icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

10660, 10733

4191, 4191

333, 350

10844, 10926

2978, 4168

11097, 11462

2357, 2398

8883, 10637

10754, 10754

8219, 8860

4208, 8193

10950, 11074

2413, 2959

283, 295

378, 1594

10817, 10823

10774, 10795

1616, 2198

2214, 2341

10,037

107,919

43546

Discharge summary

report

Admission Date: [**2170-1-22**] Discharge Date: [**2170-2-1**] Date of Birth: [**2111-4-20**] Sex: M Service: Neurosurgery CHIEF COMPLAINT: Syncope. HISTORY OF THE PRESENT ILLNESS: The patient is a 58-year-old male with a past medical history for vasovagal syncope status post pacemaker placement in [**2154**], pacemaker removal in [**2165**] secondary to infection, who presents with an episode of syncope while urinating. The patient was in his usual state of health when he awoke at 5:00 a.m. this morning to urinate. He found that he had difficulty getting up because of his left leg weakness. His wife noted that he was able to walk but had slurring of speech. He went to the bathroom where he experienced roughly one minute of unresponsiveness. Per the report of his wife, there was no seizure activity, no urinary or bowel incontinence, no biting of tongue. He went back to sleep and woke up at 8:00 a.m. without his leg weakness, normal speech, but tingling sensations persisted. He presented to the ED and was essentially asymptomatic. The vital signs were stable. Review of symptoms were negative. In the Emergency Room, he was evaluated by Neurology who felt that he had a transient ischemic attack versus seizure. During workup, there was an observed episode of slurred speech, left facial, arm, and leg tingling. On evaluation, the blood pressure was 121/76, heart rate 50. He had left facial weakness with only a mild left hemiparesis with ataxia out of proportion to his weakness that lasted 15 minutes and resolved. The vital signs remained stable. The CTA was negative for acute intracranial bleeding or abscess. The patient states that he was continued on his normal dose of Dilantin 200 mg p.o. b.i.d. for seizure prophylaxis secondary to an AVM repair in [**2128**]. The patient and the PCP report five such episodes of left-sided weakness, tingling, and dysarthria have occurred since pacemaker implantation, although current episode of syncope was void of such symptoms. Denied fevers, chills, anesthesia, illness, lightheadedness, visual changes, postictal state, chest pain, nausea, vomiting. PAST MEDICAL HISTORY: 1. As above, a pacemaker, single-chamber, inserted in [**2154**] for vasovagal syncope which was explanted in [**2165**] secondary to cellulitis. 2. AVM resection in [**2128**]. The patient was on Dilantin and phenobarbital from [**2128**] to [**2146**] for seizure prophylaxis, was taken off AEDs in [**2146**], recently restarted on Dilantin three weeks ago. 3. Gout, last flare in [**2165**] with right metatarsal head inflamed, currently stable. 4. Hypertension. 5. Hypercholesterolemia. ADMISSION MEDICATIONS: Dilantin 200 mg p.o. b.i.d. ALLERGIES: Codeine. FAMILY HISTORY: No history of stroke or seizure. Positive for chronic atrial fibrillation in a younger brother. Maternal grandmother has type 2 diabetes, no CAD, colon cancer, skin cancer. SOCIAL HISTORY: The patient is a self-employed contractor. Denied smoking, drugs. Occasional alcohol use. No substance abuse. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient was afebrile at 97, heart rate 59, blood pressure 173/85. Orthostatics checked on the floor were negative, breathing at a rate of 16, 98% on room air. HEENT: NC/AT, MMM, PERRLA, EOMI, fields full, no nystagmus. Neck: Supple. No adenopathy. No carotid bruits appreciated. Cardiac: Regular rate, no murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, normoactive bowel sounds. Extremities: No clubbing, cyanosis or edema. Capillary refill less than two seconds. Neurologic: Mental status-alert and oriented times three. Speech appropriate, fluent, naming and repetition intact, comprehension intact. Cranial nerves II through XII without deficits. Tongue midline. Palate elevation normal. Face symmetric. Motor: No tremor. Normal bulk, tone. No pronator drift, midline. Strength was symmetric and full on both sides. Sensory: Intact to light touch, pinprick, temperature, vibration, and proprioception. Reflexes were 3+ in the right upper extremity, 3+ in the left upper extremity, 3+ right lower and left lower extremities. The toes were downgoing bilaterally. Coordination: Finger-to-nose no ataxia, rapid finger tapping intact bilaterally. Gait: Romberg negative, narrow base stance. No difficulty with tandem gait. LABORATORY/RADIOLOGIC DATA: Pertinent for a creatinine of 1.1 which is his baseline, glucose 103, calcium 8.7, phosphorus 3, magnesium 2. CK troponin negative. TSH 2.7. Homocysteine 14. Triglycerides 326, HDL 42, LDL 190. White count 6.3, hematocrit 42, platelets 179,000. Prothrombin time 11, Partial thromboplastin time 25. The patient had a CTA and could not undergo MRI due to right craniotomy clips as well as retained ventricular pacing wire. No evidence of acute intracranial hemorrhage. Scattered calcifications in the left internal carotid and left vertebral body with mild midbasilar narrowing, no aneurysm identified. EKG showed sinus bradycardia, borderline left axis deviation, RSR pattern in V1 with normal QRS duration. The patient's workup for both presentations of syncope and [**Doctor First Name **] observed in the Emergency Room with stable vital signs. The Stroke Team, Cardiology, Electrophysiology, and Neurosurgery were consulted for appropriate workup. The patient remained on telemetry and the vital signs were stable throughout. An EEG had been performed prior as an outpatient which was negative for seizure which was low on the differential. TEE and TTE with bulbar study were negative for ASD or PFO. It was felt that this was less likely to represent embolic phenomenon. Carotid ultrasounds were negative. It was felt that angiography would be the best to apprise posterior circulation. Angiography was performed by Dr. [**Last Name (STitle) **] which revealed a stenosis of the left vertebral artery at its origin as well as a midbasilar stenosis of approximately 70-80%. At that time, the decision for intervention was made on the left vertebral artery on the basis of providing the most flow to the already stenotic basilar lesion. HOSPITAL COURSE: The patient was started on aspirin, Plavix, as well as risk factor modification with B12, B6, and folate administered due to elevated homocysteine. Lipitor was started given prior elevated lipid panel. The patient underwent uncomplicated stenting of the origin of the left vertebral artery with good distal flow, no focal neurologic deficit. The patient remained free of syncopal and dysarthria, left-sided weakness, or neurologic sequelae throughout. In discussion with Cardiology and Neurology, at this time, episodes likely represent dual episodes of vasovagal syncope and TIA. Transient ischemic attacks are being addressed with antiplatelet therapy of aspirin and Plavix as well as decreasing lipid profile and addressing homocysteine elevation. If the patient experiences further vasovagal episodes, this would warrant implantation of the pacer. It was felt that pacemaker placement right now was not sufficient enough to fully address his known basilar stenosis. At this time, the risks and benefits were in favor of holding pacemaker placement and continue with a trial of medical management and observation post left vertebral stenting. DISCHARGE MEDICATIONS: 1. Dilantin 100 b.i.d. This is to be tapered per PCP until off as no history nor likelihood of seizure disorder. 2. Aspirin 325 mg p.o. b.i.d. 3. Plavix 75 mg p.o. b.i.d. 4. Folic acid one tablet p.o. q.d. 5. Vitamin B12 and B6 p.o. q.d. 6. Lipitor 10 mg p.o. q.d. pending further LFT checks. Statin dose should be maximized given the patient's severe atherosclerotic risk. FOLLOW-UP: The patient is to follow-up in one to two weeks with Dr. [**Last Name (STitle) 93686**], his PCP, [**Name10 (NameIs) **] appraise neurologic examination, monitor for signs of further syncopal episodes and/or TIA episodes. Possible initiation of low-dose ACE inhibitor if blood pressure and heart rate stable. DISPOSITION: The patient was discharged to home in stable condition without neurologic deficits on antiplatelet therapy post stenting of the left vertebral artery. Dictated By:[**Last Name (NamePattern1) 972**] MEDQUIST36 D: [**2170-2-2**] 03:39 T: [**2170-2-3**] 19:26 JOB#: [**Job Number 93687**]

[ "401.9", "435.9", "427.89", "272.0", "433.20", "780.39", "427.81" ]

icd9cm

[ [ [] ] ]

[ "88.72", "39.50", "39.90" ]

icd9pcs

[ [ [] ] ]

2769, 2944

7423, 8441

6245, 7400

2700, 2751

157, 2155

3110, 6227

2177, 2676

2961, 3095

19,056

187,996

9068

Discharge summary

report

Admission Date: [**2142-7-9**] Discharge Date: [**2142-9-14**] Date of Birth: [**2079-12-12**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7141**] Chief Complaint: metastatic cholangiocarcinoma Major Surgical or Invasive Procedure: 1) [**7-9**] total pelvic exenteration, rectal anastamosis, ileal conduit, sigmoidoscopy, repair of enterotomy 2) [**8-26**] loop ileostomy 3) [**9-4**] abdominal wall closure History of Present Illness: 62-year-old G2P2 with a history of metastatic cholangiocarcinoma. History of neoadjuvant chemotherapy, resection of [**3-30**] liver in [**2137**], liver recurrence in [**2139**] treated with radiofrequency ablation complicated by liver abscess, pelvic recurrence with ureteral obstruction in [**2141**] treated with radiotherapy and nephrostomy, and pelvic recurrence again in [**2142**] with 3.1 multicystic mass noted on CT. Pt presents for treatment of pelvic recurrence & persistent ureteral obstruction. Past Medical History: 1. Metastatic cholangiocarcinoma s/p chemotherapy & radiation (as above). 2. Hypothyroid 3. Hypertension 4. Peptic ulcer disease 5. Depression/anxiety PSH: 1. Appendectomy [**2102**] 2. Ovarian surgery [**2107**] 3. Bartholin's gland surgery [**2117**] 4. Tubal ligation [**2125**] 5. Liver surgery [**2137**] 6. Bleeding ulcer requiring surgery [**2138**] 7. Radiofrequency liver ablation [**2139**] POBH: G2P2 Social History: Nonsmoker, denies EtOH and drug use divorced, remarried Family History: Father with lymphoma, aunt with stomach cancer, cousin with melanoma Physical Exam: Well-appearing, NAD HEENT no icterus Lymph node survey negative RRR Lungs CTA B Abd soft ntnd no masses Extremities no edema Vulva and vagina normal Speculum exam: pinpoint red lesion near top of vagina (biopsied)Bimanual/rectovaginal exam: significant left parametrial thickening. Rectum intrinsically normal. Pertinent Results: Summary of Studies: CXR [**9-11**]: likely aspiration event CTA [**8-26**], [**8-24**]: no evidence of PE, nodules c/w possible metastasis Abdominal CT [**8-24**]: intraabdominal collection of fluid with pelvic collections decreased [**8-10**] ileogram: no communication between abdominal collection and ileal conduit [**8-8**] CT abd: loculated intraabdominal fluid collection [**2142-8-1**] DVT LE: negative [**7-24**] CT abd: Large collection of gas and debris in the deep pelvis concerning for anastomotic leak, but leakage of oral contrast material has not been demonstrated. [**7-24**] ECHO: EF >55%, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 31326**], trivial MR, borderline pulmonary artery systolic hypertension [**7-21**] EKG: Atrial fibrillation, extensive ST-T changes Pathology: 1. Uterus/cervix: Poorly-differentiated adenocarcinoma (similar to prior biospy of cholangiocarcinom) extensively involving walls of uterus and cervix, bilateral parametria, peritubal and periureteral soft tissues, and vaginal cuff. 2. Bladder/Rectum/LN(3)/Pelvic side wall tumor: no evidence of malignancy. Most recent labs: [**2142-9-11**] 01:00AM BLOOD WBC-11.2* RBC-3.45* Hgb-8.6* Hct-27.4* MCV-80* MCH-25.0* MCHC-31.3 RDW-18.9* Plt Ct-217 [**2142-9-9**] 05:08AM BLOOD Neuts-79* Bands-6* Lymphs-6* Monos-3 Eos-4 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2142-9-11**] 01:00AM BLOOD Plt Ct-217 [**2142-9-10**] 04:35AM BLOOD Glucose-114* UreaN-30* Creat-0.5 Na-136 K-4.4 Cl-107 HCO3-22 AnGap-11 [**2142-9-10**] 04:35AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.7 Pertinent cultures: [**8-26**] Fluid from Wound: Enterococcus and CNS [**9-11**] Cultures: NGTD Brief Hospital Course: Hospital Course by systems: 1) CV: Developed rapid atrial fibrillation on two occasions. First time converted spontaneously and was controlled with metoprolol IV. The second time 200J conversion was needed and amiodarone used for maintenance. Cardiac enzymes and echocardiogram were essentially normal (borderline PA HTN). No anticoagulation started as she converted within 24 hours on both occasions. 2) Respiratory: She was intubated following each of her surgeries. When fit for extubation, she had no complications. She developed metabolic alkalosis on lasix gtt (used to decrease bowel edema prior to closure) without any significant untoward effects. Two CTA studies to evaluate for PE were negative. Pulmonary nodules possibly c/w metastatic disease were seen on multiple studies. Possible aspiration occured on [**2142-9-11**] based on CXR findings. 3) GI: Fecal drainage per vagina noted approximately 2 weeks postop. On [**2142-7-24**], CT revealed collection at rectal anastomosis. In abscence of signs of peritonitis, she was managed conservatively with IV antibiotics (Levofloxacin/Metronidazole), NPO, and TPN for approximately 3 weeks. Overall she improved, but continued to have stool drainage and nausea. A new fluid collection developed in the right abdomen. A percutaneous drain was placed and symptoms improved. A low residue diet was attempted but patient continued to have vomiting and therefore returned to OR for ostomy for stool diversion. Pt was followed by general surgery after ileostomy for managment of her abdominal wound dressings including a vac dressing. An alloderm closure was attempted on [**2142-9-4**]. Abdominal fistulas with drainage of feculent material devloped on POD#6. Necrotic tissue on the wound was noted. The alloderm closure had multiple defects. A modified low suction vacuum dressing was applied with occlusive dressing to aid in keeping wound area clean from fecal drainage. No overt signs of sepsis (hemodynamically stable, WBC stable, low grade fever only, blood culture NGTD). However, given multiple fistulas and no effective surgical/medical management, hospice services were offered and palliative care consult obtained. She was tolerating fluids at time of discharge. TPN was discontinued given wishes for hospice care. 4) GU: Initially elevated creatinine returned to baseline level of 0.9 by POD#9. Peritoneal fluid collection developed near urostomy site (see above). Loopogram and repeated creatinine levels of drained fluid were not consistent with a urostomy leak. Urology followed patient throughout her hospital course. Ileal conduit continues to work well. 5) ID: Patient received levofloxacin and metronidazole for empiric coverage in setting of rectal anastomotic leak. She had several courses of levofloxacin/flagyl but this was discontinued completely on [**2142-9-6**]. Vancomycin was started on [**9-3**] for enterococcus in fluid from abdomen and increased WBC. Vancomycin was discontinued on [**2142-9-10**] (hospice). 6) Heme: pt received multiple transfusions throughout her stay. Her Hct continued to trend down to baseline 27-28. Laboratory studies consistent with anemia of chronic disease. Procrit was started on [**2142-8-5**] and discontinued prior to discharge (hospice). 7) Endocrine: Synthroid was continued at outpatient doses. TSH was elevated twice (peak 27) but T4 was normal/borderline so dose was not changed. 8) Mental Status changes: Pt was confused and disoriented on [**2142-9-9**]. TSH elevated 27 and possible aspiration as described above. Changes thought to be secondary to pain medication changes (starting methadone). Returned to baseline mental status after discontinuing methadone. Pain controlled on oxycodone, lexapro, ativan, and prn SL morphine at time of discharge to hospice. **Patient was discharged to hospice on Hospital Day #66 and POD#66/19/9. Medications on Admission: Lexapro 10 mg po qd Prilosec 40 mg po qd Norvasc 10 mg po qd Levothyroxine 125 mcg po qd HCTZ 25 mg po qd Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 2. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*40 Tablet(s)* Refills:*1* 3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO twice a day. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*1* Hospice medication rx provided separately - include anxiety, pain and nausea meds. Discharge Disposition: Home With Service Facility: [**Hospital3 **]Hospice Discharge Diagnosis: metastatic cholangiocarcinoma Discharge Condition: stable Discharge Instructions: Call your doctor for anything that concerns you. Followup Instructions: No further follow up at this time; call if you feel you need an appointment.

[ "V15.3", "793.1", "155.1", "427.31", "198.82", "198.89", "507.0", "276.2", "998.13", "280.0", "593.3", "998.2", "560.81", "619.1" ]

icd9cm

[ [ [] ] ]

[ "68.8", "56.51", "54.59", "99.62", "46.75", "46.01", "00.17", "40.3", "38.93", "46.73", "45.94", "97.29", "99.15", "54.91", "86.67" ]

icd9pcs

[ [ [] ] ]

8216, 8270

3697, 3697

358, 536

8344, 8352

2019, 3674

8449, 8529

1603, 1673

7760, 8193

8291, 8323

7630, 7737

8376, 8426

3726, 7604

1688, 2000

289, 320

564, 1077

1099, 1514

1530, 1587

31,464

169,150

47150+58981

Discharge summary

report+addendum

Admission Date: [**2132-10-28**] Discharge Date: [**2132-11-1**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Incidental finding when had routine echo for heart murmur Major Surgical or Invasive Procedure: s/p Ascending Aortic Aneurysm resection and reconstruction with 32mm gelweave graft [**2132-10-28**] History of Present Illness: 83 year old female incidental found to have 7.2 cm ascending aortic aneurysm on echocardiogram after PCP discovered heart murmur Past Medical History: HTN spinal stenosis SIADH Anemia of chronic illness Osteoporosis Spinal Stenosis Social History: Tobacco occassional h/o 2 PPD x 40 yrs, quit 3 years ago rare EtOH lives alone at senior community center Family History: no premature CAD Physical Exam: Admission Pleasant elderly female in NAD Skin unremarkable HEENT unremarkable Neck supple full ROM Chest CTA bilat Heart RRR 2/6 systolic murmur Abdomen soft, NT ND Ext warm trace bilat edema no varicosities pulses palpable Pertinent Results: [**2132-11-1**] 07:45AM BLOOD WBC-7.4 RBC-3.05* Hgb-9.5* Hct-28.5* MCV-93 MCH-31.2 MCHC-33.4 RDW-14.8 Plt Ct-124* [**2132-10-28**] 10:58AM BLOOD WBC-12.0*# RBC-2.58*# Hgb-7.9*# Hct-23.0*# MCV-90 MCH-30.6 MCHC-34.2 RDW-14.4 Plt Ct-136* [**2132-11-1**] 07:45AM BLOOD Plt Ct-124* [**2132-10-29**] 01:16AM BLOOD PT-13.8* PTT-29.9 INR(PT)-1.2* [**2132-10-28**] 10:58AM BLOOD PT-16.9* PTT-44.7* INR(PT)-1.5* [**2132-10-28**] 10:58AM BLOOD Fibrino-112* [**2132-11-1**] 07:45AM BLOOD Glucose-93 UreaN-24* Creat-0.8 Na-134 K-4.3 Cl-101 HCO3-25 AnGap-12 [**2132-10-28**] 12:08PM BLOOD UreaN-15 Creat-0.7 Cl-110* HCO3-20* [**2132-10-29**] 01:16AM BLOOD ALT-15 AST-47* AlkPhos-33* Amylase-35 TotBili-0.4 [**2132-10-29**] 01:16AM BLOOD Lipase-12 [**2132-10-31**] 07:40AM BLOOD Mg-2.1 CHEST (PORTABLE AP) [**2132-10-31**] 11:02 AM CHEST (PORTABLE AP) Reason: eval for pneumothorax [**Hospital 93**] MEDICAL CONDITION: 83 year old woman s/p cardiac surgery REASON FOR THIS EXAMINATION: eval for pneumothorax SINGLE AP PORTABLE VIEW OF THE CHEST. REASON FOR EXAM: Follow up right pneumothorax. Comparison is made with prior study of [**2132-10-29**]. A small right apical pleural catheter is still in place. Tiny apical pneumothorax is almost resolved. Large left pleural effusion and moderate right pleural effusion are stable. The aorta is elongated. Moderate cardiomegaly is unchanged. Atelectases in the bases are greater in the left side. Patient is post median sternotomy. DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**] DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Approved: FRI [**2132-10-31**] 9:52 PM SPECIMEN SUBMITTED: Aorta. Procedure date Tissue received Report Date Diagnosed by [**2132-10-28**] [**2132-10-28**] [**2132-10-30**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/vf Previous biopsies: [**Numeric Identifier 99920**] BONE MARROW/mk. [**Numeric Identifier 99921**] CYST LT 2ND FINGER/bq. [**Numeric Identifier 99922**] (Not on file) [**Numeric Identifier 99923**] (Not on file) (and more) DIAGNOSIS: Aortic segment: Portion of large blood vessel wall with severe medial degeneration. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 99924**] (Complete) Done [**2132-10-28**] at 9:26:22 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 1112**] W. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2049-3-30**] Age (years): 83 F Hgt (in): 62 BP (mm Hg): 112/68 Wgt (lb): 140 HR (bpm): 72 BSA (m2): 1.64 m2 Indication: Intra-op TEE for Ascending aorta replacement and arch replacement ICD-9 Codes: 441.2, 424.1 Test Information Date/Time: [**2132-10-28**] at 09:26 Interpret MD: [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW02-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Sinus Level: 3.5 cm <= 3.6 cm Aorta - Sinotubular Ridge: *3.2 cm <= 3.0 cm Aorta - Ascending: *7.1 cm <= 3.4 cm Aorta - Arch: *3.2 cm <= 3.0 cm Aorta - Descending Thoracic: *3.4 cm <= 2.5 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Markedly dilated ascending aorta. Mildly dilated aortic arch. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Small pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending aorta is markedly dilated The aortic arch is mildly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. Mild (1+) mitral regurgitation is seen. 7. There is a small pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine. 1. An ascending aortic graft is seen in position. 2. AI is unchanged. 3. Biventricular systolic function is preserved. 4. Other findings are unchanged I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD, Interpreting physician [**Last Name (NamePattern4) **] [**2132-10-28**] 14:41 Cardiology Report ECG Study Date of [**2132-10-28**] 1:14:26 PM Sinus rhythm. Low QRS voltage. Left axis deviation. Left anterior fascicular block. Non-diagnostic repolarization abnormalities. Compared to previous tracing of [**2132-10-20**] multiple abnormalities persist without major change. Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**] Intervals Axes Rate PR QRS QT/QTc P QRS T 78 152 102 410/441 72 -73 52 Brief Hospital Course: Ms. [**Known lastname **] was same day admission and was brought to the operating room where she underwent ascending aorta replacement. Please see operative report for surgical details. She tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. In the first 24 hours she was weaned from sedation, awoke neurologically intact and was extubated. On post-op day her mediastinal tubes were removed and was noted to have right pneumothorax on post removal chest Xray. A dart was placed and the right lung re expanded. She was started on beta blocker and diuretics. Later on post op day one she was transferred to the post op floor for the remainder of her care. She was gently diuresed towards her pre-op weight. On post op day three she had atrial fibrillation that converted with amiodarone and beta blockers, with no further episodes. Her right chest tube and epicardial pacing wires were removed on post-op day four. Physical followed patient during entire post-op course for strength and mobility. She continued to make steady process and was ready for discharge to rehab on post op day 4. Medications on Admission: Fosamax Lisinopril Nifedipine Vit D Caltrate Centrum Silver Citracel Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: please given 400mg daily for 7 days then decrease to 200mg daily . 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day). 10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 11. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Ascending Aortic aneurysm s/p ascending aorta repair Hypertension SIADH Anemia of chronic disease Osteoporosis Spinal Stenosis Melanoma s/p excision Left lower leg 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**] Please leave dressing occlusive on right subclavian intact until [**2132-11-4**] Please remove staples from sternal incision on [**11-13**] Followup Instructions: Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**Last Name (STitle) 26894**] after discharge from rehab ([**Telephone/Fax (1) 3329**]) please call for appointment Completed by:[**2132-11-1**] Name: [**Known lastname **],[**Known firstname 2243**] Unit No: [**Numeric Identifier 16022**] Admission Date: [**2132-10-28**] Discharge Date: [**2132-11-1**] Date of Birth: [**2049-3-30**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4551**] Addendum: Dr [**Last Name (STitle) 16023**] was consulted in relation to her right gluteal mass noted on CTA from [**10-1**]. Plan to follow up as an outpatient after she is recovered from surgery. Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - MACU [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**] Completed by:[**2132-11-3**]

[ "401.9", "512.1", "V10.82", "427.31", "285.29", "E878.2", "441.2", "997.1", "733.00" ]

icd9cm

[ [ [] ] ]

[ "39.61", "38.45", "34.04" ]

icd9pcs

[ [ [] ] ]

11608, 11829

7564, 8709

327, 430

10093, 10100

1110, 1982

10751, 11585

832, 850

8828, 9796

2019, 2057

9906, 10072

8735, 8805

10124, 10728

865, 1091

230, 289

2086, 7541

458, 588

610, 693

709, 816

27,258

122,874

17513

Discharge summary

report

Admission Date: [**2141-11-16**] Discharge Date: [**2141-11-18**] Date of Birth: [**2097-7-8**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 562**] Chief Complaint: Bright red blood per rectum s/p anoscopy Major Surgical or Invasive Procedure: Colonoscopy - [**2141-11-17**] History of Present Illness: 44 yo M with HIV (last CD4 count in [**3-29**] was 471 and VL undetectable), h/o CMV colitis and cryptococcous/adenovirus colitis in [**3-28**], who presented to the ED with BRBPR after high resolution anoscopy today in clinic. Per report, lesions were ulcerated and there was concern for CMV infection. Biopsy was taken. The patient then noticed large amount of BRBPR when going to the bathroom x6. Denied lightheadedness, dizziness, n/v, SOB, CP at that time. He returned to clinic and they called EMS. His vitals on the EMS sheet in clinic were BP 118/90, HR 68, RR 20. He was sent to the ED. . In the ED, his initial vital signs were HR 124, BP 154/101, RR 16, O2sat 99% RA. Labs were taken. He had 2 more episodes of BRBPR. Per report, he was given IVF 2L. GI was notified and he was sent to the MICU for further care. . MICU course: Pt received 2u pRBCs and hematocrit remained stable at 30 from baseline 40. Colonoscopy [**2141-11-17**] showed diverticulosis of the sigmoid, erythema in the cecum and ascending/descending colon c/w colitis. There was no evidence of active bleed on Colonoscopy. Past Medical History: 1. HIV/AIDS, diagnosed in [**2124**]. Has had rectal gonorrhea, syphillis, and staph skin infections that have required I&D. CD4 count Reportedly 70. 2. Hx infectious colitis with shigella (culture proven) [**2137**] as well as giardia at that time. 3. Depression 4. GERD 5. bilateral knee arthroscopies 6. Chronic Back pain 7. ?herpes zoster.-recent [**2140-4-5**] Social History: lives in [**Location 39908**] with his partner. [**Name (NI) **] tobacco or EtOH. + crystal meth. Family History: HTN, MI, CVA, prostate ca. Physical Exam: Vitals: BP 127/89, HR 93, RR 10, O2sat 97% General: NAD; lying in bed, lipodystrophy in the face. HEENT: MMM, pink conjunctiva, PERRL, EOMI, OP clear without erythema/exudate CV: RRR no m/r/g appreciated Lungs: CTAB no w/r/r Abdomen: +BS, soft, NTND Extremities: no e/c/c, DP pulses 2+ symmetric, radial pulses 2+ symmetric Rectal per ED report: some blood and stool on rectal exam Pertinent Results: Imaging: CHEST film: No acute cardiopulmonary process, no evidence of free air. . Micro: Colonoscopy biopsies-reports pending . Labs: [**2141-11-18**] BLOOD WBC-7.0 RBC-3.19* Hgb-11.3* Hct-32.3* MCV-101* MCH-35.4* MCHC-34.9 RDW-16.7* Plt Ct-246 [**2141-11-17**] BLOOD WBC-9.1 RBC-3.40* Hgb-11.6* Hct-33.6* MCV-99* MCH-34.0* MCHC-34.4 RDW-16.3* Plt Ct-259 [**2141-11-17**] 07:15PM BLOOD WBC-7.6 RBC-3.20* Hgb-10.9* Hct-31.7* MCV-99* MCH-34.2* MCHC-34.6 RDW-16.6* Plt Ct-253 [**2141-11-18**] 06:20AM BLOOD Glucose-98 UreaN-7 Creat-0.7 Na-139 K-3.9 Cl-103 HCO3-30 AnGap-10 [**2141-11-18**] 06:20AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.1 . [**2141-11-17**] Colonic mucosal biopsies (two): 1. Cecum: Colonic mucosa with rare degenerated crypts and reactive epithelial changes; no viral inclusions or Cryptosporidium seen. 2. Ascending:Colonic mucosa with rare degenerated crypts; no viral inclusions or Cryptosporidium seen. . Brief Hospital Course: 44 y/o M with PMhx of HIV on HAART (last CD4 370) h/o CMV colitis, h/o Crypto & adenovirus colitis who presented to the ED after multiple episodes of BRBPR and high resolution anoscopy with biopsies earlier that day in clinic. Pt had 6 episodes of BRBPR post anoscopy and was sent directly to the ED. VS were stable in the ED and pt was transferred to MICU due to concern for active lower GI bleed. Pt received 2u prbcs and hematocrit remained essentially stable at 30. Pt was transfered to medicine floor in stable condition. . Pt had a repeat colonoscopy that did not show any sign of active bleed and hematocrit remained stable on the floor. It was though that the active bleed may have been due to biopsies taken during anoscopy vs diverticuli. Pt will be seen at [**Hospital1 778**] for follow up of biopsies performed in clinic. CMV VL was negative & colonic biopsy viral cultures returned negative after discharge. Hematocrit was stable at 32.3 on day of discharge and pt was strongly encouraged to return to the ED if he noticed any recurrent BRBPR. . HIV: Pt remained afebrile in house & was continued on home regimen of TIPRANAVIR 500MG [**Hospital1 **], NORVIR CAP 100MG 2 caps [**Hospital1 **], TRUVADA 200-300 MG tabs, FUZEON 90 MG SC bid, ZERIT CAP 20MG po bid. Pt was continued on valcyclovir ppx and plan for follow up with [**Hospital1 **] regarding pending CMV pcr. . Depression: stable, pt was continued on home regimen of wellbutrin . Chronic back pain/hernia pain: Pt was continued on percocet q8hr prn pain Medications on Admission: MEDS: per Logician and confirmed with patient: ROBITUSSIN DAC 30-10-100 MG/5ML SOLN 10 ml Q6 hours PRN cough LEVAQUIN 500 MG TAB 1 tab po daily finished yesterday 10 day course. TRAZODONE HCL 50 MG TABS 1-2 tabs by mouth at hs prn ENSURE LIQD 1 can po TID VIAGRA 50MG TAB (SILDENAFIL CITRATE) take one hour prior to activity WELLBUTRIN SR 150 MG CR TAB 1 TAB PO Q day REMERON 30 MG TAB 1 tab PO qhs ALBUTEROL 90 MCG/ACT AERO SOLN two puffs tid prn VALCYTE 450 MG TABS Take 2 tabs by mouth daily CIALIS 20 MG TABS 1 tab 1 hour prior to sexual activity OXYCODONE HCL 5 MG CAPS 1 cap [**Hospital1 **] PRN MULTIVITAMIN WITH IRON Take 1 capsule by mouth daily TIPRANAVIR 500MG Take one tab [**Hospital1 **] NORVIR CAP 100MG 2 caps po Q12 TRUVADA 200-300 MG TABS 1 tab po daily FUZEON 90 MG KIT inject SC bid ZERIT CAP 20MG 1 cap po bid PANCRECARB MS-16 CPEP 1 cap po with each meal tid DEPO-TESTOSTERONE 200 MG/ML OIL 200mg im q2wks IMODIUM 2 MG CAPS Use tabs QID PRN Discharge Medications: 1. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 2. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 3. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Tipranavir 250 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 5. Ritonavir 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Capsule(s) 6. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Enfuvirtide 90 mg Kit Sig: One (1) Kit Subcutaneous [**Hospital1 **] (2 times a day). 8. Stavudine 20 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 9. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Home Discharge Diagnosis: Primary; Lower GI bleed . Secondary: HIV on HAART h/o infectious colitis Depression Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital because of bleeding from your rectum. You received blood transfusions and had a colonoscopy that did not show any active site of bleeding. Your blood counts have been stable for the last 2 days without any ongoing signs of bleeding. It is important for you to continue watching your stools for any evidence of bleeding, maroon colored stools or any other concerning change in bowel habits. If you experience any chest pain, shortness of breath, dizziness, palpitations or any recurrence of bleeding from your rectum, you should go directly to the ER. Followup Instructions: You should follow up with PCP at [**Name9 (PRE) 778**] early next week. He is expecting you to call and schedule on Monday [**11-20**].

[ "564.1", "042", "530.81", "578.9", "285.1", "558.9", "562.10", "078.5", "311" ]

icd9cm

[ [ [] ] ]

[ "45.24", "99.04", "45.25" ]

icd9pcs

[ [ [] ] ]

6911, 6917

3401, 4933

322, 354

7045, 7054

2457, 3378

7692, 7832

2011, 2039

5947, 6888

6938, 7024

4959, 5924

7078, 7669

2054, 2438

242, 284

382, 1488

1510, 1877

1893, 1995

50,141

129,546

4990

Discharge summary

report

Admission Date: [**2157-8-29**] Discharge Date: [**2157-9-3**] Date of Birth: [**2118-7-30**] Sex: M Service: [**Doctor First Name 147**] Allergies: Codeine Attending:[**First Name3 (LF) 1384**] Chief Complaint: ESRD secondary to focal segmental glomerulosclerosis Major Surgical or Invasive Procedure: s/p cadeveric kidney [**First Name3 (LF) **] History of Present Illness: Admitted for Cadeveric Renal [**First Name3 (LF) 1326**] Past Medical History: ESRD secondary to focal segmental glomerulosclerosis Hepatitis C on peg-IFN congenital single kidney HTN heterogygous for hemochromatosis depression s/p MVA [**7-3**] with R forearm fx and L zygoma, orbit fx Social History: Lives with wife. 2kids: 13 and 17. + h/o inhaled cocaine. Denies IVDA. Prior tobacco use. Prior alcohol use, stopped 4 mos ago. Sexually active with wife. Family History: No CAD or DM. Mom and kids healthy. Dad died from lung CA associated with smoking. Physical Exam: NAD, AAO times 3 PERRLA, EOMI RRR S1+S2 CTA Bilat Soft, NT/ND BS+ Pertinent Results: [**2157-8-29**] 04:58AM CREAT-8.4* [**2157-8-29**] 03:53PM CREAT-8.4* [**2157-8-30**] 04:13AM Creat-6.2*# [**2157-8-31**] 09:00AM Creat-3.5*# [**2157-9-1**] 08:24AM Creat-2.3*# [**2157-9-2**] 06:25AM Creat-2.0* [**2157-9-3**] 08:30AM Creat-1.8* RENAL [**Month/Day/Year **] U.S. [**2157-9-1**] 10:16 AM IMPRESSION: Unremarkable [**Month/Day/Year **] kidney with no hydronephrosis. Minimal perirenal fluid collection. No evidence of acute rejection. Brief Hospital Course: Pt admitted on [**2157-8-29**] for cadveric renal [**Date Range **]. Pt volunteered for study group for FTY720. Pt to OR and tolerated procedure well. Started on study protocol post-op. Pt continued to do well. Pain was well controlled. Pt's diet was advanced as tolerated. On discharge, patient made 1.7L of urine freely and Cr was 1.8 - and decreasing. Medications on Admission: Prozac 20 mg po QD Ativan 2mg po qHS prn Nephrocaps 1 cap po QD Discharge Medications: 1. Diphenhydramine HCl 25 mg Capsule Sig: [**12-31**] Capsules PO Q12H OR QHS PRN () as needed for sleep. 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 7. Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO QD (once a day). Discharge Disposition: Home Discharge Diagnosis: ESRD due to Focal Segmental Glomerulosclerosis (FSGS) Hepatitis C hypertension Discharge Condition: stable Discharge Instructions: Please return for all follow-up appointments Take all medications as described Return to the ER if any increased pain, swelling or redness, fevers, significant weight gain or weight loss, shortness of breath, or nausea and vomitting Followup Instructions: Provider: [**Name10 (NameIs) 1345**],[**Name11 (NameIs) 1344**] ([**Name11 (NameIs) **]) [**Name11 (NameIs) **] CENTER (NHB) Where: LM [**Hospital 5628**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2157-9-8**] 9:40 Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB) Where: LM [**Hospital 5628**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2157-9-13**] 11:20 Completed by:[**2157-9-3**]

[ "585", "753.0", "401.9", "070.54" ]

icd9cm

[ [ [] ] ]

[ "55.69" ]

icd9pcs

[ [ [] ] ]

2707, 2713

1565, 1921

339, 386

2836, 2844

1076, 1542

3125, 3627

891, 975

2035, 2684

2734, 2815

1947, 2012

2868, 3102

990, 1057

247, 301

414, 472

494, 703

719, 875

9,923

170,192

8253

Discharge summary

report

Admission Date: [**2195-1-21**] Discharge Date: [**2195-1-22**] Date of Birth: [**2127-12-26**] Sex: F Service: NEUROLOGY Allergies: Heparin Agents Attending:[**First Name3 (LF) 8747**] Chief Complaint: CODE STROKE Major Surgical or Invasive Procedure: Intra-arterial TPA Right vertebral stenting History of Present Illness: (Per chart, family, nursing home staff) 67 year old woman with multiple vascular risk factors s/p CABG and porcine MVR in [**12-7**], recent left leg cellulitis, now found unresponsive at nursing home at about 10:15 a.m. today. Per her daughter she has been intermittently confused since the left leg cellulitis a week ago, but she has been conversant and interactive. Today at around 10 a.m. she was speaking with her daughter on the phone and complained that she felt very short of breath, and she also sounded confused. She hung up and about 10-15 minutes later the physical therapist found her sitting unresponsive in her chair. She had been incontinent of urine, which is unusual for her. Per the nurse on her unit she was not weak on one side, did not have a facial droop, but had her eyes half open and was moaning, and did not respond to their voices or touch. BG was 130's. EMS arrived and reportedly noted a right hemiparesis. She was brought to [**Hospital6 17032**], where she was described to be "aphasic," not following commands, but withdrawing all four extremities to noxious stimuli. No further details of the neurologic exam are available. Her blood pressure was 161/79 and HR was 51, RR 20 and she was afebrile at 99.6. She did not have a gag and was intubated for airway protection. She received a total of 4 mg of Ativan surrounding the intubation but there is no report of any improvement in her mental status with this. She had a head CT which reportedly showed a subacute right frontoparietal infarct. Per records she was not given tPA due to her recent cardiac surgery. She did receive 600 mg ASA PR. She was then transferred to [**Hospital1 18**] for further evaluation. There has reportedly been no change in her status since her initial presentation. Review of systems: She was recently discharged on [**1-16**] after an admission from rehab for fever and altered mental status, found to have left leg cellulitis and likely C.diff. She complained of SOB while on the phone with her daughter this morning. Otherwise, as above. Past Medical History: CAD, s/p MIs [**2186**],[**2191**], s/p 3 vessel CABG and porcine MVR on [**2194-12-30**] CHF, last EF 35-40% in [**12-7**] CRI ( baseline Cr. was 2.8 to 3.8 in [**12-7**]) Diabetes Hypercholesterolemia HTN Hypothyroidism Chronic back pain Depression Presumed C. diff., Recent left leg cellulitis Social History: She has a 30 pack-year history of smoking; she quit in [**2186**]. She does not consume EtOH. Denies illicit substance use. She lives alone and has five daughters. Family History: No family history of CAD or DM. Physical Exam: T afebrile HR 50's BP 170's/70's Intubated, NOT sedated General appearance: 67 year old woman intubated in NAD HEENT: NC/AT, neck supple with full ROM CV: Regular rate and rhythm without murmurs, rubs or gallops. No carotid bruits. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, no hsm or masses palpated Extremities: no clubbing, cyanosis or edema, erythematous indurated area on left calf c/w prior cellulitis Mental Status: Intubated, not sedated. Eyes are closed, does not open to sternal rub or voice. After stimulated for several minutes, eyes are half open. Does not follow commands. Cranial Nerves: Pupils are equal, round, and reactive to light 2.5>2 mm. Fundi could not be well visualized. She blinked to threat bilaterally when eyes held slightly open. Gaze was midline and conjugate. She would not track visual stimuli. When her eyelids were held open her eyes occasionally drifted downwards, then slowly came back up. There did not seem to be a Bell's phenomenon. Corneals were present bilaterally. She grimaced to nasal tickle bilaterally, perhaps more vigorously on the right. Facial symmetry was difficult to assess due to ETT. There were no OCR's present. She did not gag. Tongue position/palate elevation could not be assessed due to intubation. Motor System: Diminished tone throughout. Occasionally spontaneously wiggles toes, but no other spontaneous movement. With deep nailbed pressure, flexes both arms and legs equally. Once or twice extended either arm into stimulus briefly, then flexed. Reflexes: Deep tendon reflexes are a brisk 2+ and symmetric. Plantar responses are extensor bilaterally. No [**Doctor Last Name 937**]. Sensory: Responds to deep nailbed pressure as above. Coordination, Gait: Could not be assessed. Pertinent Results: [**2195-1-21**] 3:00p 140 110 30 156 AGap=16 4.2 18 1.8 CK: 37 MB: Notdone Trop-T: 1.37 Ca: 8.3 Mg: 2.2 P: 2.5 Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative MCV 87 7.9 > 9.3 < 140 D 29.6 N:84.4 L:9.3 M:3.4 E:1.7 Bas:1.2 Hypochr: 2+ Anisocy: 1+ Poiklo: 1+ Microcy: 1+ PT: 13.2 PTT: 24.4 INR: 1.2 Imaging: Head CT: IMPRESSION: Hypodensity in the right middle cerebral artery territory, which may represent a subacute infarction. No acute intracranial hemorrhage identified. Please note that MRI is more sensitive for detection of acute infarction. [**2194-12-12**] - Carotid US - less than 40% stenosis bilaterally Other studies: EKG with LBBB, NSST changes Brief Hospital Course: 67 year old woman with multiple vascular risk factors, 3 weeks s/p 3 vessel CABG and porcine MVR, not on coumadin, found unresponsive and incontinent at 10:15am. Last well when she spoke with daughter on the phone at 10am. Initially taken to [**Hospital3 **] where thought to have R sided weakness and aphasia. Transferred to [**Hospital1 18**]. Neuro: Code stroke called and neurology evaluated patient. Initially, patient was sedated by Ativan. Thought to have either an epileptic process or a brainstem process and taken for stat MRI/MRA after CT scan found to be essentially negative except for subacute or chronic R frontal infarct. MRI/MRA revealed large mid-basilar to top of basilar clot with diffusion changes in bilateral pons and in R MCA distribution. Mechanism of stroke likely cardioembolic given multiple vascular territory involvement. Patient was not eligible for IV t-[**MD Number(3) 6360**] presentation at >3 hours. After extensive discussion with family re: risks and benefits of intervention stroke attending and interventional neurosurgeons, patient was taken to the INR suite for consideration of clot retrieval or intra-arterial therapy. Patient had extensive vertebral and subclavian origin stenosis and were unable to deploy a clot retrieval device. She did receive 2mg of IA t-PA into L vertebral artery which was hypoplastic and she underwent stenting of the R veretebral artery. Family members were informed. We will ask cardiology to consult on patient tonight given increased troponin. Post Neuroradiology procedure, patient was admitted to neurology ICU for close monitoring and neuro checks: q15 min x 2 hr post TPA, then q30 min x 6h, then q1h x 16h, then per routine. Avoided instrumentation (foley, arterial puncture) x 24 hrs and antiplatelet or anticoag x 24 hrs. Patient was started on integrillin gtt per INR service for 24 hours. Repeat head CT was negative for intracranial hemorrhage and was otherwise unchanged. The following morning patient's exam was unchanged. Discussed locked-in syndrome and the associated of function she would have. Family meeting was held at 11AM: After long discussion with family who expressed understanding of the patient's status in their words, patient was made comfort measures only according to patient's wish not to be ventilator dependent or have a tracheostomy. Patient was made comfort measures only which was confirmed with TICU team and NeuroICU attending. Pt. expirted at 11:50 AM with family at the bedside. Autopsy was declined. CV: Kept <180 systolic and <105 diastolic; PRN labetalol to achieve this goal. Cardiac enzymes were elevated unclear whether this was associated with increased troponin Medications on Admission: - Calcium Carbonate 500 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO TID W/MEALS - Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H - Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY - Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). - Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID - Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) 10,000 units Injection QMOWEFR (Monday -Wednesday-Friday). - Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H x 10 d - Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). - Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three times a day for 10 days. Discharge Disposition: Expired Discharge Diagnosis: CVA s/p cabg x3/MVR [**2194-12-30**] MI HTN CHF CRI NIDDM hypothyroidism elev. chol. Discharge Condition: expired Completed by:[**2195-3-5**]

[ "428.0", "434.91", "272.0", "V42.2", "250.00", "403.90", "414.00", "V45.81", "585.9" ]

icd9cm

[ [ [] ] ]

[ "88.41", "99.10", "96.71" ]

icd9pcs

[ [ [] ] ]

9019, 9028

5552, 8255

289, 334

9158, 9195

4830, 5171

2952, 2985

9049, 9137

8281, 8996

3000, 3453

2174, 2432

238, 251

362, 2154

3653, 4811

5180, 5529

3469, 3636

2454, 2753

2769, 2936

1,770

158,667

27602

Discharge summary

report

Admission Date: [**2115-10-15**] Discharge Date: [**2115-10-19**] Date of Birth: [**2052-10-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Pulmonary secretions, dyspnea Major Surgical or Invasive Procedure: Bronchoscopy x3 with stent revision. Upper endoscopy. History of Present Illness: 62 year old male with stage IV NSCLC c/b tracheoesophageal fistula with Y stent and esophageal stent placement in [**6-18**] transferred from OSH with hypoxia and pneumonia. Patient is followed by oncology at [**Hospital1 18**] and is receiving [**Doctor Last Name **]/Taxol chemotherapy, most recently one week prior to admission. On [**10-13**], patient tried to eat a grilled cheese [**Location (un) 6002**] and was unable to swallow; reports choking sensation. He has had dysphagia since then, but denies odynophagia. Patient states that he has had to crush pills prior to swallowing. On [**10-14**], patient became more short of breath with increased secretions and went to [**Hospital6 6689**] where he was admitted to the ICU and treated for aspiration and nosocomial pneumonia with Vanc/Ceftazadime/Clindamycin. . On [**10-15**], patient was transferred to [**Hospital1 18**] as he had Y stent and esophageal stents placed here. Past Medical History: Metastatic Lung Cancer (T9 met) Tracheoesophageal fistula s/p Y stent and esophageal stent [**6-18**] with stent revision [**2115-10-18**] Hypertension Small/stable pericardial effusion Social History: lives with wife. Former tobacco [**1-14**] ppd x 25 yrs, quit 12 years ago and quit EtOH. Family History: There is no family history of breast, ovarian, uterine, or lung cancer. His father died at age 65 and had [**Month/Day (2) 499**] cancer. He also believes a paternal grandfather had [**Name2 (NI) 499**] cancer. His mother aged 78 died of emphysema. He has no siblings. Physical Exam: T 98.4F HR 113 BP 127/71 RR 20 98%/4L n.c. Gen: awake, alert, sitting upright in bed, NAD HEENT: PERRL, EOMI, anicteric, OP clear, MMM, cheeks flushed CV: S1, S2, RRR Pulm: Crackles left base Abd: (+) BS, soft, ND/NT, no rebound or guarding Ext: warm, well-perfused, no edema Pertinent Results: [**2115-10-15**] 10:06PM GLUCOSE-86 UREA N-14 CREAT-0.5 SODIUM-134 POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-21* ANION GAP-17 [**2115-10-15**] 10:06PM CALCIUM-8.9 PHOSPHATE-2.9 MAGNESIUM-1.0* [**2115-10-15**] 10:00PM WBC-9.4 RBC-2.49*# HGB-7.9* HCT-22.5*# MCV-90 MCH-31.7# MCHC-35.1* RDW-18.1* [**2115-10-15**] 10:00PM NEUTS-91.8* BANDS-0 LYMPHS-4.5* MONOS-3.0 EOS-0.4 BASOS-0.3 [**2115-10-15**] 10:00PM PLT SMR-LOW PLT COUNT-91*# [**2115-10-15**] 10:00PM PT-13.3* PTT-25.7 INR(PT)-1.2* . CHEST (PORTABLE AP) [**2115-10-15**] IMPRESSION: Increased consolidation of the left base and patchy right lower lobe opacities, which may be due to aspiration or developing pneumonia. . EGD [**2115-10-16**] The previously placed ultraflex stent was completely patent. There was no evidence of any tumour ingrowth. . ECHO [**2115-10-17**] Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. There is an anterior space which most likely represents a fat pad. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. A calcified spherical mass (2.6 by 2.6 cm) is present in the para-aortic region abutting the posterior wall of the left atrium. . VIDEO OROPHARYNGEAL SWALLOW [**2115-10-18**] FINDINGS: An oral and pharyngeal swallowing video fluoroscopy study was performed in collaboration with the speech and swallow department. Varying consistencies of barium were administered under constant fluoroscopic video guidance. Patient demonstrated aspiration with continuous straw sips of thin liquids. Otherwise, no evidence of aspiration was identified with other consistencies of barium.. . CHEST (PORTABLE AP) [**2115-10-18**] IMPRESSION: Interval increased consolidation of the left base with persistent right lower lobe patchy opacities. . CHEST (PA & LAT) [**2115-10-18**] IMPRESSION: PA and lateral chest compared to [**9-24**] and [**10-15**]: Pneumonia in the right lower lobe has worsened since [**10-15**]. Severe left lower lobe atelectasis and a small left pleural effusion are unchanged. Esophageal and left bronchial stents are stable in position relative to [**9-24**]. Heart is normal size. No pneumothorax. Elevation of the left hemidiaphragm is mild with respect to the right and less pronounced since [**Month (only) **]. . [**2115-10-16**] 9:29 am BRONCHOALVEOLAR LAVAGE LT. LOWER LOBE. STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S PENICILLIN------------ =>0.5 R . [**2115-10-16**] 9:28 am BRONCHIAL WASHINGS LMS BRONCHUS. KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S . Labwork on discharge: [**2115-10-19**] 09:50AM BLOOD WBC-3.4* RBC-2.94* Hgb-9.3* Hct-26.8* MCV-91 MCH-31.5 MCHC-34.6 RDW-17.3* Plt Ct-140* [**2115-10-19**] 05:10AM BLOOD Glucose-111* UreaN-8 Creat-0.8 Na-136 K-4.0 Cl-101 HCO3-25 AnGap-14 Brief Hospital Course: A/P: 62 yoM with stage IV NSCLC complicated by tracheoesophageal fistula s/p stents transferred from OSH with likely aspiration pneumonia and dysphagia. Transferred from MICU [**10-16**]. . 1. Pneumonia. The patient was empirically treated with vancomycin and zosyn for aspiration and hospital-acquired pneumonia. The patient was discharged on levofloxacin per interventional pulmonology recommendations to complete a 14-day course when sensitivities returned on the bronchoalveolar cultures as above. The patient was given supplemental oxygen and continued on nebulizers, guaifenesin and tessalon perles as needed. Interventional pulmonology followed the patient throughout hospitalization. . 2. Dysphagia. Upper endoscopy showed patent stent as above. The patient was followed by gastroenterology and speech and swallow during hospitalization. Video swallow performed with results as above. The patient was instructed not to use straws. . 3. Lung cancer. Staging/treatment, tracheoesophageal fistula as above. The patient was followed by his oncologist during hospitalization. Interventional pulmonology followed the patient throughout hospitalization. The patient received three bronchoscopies with successful stent placement. The patient was continued on pain control as needed. The patient was scheduled for follow-up with oncology on discharge. The patient will return in [**4-18**] weeks for repeat bronchoscopy to assess stent position. . 4. Shortness of breath. Improved on discharge. Likely multifactorial secondary to lung cancer, pneumonia, and anemia. Treatment as above. . 5. Anemia. Likely secondary to chemotherapeutic agents and anemia of chronic disease. The patient was continued on Epogen. Iron studies were not able to be performed prior to blood transfusion. Hemolysis and DIC panels were negative. The patient was transfused one unit packed red blood cells prior to transfer from the OSH and was transfused one unit during this hospitalization two days prior to discharge. The patient's hematocrit bumped appropriately and remained stable. . 6. Thrombocytopenia. Most likely secondary to chemotherapeutic agents. Stable. The patient was followed by his oncologist during hospitalization. . 7. Pericardial effusion per OSH echo. Hemodynamically stable. Likely secondary to cancer and chemotherapeutic agents. Small/stable per echocardiogram prior to discharge as above. . Full code confirmed with patient while in intensive care. Medications on Admission: Percocet Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*QS One* Refills:*2* 2. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Disp:*QS ML(s)* Refills:*0* 3. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:*30 Capsule(s)* Refills:*0* 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* 5. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q4-6H (every 4 to 6 hours) as needed. 6. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*QS One* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA Discharge Diagnosis: Primary: aspiration pneumonia . Secondary: Metastatic Lung Cancer (T9 met) Tracheoesophageal fistula s/p Y stent and esophageal stent [**6-18**] with stent revision [**2115-10-18**] Hypertension Small/stable pericardial effusion Discharge Condition: Afebrile, vital signs stable. Discharge Instructions: Please contact a physician if you experience increased shortness of breath, chest pain, or any other concerning symptoms. . Please take your medications as prescribed. You should take levofloxacin, an antibiotic, for ten days. You have been given prescriptions for albuterol and ipratropium inhalers and cough suppressents as needed. . Please keep your follow-up appointments as below. Followup Instructions: Follow-up with oncology: Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9 Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2115-10-29**] 1:00 Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**] Date/Time:[**2115-10-29**] 1:00 . Follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on [**11-4**] at 11:20AM. Please call [**Telephone/Fax (1) 37713**] if you need to reschedule. . You should call Interventional Pulmonology at [**Telephone/Fax (1) 3020**] about returning in [**4-18**] weeks for repeat bronchoscopy to reevaluate stent placement. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "401.9", "287.4", "530.84", "162.8", "285.22", "518.84", "423.9", "507.0", "E933.1", "198.5" ]

icd9cm

[ [ [] ] ]

[ "33.24", "99.04", "96.05", "45.13" ]

icd9pcs

[ [ [] ] ]

9678, 9729

6279, 8732

347, 403

10002, 10034

2290, 6025

10468, 11247

1703, 1974

8791, 9655

9750, 9981

8758, 8768

10058, 10445

1989, 2271

6039, 6256

278, 309

431, 1370

1392, 1579

1595, 1687

83,065

115,535

31788

Discharge summary

report

Admission Date: [**2146-12-13**] Discharge Date: [**2146-12-30**] Date of Birth: [**2123-10-15**] Sex: F Service: SURGERY Allergies: Baclovent Attending:[**First Name3 (LF) 695**] Chief Complaint: nausea, vomiting, diarrhea; liver masses Major Surgical or Invasive Procedure: [**2146-12-19**]: Right hepatic trisegmentectomy, cholecystectomy, portal vein thrombectomy, intraoperative ultrasound. History of Present Illness: This is a 23 year old female with no significant past medical history presenting with subacute GI process over past 3 months. In [**2146-8-19**], she noted intermittent nausea and vomiting, about 2-3 times per week, usually worse in the morning, prior to eating. About 1 month prior to admission, these symptoms have worsened in frequency and severity with daily nausea and vomiting associated with diarrhea up to 3-4 times / day. Appetite is present however her PO intake has dramatically decreased over the past month. She has lost about [**3-28**] lbs over the past three months. She did admit to intermittent fevers and intermittent night sweats. She has also noted yellowish stool, looser in consistency; urine color unchanged. Over the past two weeks she's had increasing lethargy and confusion; on the day prior to admission, her parents stated that she did not come down for breakfast and they found her upstairs in bed, sleeping late into the morning and confused upon arousal. She was too lethargic to make it down the stairs. Given progressive lethargy, worsening nausea/vomiting and diarrhea, and confusion, she was brought to the hospital for evaluation. In the ED, her vitals were noted to be stable with electrolytes within normal limits. INR was elevated to 1.5 and PTT was elevated at 41.2. Transaminases were mildly elevated. Outside hospital CAT scan of abdomen was reviewed which showed multiple liver masses suggestive for focal nodular hyperplasia versus hepatic adenoma, hemangioendothelioma, or fibrolamellar carcinoma. Expansion of the right portal vein likely secondary to tumor thrombus was noted with thrombus seen in the proximal portal vein. She was pain-free and nausea free, although mildly confused. She was transferred to the floor for in-patient evaluation. Past Medical History: 1. Shingles in spring of [**2142**] 2. Asthma 3. Recurrent tendinitis 4. s/p appendectomy Social History: Current attends college at [**Hospital1 **]. Recently working on dissertation regarding the rise of democracy in Liberia. No smoking history, rare alcohol use, never used IV drugs. Not currently sexually active (history taken while parents in room). . Travel history: Spent time in [**Country 3396**] in summer of [**2144**] for 3 weeks, ate fish at markets, beef, pork. Spent time in [**Country 149**] in Spring of [**2142**] where she ate beef,pork. No history of travel to south America or [**Country 480**]; no freshwater swimming history. No pets at home. Family History: No history of liver or renal disease; no malignancy history in immediate family. Brother had ITP at age 6. Physical Exam: VS: 98.2, 119/81, 90, 20, 99% RA, 56 kg Gen: Pleasant female, mildly confused - able to say months of the year backwards accurately (albeit with some delay); states name of President, is able to tell me name of her recent dissertation Neuro: Mental status as above, mild asterixis, otherwise nonfocal HEENT: No icteris, oropharynx clear, no jaundice noted Lymph: Gross lymph exam reveals no lymphadenopathy Cardiac: Nl s1/s2, RRR no murmurs appreciable Pulm: clear to auscultation bilaterally Abd: Multiple discrete nodular masses palpable in the right upper quadrant; no splenomegaly noted; no CVA tenderness, normoactive bowel sounds, mild tenderness in right upper and lower quadrant Ext: 1+ lower extremity edema, good distal pulses Pertinent Results: Admission Labs: [**2146-12-13**] 08:00PM BLOOD WBC-5.3 RBC-4.45 Hgb-12.8 Hct-36.8 MCV-83 MCH-28.8 MCHC-34.8 RDW-14.2 Plt Ct-291 [**2146-12-13**] 08:00PM BLOOD Neuts-62.1 Lymphs-32.5 Monos-4.5 Eos-0.4 Baso-0.4 [**2146-12-13**] 08:00PM BLOOD PT-16.9* PTT-41.2* INR(PT)-1.5* [**2146-12-13**] 08:00PM BLOOD Glucose-96 UreaN-5* Creat-0.5 Na-142 K-3.6 Cl-112* HCO3-21* AnGap-13 [**2146-12-13**] 08:00PM BLOOD ALT-118* AST-91* LD(LDH)-168 AlkPhos-96 TotBili-0.7 [**2146-12-13**] 08:00PM BLOOD Lipase-34 [**2146-12-13**] 08:00PM BLOOD Albumin-3.0* Calcium-8.4 Phos-3.4 Mg-1.6 [**2146-12-13**] 08:00PM BLOOD Ammonia-245* [**2146-12-13**] 08:00PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE [**2146-12-14**] 05:20AM BLOOD CEA-4.3* AFP-2.4 [**2146-12-13**] 08:00PM BLOOD HCV Ab-NEGATIVE Discharge Labs: Imaging: [**2146-12-14**] Liver ultrasound with duplex - IMPRESSION: Multiple hepatic masses involving majority of the right lobe as seen on the [**Hospital1 18**] [**Location (un) 620**] CT. Expansile hyperechoic vascularized tumor thrombus is present within the proximal main portal vein extending into the right and left portal system with cavernous transformation noted in the portal hilum. A portion of the left portal vein is not involved by tumor thrombus. The presence of tumor thrombus is highly suggestive of an underlying malignancy with differential again including fibrolamellar HCC, conventional HCC, malignant hemangioendothelioma, or given GI symptoms atypical appearance of metastatic neuroendocrine tumor. Malignant degeneration of adenomas is also possible. [**2146-12-14**] CT chest without contrast - IMPRESSION: 1. No suspicious lesions concerning for malignant disease in the chest. 2. Right lower lobe subpleural density, adjacent to an area of scarring, likely a granuloma. 3. Two large liver masses, better evaluated on dedicated abdominal imaging. [**2146-12-14**] MRI Head with and without contrast [**2146-12-15**] CT Abdomen with contrast Brief Hospital Course: [**Known firstname **] [**Known lastname 72714**] is a 23 year old female who presented after several months of nausea and vomitting, found to have subacute hepatic failure due to fibrolamellar hepatocellular carcinoma with associated portal vein tumor thrombus. She received right lobe US guided biopsy that confirmed fibrolamellar HCC on [**2146-12-14**]. CT and MRI were completed which did not show metastatic lesions and MRI did not show cerebral edema. She received left lobe liver biopsy [**2146-12-16**] that showed severe macrosteatosis likely secondary to prolonged malnutrition. She was promptly started on TPN [**2146-12-16**] after left liver biopsy results were obtained. She was started on a heparin drip [**2146-12-17**] to prevent tumor propagation. She was transferred to Dr.[**Name (NI) 1369**] hepatobiliary surgical service [**2146-12-17**] in preparation for triple lobectomy and portal vein thrombectomy on [**2146-12-19**]. She was taken to the operating room on [**2146-12-19**] for a right hepatic trisegmentectomy, cholecystectomy, and portal vein thrombectomy with intraoperative ultrasound. Please refer to the operative note by Dr. [**Last Name (STitle) **] for additional details. She received a total of 8000 mL of plasmalyte, 1250 mL of albumin, 3 units of fresh frozen plasma, 16 units of packed red cells, 1 unit of cryo and made 1530 mL of urine intraoperatively. She tolerated the procedure well but due to the extensive nature of the resection she was returned to the surgical ICU post-operatively. She received an additional 2 units of PRBC overnight on POD 0 into POD 1 and was briefly on neosynephrine to maintain her blood pressure. On POD 1, she was off pressors, cardiovascularly stable (no additional blood products) and was extubated. Her diet was advanced and she was transferred to the floor on POD 2 tolerating clears. The remainder of her post-operative course was largely uncomplicated. Pertinents, by system: Neuro: After receiving intermittent fentanyl and propofol in the ICU, she was on intermittent IV dilaudid in the initial days following the operation and subsequently transitioned to oral dilaudid which she tolerated well. There was initial concern of oversedation and the patient voluntarily agreed to decrease dosing. Her sedation was not an issue in the latter portion of her hospitalization after dosing adjustment. Her pain was well controlled at time of discharge on a regimen of oral dilaudid 2-4 mg Q4H prn pain which she was using approximately every six hours. CV: Ms. [**Known lastname 72714**] was tachycardic initially post-operatively in the 130s. Her heart rate gradually came down on its own throughout her hospitalization without the use of beta blockers or other medications to slow the heart rate. Resp: Ms. [**Known lastname 72714**] was extubated without event on POD 1. She has initial difficulty with deep inspiration due to splinting from the abdominal pain and was noted to have decreased breath sounds at the bases on POD 6 into POD 7. Her oxygen saturation dropped while working with physical therapy to the mid 80s and CXR confirmed mild to moderate bilateral atelectasis with associated pleural effusion. The effusion was re-evaluated with another CXR on POD 9 and it was deemed of insufficient size to treat with therapeutic intervention. She continued to improve her activity level with physical therapy and concurrently continued to improve in her respiratory status. GI: Ms. [**Known lastname 72714**] was NPO with ice chips for comfort initially after the operation. She was advanced first to clears on POD 2, then to a regular diet on POD 3. She tolerated all advances well. Her caloric intake along with appetite gradually improved throughout her hospitalization. Calorie count for POD 9 showed 700 calories intake and 11 gms of protein but this only counted her consumption of the hospital food service meals (not including the food brought in by her family, which was documented by the nurses and more than half of her daily intake). She was started on TPN three days prior to the operation and this was continued until POD 4 (volume reduced by a third) and discontinued on POD 5 as she was tolerating regular diet well at this point. Heme: Ms. [**Known lastname 72714**] was treated with a heparin drip preoperatively from [**12-16**] until the morning of her surgery on [**2146-12-19**]. She was initially autoanticoagulated after the surgery (INR 2.3). The drip was restarted on POD 2 and eventually bridged to coumadin. Her daily coumadin dosing starting on POD 4 until discharge with associated INR in parenthesis: 1.7 ( 2 ) - - > 1 . 6 ( 1 ) -->1.4(5)-->2.2(5)-->1.6(5)-->1.6(5)-->2.7(3)-->2.2(5)-->1.9(4). Heparin drip was stopped on POD 9 when INR was greater than 2. She was discharged with detailed instructions for scheduled blood draws to manage her INR and coumadin dosing. Please refer to the discharge instructions at the end of this discharge summary for additional details. Of additional note, Ms. [**Name14 (STitle) 74617**] had duplex ultrasound to assess flow in the portal vein and hepatic artery on POD 1 and POD 7. Both showed patency and normal flow. Finally, Ms. [**Known lastname 72714**] was transfused an additional 2 units of PRBCs on POD 7 when her hematocrit which was otherwise stable in the mid-to-high 20s dropped to 21.4. Her hematocrit responded to the transfusion. She had no additional issues or concerns of bleeding. Her hematocrit on discharge was 30.4. GU: Ms. [**Known lastname 72714**] had a foley catheter which was dc'd on POD 4. She subsequently voided without issue. She was noted to be several liters positive and well above her dry weight in kilograms with equal bilateral lower extremity edema on physical examination. She was diuresed with furosemide 40 PO BID and intermittent doses of IV furosemide. She lost significant water weight during the later days of her hospitalization and weighed 63.4 kg on POD 10. Onc: Ms. [**Known lastname 72714**] had a bone scan on POD 9 as part of workup to assess for metastatic disease. It was negative. On POD 11, she was ambulating, tolerating regular diet and her pain was well controlled with PO pain medications. She was discharged home. Medications on Admission: Advil prn Discharge Medications: 1. Outpatient Lab Work Saturday [**12-31**] and Monday [**1-2**] PT/INR, chem 7 On Saturday, Please call results to [**Telephone/Fax (1) 74618**], pager [**Numeric Identifier 28794**] On Monday, Fax results to [**Telephone/Fax (1) 697**] [**First Name9 (NamePattern2) 5035**] [**Doctor First Name 5969**] 2. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day: Take as directed per Dr [**Last Name (STitle) 4727**] office. Disp:*150 Tablet(s)* Refills:*2* 6. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed per Dr [**Last Name (STitle) 4727**] office. Disp:*30 Tablet(s)* Refills:*2* 7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO twice a day: While taking Lasix. Disp:*60 Tablets* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: HCC/Fibrolamellar h/o portal vein thrombus 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 Dr[**Name (NI) 1369**] office at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, diarrhea, constipation, increased abdominal size, increased abdominal pain, redness, increased drainage or bleeding at the incision site, yellowing of skin or eyes, confusion or lethargy. No heavy lifting/straining. No driving You may shower with soap and water. Pat incision dry. Do not apply powder/ointment/lotion to the incision. Eat as well as possible and drink supplements such as ovaltine, carnation instant breakfast, milkshakes (you can add protein powder) Drink enough fluids to keep the urine light yellow in color Weigh yourself daily, if the weight changes by more than 3 pounds daily, or you are back to your pre-operative weight please call the office as the lasix dose may need to be decreased or stopped. Have labs drawn with the VNA Saturday and Monday for PT/INR and Chem 7 Ancillary Lab: [**Hospital3 3765**] Satelitte lab:, [**Hospital3 3765**] Lab [**Location (un) 74619**] [**Location (un) 1514**] Lab hours on Saturday 8 AM - 2:15 You will need labs again Monday and then have your appointment with Dr [**Last Name (STitle) **] Wednesday and you can have labs drawn at the hospital lab in the [**Hospital Unit Name **]. You will be going home on 5 mg of Coumadin, however this dose is VERY subject to change based upon lab results. You are being given scripts for 1 mg and 5 mg. Please fill them both. You should take colace as long as you are taking narcotic pain medication. You may take Milk of Magnesia to assist in moving your bowels Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2147-1-4**] 10:40 Labwork Saturday and Monday at home and Wednesday at [**Hospital Unit Name 3269**] Lab [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2146-12-31**]

[ "155.0", "493.90", "263.9", "570", "452", "780.62" ]

icd9cm

[ [ [] ] ]

[ "38.93", "50.22", "50.11", "99.15", "38.07", "51.22" ]

icd9pcs

[ [ [] ] ]

13306, 13355

5863, 12142

312, 434

13442, 13442

3848, 3848

15223, 15630

2966, 3075

12203, 13283

13376, 13421

12168, 12180

13625, 15200

4666, 5840

3090, 3829

232, 274

462, 2257

3864, 4649

13457, 13601

2279, 2370

2386, 2950

6,010

143,429

10982

Discharge summary

report

Admission Date: [**2145-10-18**] Discharge Date: [**2145-10-21**] Date of Birth: [**2113-10-8**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 32-year-old male with a history of systemic lupus erythematosus, systemic lupus erythematosus cerebritis, chronic renal insufficiency and psychosis who was sent to the [**Hospital1 **] Emergency Department for fever and rigors. He resides at [**Hospital1 2670**] [**Location (un) **] Group Home where the staff had noticed increasing behavioral problems with [**Name2 (NI) 29399**] for several days leading up to [**2145-10-15**]. He then became calm and withdrawn and stopped taking po medications. On the date of admission, the patient was noted to be febrile with rigors at [**Hospital1 2670**] and thus was brought to the [**Hospital3 **] Emergency Department. The patient denied pain but complained of feeling hot on arrival to the Emergency Department. The patient was febrile to 103, tachy with sinus tachycardia at 120 beats per minute. Blood pressure was stable. 02 saturation 80s on room air, 99% on 100% nonrebreather. He was responsive to voice and pain stimulus but not following commands and noncommunicative. He was moaning. Laboratories were notable for a white count of 11.2 with 29% bands, bicarbonate of 13, BUN and creatinine 119/35, 7.5 over baseline of 15/1. Chest x-ray with hazy left lower lobe consolidation. He received 1 amp of D50, insulin 10 units, 1 amp of bicarbonate at 5 mg, droperidol, 1 gram of vancomycin, 500 mg of Levaquin. Patient then underwent lumbar puncture in the Emergency Department by the Medical Intensive Care Unit staff prior to transfer to the Medical Intensive Care Unit. Arterial blood gases in the Emergency Department were 7.19, 35 and 52 on two liters of nasal cannula. He continued to desaturate to the 80s on 100% non rebreather and his respiratory rate increased to 40. The patient was intubated prior to the transfer to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: Systemic lupus erythematosus with a positive [**Doctor First Name **] of 1:1280, negative double stranded DNA, positive rheumatoid factor, positive [**Doctor Last Name 1968**], positive ribonuclear protein, positive Ro, positive antihistone, negative LA, normal complement levels this year. Systemic lupus erythematosus cerebritis with previous admissions. MR [**First Name (Titles) **] [**2145-2-28**] was consistent with cerebritis. The patient also has a history of bipolar disorder, seizure disorder, psychosis, impulsive behavior, avascular necrosis of the hips bilaterally, status post bilateral hip replacement unclear history, status post laparotomy for a question of gastric ulcers, hemolytic anemia, chronic renal insufficiency, probably secondary to lupus nephritis, hypothyroidism, pulmonary hypertension, Klinefelter syndrome, diagnosed secondary to delayed secondary sexual characteristics, right knee avascular necrosis with meniscal tear by MRI in [**2145-2-28**] tibial plateau collapse. MEDICATIONS ON ADMISSION: Vioxx 50 po q.d., Norvasc 5 mg po q.d., Synthroid 50 mcg po q.d., Megace 400 mg po q.d., Trilafon 16 mg po b.i.d., lamictal 50 mg po q.d., Depakote 500 mg po b.i.d., Protonix 40 mg po q.d., cogentin 1 mg po b.i.d., Fosamax 5 mg po q.a.m., Tums 500 mg po t.i.d., testosterone patch. ALLERGIES: Patient is allergic to penicillin and Zyprexa. SOCIAL HISTORY: He is a nursing home resident at [**Hospital1 2670**] [**Location (un) **] for the prior nine months. He denies smoking, drinking and intravenous drug use. No family in the area. Originally from [**State 2690**]. PHYSICAL EXAM ON ADMISSION: Blood pressure 112/68. Heart rate 120. Respiratory rate 30. Temperature 1032. O2 saturation 96% on 100% nonrebreather. In general, he is obtunded and moaning, no jugular venous distention. Pupils equal, round and reactive to light. No lymphadenopathy. Neck is supple. Lungs are clear bilaterally. Cardiovascular: Sinus tachycardia with normal S1, S2, no audible extra sounds. Abdomen soft, nontender, nondistended, faint bowel sounds, well-healed midline scar. Extremities: Warm, 2+ pulses, no edema. Neurological: No meningeal or focal signs. Skin: Faint erythematous rash on left medial foot. LABORATORIES ON ADMISSION: White blood cell count 11.2, hematocrit 25.6, platelets 196,000. Neutrophils 58%, bands 29, lymphocytes 12, sodium 145, potassium 8, chloride 113, bicarbonate 13, BUN 119, creatinine 7.5, glucose 86, anion gap is 19. Urinalysis showed large blood, protein greater than 300, red blood cells [**5-9**], white blood cells [**2-1**], moderate bacteria, occasional yeast, epithelial cells [**5-9**]. Arterial blood gas was 719, 35 and 52. Cerebrospinal fluid on admission: 3 white blood cell and 1 red blood cells, 18 polys, 4 bands, 40 lymphocytes, 30 monocytes, 2 neutrophils, protein 35, glucose 69. Gram stain was negative. Chest x-ray showed an enlarged cardiac silhouette with patchy areas of consolidation in the left lung and a hazy costophrenic angle. Electrocardiogram showed mildly peaked T waves in V3 through V5. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit. He was started on assist control with goal of correcting his acidosis and improving his mental status and protecting his fluid overload. He received four liters of intravenous fluids in the Emergency Department. He was treated for a pneumonia with broad spectrum antibiotics. His sputum was cultured. Results of his sputum were negative. Most likely etiology of the patient's admission was considered a sepsis from his left lower lobe pneumonia. The patient was noted to be hypotensive while in the Medical Intensive Care Unit and he was started on intravenous pressors. His creatinine did not resolve. It continued to remain in the high 7 to 8 range. The patient also was noted to be bleeding which was felt to be secondary to DIC during this admission. Patient's platelets rapidly fell and his coags increased. The patient's hematocrit also decreased to 21. He was transfused to correct this problem, however, the patient remained in DIC given the fact that he had fever, mental status change, renal failure, thrombocytopenia and hemolytic anemia, the possibility of TTP was considered. The patient was prepared for pheresis. During the placement of a Quinton catheter, patient developed a pneumothorax and a pneumohemothorax. Attempts to resuscitate the patient were unsuccessful. He died at 5:50 p.m. on [**2145-10-21**]. The patient's father was notified in [**State 2690**]. The patient's case was referred to the Medical Examiner for autopsy. DISCHARGE CONDITION: Death. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**] Dictated By:[**Last Name (NamePattern1) 5476**] MEDQUIST36 D: [**2145-11-5**] 15:16 T: [**2145-11-5**] 15:16 JOB#: [**Job Number 35611**]

[ "276.2", "486", "710.0", "038.9", "518.81", "758.7", "286.6", "584.5", "446.6" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.09", "38.93", "89.64", "96.56", "96.72", "38.91", "37.91", "03.31" ]

icd9pcs

[ [ [] ] ]

6703, 6982

3062, 3405

5153, 6681

158, 2004

4778, 5135

2027, 3035

3422, 3652

62,527

154,061

21007+57214

Discharge summary

report+addendum

Admission Date: [**2115-8-6**] Discharge Date: [**2115-8-15**] Date of Birth: [**2031-3-23**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 84 year old female s/p Aortic Valve Replacement ([**Street Address(2) 6158**]. [**Hospital 923**] Medical Epic Biocor tissue valve), Coronary artery bypass grafting x 1 with reverse saphenous vein graft to the right coronary artery on [**7-15**] and was discharged to rehab. Over the last few days she has felt weaker and shortness of breath progressively increased and was then transferred to the ED at outside hospital for shortness of breath. She was treated for rapid atrial fibrillation and heart failure being admitted to ICU at outside hospital. Past Medical History: AF s/p CABG/AVR Meniere's disease Leukemia in [**2097**] treated with Chemotherapy Myelodysplastic syndrome COPD Paroxsymal Atrial Fibrillation - She did not know of this diagnosis. Denied ever taking Coumadin. Aortic Stenosis with valve area 0.7 cm2 Pulmonary Hypertension Hemorrhoidectomy Tonsillectomy Appendectomy GERD Chronic Diarrhea Frequent Urination Previous UTI's Degenerative Disc Disease Social History: Ms. [**Name14 (STitle) 55821**] alone in [**Location (un) 2498**] MA. She recently had a visiting nurse [**First Name8 (NamePattern2) 767**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Health Agency for three weeks after her hospitalization in [**Month (only) **]. Her contact person in her stepson [**Name (NI) **] [**Name (NI) 41323**]; his home number is [**Telephone/Fax (1) 55822**]. The patient still drives. She has bilateral hearing aides. She occasionally uses a cane when she is out of her house and has to go some distances. Family History: Mother died at 103 of old age. Father died with stomach CA. Physical Exam: Pulse: 109 Resp:20 O2 sat: 96 2 l nc B/P Right: 97/63 General: No acute distress Skin: Dry [x] intact [x] Bruising right hip, Sternal incision healing no erythema or drainage, Right Leg EVH healing ecchymosis calf area HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [] Diminished bilateral bases Heart: RRR [] Irregular [x] Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses last BM [**8-5**] Extremities: Warm [x], well-perfused [x] Edema + 1 Varicosities: bilateral Neuro: alert and oriented x3 nonfocal Pulses: Femoral Right: +1 Left: +1 DP Right: D Left: D PT [**Name (NI) 167**]: D Left: D Radial Right: +1 Left: +1 Pertinent Results: [**2115-8-6**] ECHO The left atrium is dilated. The right atrium is dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2115-7-15**], the severity of mitral regurgitation has increased, although may have been not as well visualized on prior study (image quality was limited). Systolic anterior motion of the mitral chordal structures is similar in appearance. The resting heart rate is now faster. The pericardial effusion appears similar. [**2115-8-15**] 06:40AM BLOOD WBC-8.5 RBC-3.35* Hgb-10.1* Hct-31.3* MCV-94 MCH-30.1 MCHC-32.2 RDW-17.6* Plt Ct-403 [**2115-8-15**] 06:40AM BLOOD PT-23.6* INR(PT)-2.2* [**2115-8-15**] 06:40AM BLOOD Glucose-122* UreaN-30* Creat-1.3* Na-136 K-4.1 Cl-97 HCO3-27 AnGap-16 [**2115-8-12**] 06:36AM BLOOD ALT-47* AST-28 LD(LDH)-468* AlkPhos-121* Amylase-64 TotBili-0.7 [**Known lastname **],[**Known firstname 3996**] [**Medical Record Number 55825**] F 84 [**2031-3-23**] Radiology Report CHEST (PA & LAT) Study Date of [**2115-8-13**] 2:23 PM [**Last Name (LF) **],[**First Name3 (LF) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 147**] FA6A [**2115-8-13**] 2:23 PM CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 55826**] Reason: evaluate for infiltrate and effusions [**Hospital 93**] MEDICAL CONDITION: 84 year old woman with afib s/p cabg and avr REASON FOR THIS EXAMINATION: evaluate for infiltrate and effusions Final Report HISTORY: 84-year-old female with AFib status post CABG and aortic valve replacement. Please evaluate for infiltrate/effusions. STUDY: Upright AP and lateral chest radiographs. COMPARISON: [**2115-8-11**]. FINDINGS: Midline sternotomy wires are intact and unchanged from previous study. The heart and mediastinal contours are consistent with a post-CABG patient. There are bilateral pleural effusions, left greater than the right. The lungs are clear with no focal or lobar consolidation. Pulmonary vasculature is somewhat vague suggestive of pulmonary vascular congestion. There is no pneumothorax. IMPRESSION: Bilateral pleural effusions, left greater than right; mild pulmonary vascular congestion; no pneumonia. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**] Approved: TUE [**2115-8-13**] 8:08 PM Brief Hospital Course: Ms. [**Name14 (STitle) 55827**] was admitted to the [**Hospital1 18**] on [**2115-8-6**] for further management of her shortness of breath. She was found to be in atrial fibrillation which was treated with amiodarone. She was diuresed for volume overload. An echo showed no evidence of tamponade. Amiodarone was stopped given that her atrial fibrillation was a chronic condition. She was anticoagulated with coumadin. Her primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] will assume coumadin management as an outpatient. The neurology service was consulted as she had a breif episode of word finding difficulty. A head CT was not suggestive of an acute hemorrhage or infarct. Ampicillin was started for a urinary tract infection. Free water was restricted for hyponatremia. The physical therapy servicew worked with her daily to increase her strength and mobility. Flagyl was started for a question of c. difficile infection. Ms. [**Known lastname 41323**] continued to make steady progress and was discharged to rehabilitation on [**2115-8-15**]. She will follow-up with Dr. [**Last Name (STitle) **], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Meclizine 25 mg twice a day prn dizziness Simvastatin 20 mg daily Aspirin 81 mg daily Ranitidine HCl 150 mg daily Carvedilol 6.25 mg twice a day Lasix Discharge Medications: 1. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Warfarin 1 mg Tablet Sig: Dose for goal INR of 2.0-2.5 Tablets PO DAILY (Daily): Coumadin is for atrial fibrillation. Likely dose will be 1mg alternating with 2mg daily. 7. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation Q2H (every 2 hours) as needed for wheezing. 11. Zocor 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 13. Ampicillin 500 mg Capsule Sig: One (1) Capsule PO once a day for 5 days. 14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks: Stop [**8-29**]. Discharge Disposition: Extended Care Facility: Life CAre of [**Location (un) 5165**] Discharge Diagnosis: Primary diagnosis: Atrial fibrillation s/p AVR/CABG Pleural effusion Secondary: Meniere's disease Leukemia in [**2097**] treated with Chemotherapy Myelodysplastic syndrome COPD Atrial Fibrillation Coronary artery disease s/p CABG Aortic Stenosis s/p AVR Pulmonary Hypertension Hemorrhoidectomy Tonsillectomy Appendectomy GERD Chronic Diarrhea Previous UTI's Degenerative Disc Disease CVA found by MRI in [**2099**] Anemia Bilateral cataracts Past Surgical History s/p appy s/p T & A s/p hemorroidectomy s/p Rt cataract s/p left leg vein ligation s/p Aortic Valve Replacement ([**Street Address(2) 6158**]. [**Hospital 923**] Medical Epic Biocor tissue valve), Coronary artery bypass grafting x 1 with reverse saphenous vein graft to the right coronary artery Discharge Condition: Good. Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Coumadin daily for atrial fibrillation with goal INR 2.0-2.5. Per Ms. [**Known lastname 41323**], Dr. [**Last Name (STitle) **] will assume coumadin management upon discharge from rehab. Please contact his office prior to discharge to arrange coumadin follow-up. [**Telephone/Fax (1) 55824**] 8) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2115-8-22**] 1:00PM Please follow-up with Dr. [**Last Name (STitle) 8098**] in [**12-25**] weeks. Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 55824**] Please contact Dr.[**Name2 (NI) 55828**] office on discharge from rehabilitation for coumadin follow-up. [**Telephone/Fax (1) 55824**] Call providers for appointments. Completed by:[**2115-8-15**] Name: [**Known lastname 10463**],[**Known firstname 1116**] Unit No: [**Numeric Identifier 10464**] Admission Date: [**2115-8-6**] Discharge Date: [**2115-8-15**] Date of Birth: [**2031-3-23**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 741**] Addendum: 84yoW s/p Aortic Valve Replacement([**Street Address(2) 743**]. [**Male First Name (un) 744**] Epic Biocor) Coronary artery bypass grafting x 1 with reverse saphenous vein graft to the right coronary artery on [**7-15**]. Discharged to rehabilitation on [**7-19**]. Readmitted to [**Hospital1 8**] on [**8-6**] For a few days prior to admission she felt weaker and shortness of breath progressively increased. She was seen in the ED at an outside hospital for shortness of breath. An Xray showed bilat pleural effusions, she was treated for rapid atrial fibrillation and heart failure. She was transferred to [**Hospital1 8**] for further care. While here she was treated for acute on chronic diastolic heart failure. She was discharged to rehabilitation on [**8-15**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: as above Past Medical History: AF s/p CABG/AVR Meniere's disease Leukemia in [**2097**] treated with Chemotherapy Myelodysplastic syndrome COPD Paroxsymal Atrial Fibrillation - She did not know of this diagnosis. Denied ever taking Coumadin. Aortic Stenosis with valve area 0.7 cm2 Pulmonary Hypertension Hemorrhoidectomy Tonsillectomy Appendectomy GERD Chronic Diarrhea Frequent Urination Previous UTI's Degenerative Disc Disease Social History: Ms. [**Name14 (STitle) 10465**] alone in [**Location (un) 4977**] MA. She recently had a visiting nurse [**First Name8 (NamePattern2) 4038**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Health Agency for three weeks after her hospitalization in [**Month (only) **]. Her contact person in her stepson [**Name (NI) **] [**Name (NI) **]; his home number is [**Telephone/Fax (1) 10466**]. The patient still drives. She has bilateral hearing aides. She occasionally uses a cane when she is out of her house and has to go some distances. Family History: Mother died at 103 of old age. Father died with stomach CA. Discharge Medications: 1. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Warfarin 1 mg Tablet Sig: Dose for goal INR of 2.0-2.5 Tablets PO DAILY (Daily): Coumadin is for atrial fibrillation. Likely dose will be 1mg alternating with 2mg daily. 7. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation Q2H (every 2 hours) as needed for wheezing. 11. Zocor 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 13. Ampicillin 500 mg Capsule Sig: One (1) Capsule PO once a day for 5 days. 14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks: Stop [**8-29**]. Discharge Disposition: Extended Care Facility: Life CAre of [**Location (un) 8807**] Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 4294**] at ([**Telephone/Fax (1) 2092**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Coumadin daily for atrial fibrillation with goal INR 2.0-2.5. Per Ms. [**Known lastname **], Dr. [**Last Name (STitle) **] will assume coumadin management upon discharge from rehab. Please contact his office prior to discharge to arrange coumadin follow-up. [**Telephone/Fax (1) 10467**] 8) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1477**] Date/Time:[**2115-8-22**] 1:00PM Please follow-up with Dr. [**Last Name (STitle) 10468**] in [**12-25**] weeks. Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 10467**] Please contact Dr.[**Name2 (NI) 10469**] office on discharge from rehabilitation for coumadin follow-up. [**Telephone/Fax (1) 10467**] Call providers for appointments. [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2115-9-3**]

[ "599.0", "041.01", "435.9", "V45.81", "386.00", "428.0", "276.1", "416.8", "496", "427.31", "285.9", "V42.2", "428.33", "008.45", "414.00", "V10.61" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14958, 15022

5927, 7131

12397, 12404

15043, 15052

2743, 4725

16142, 16722

13456, 13517

13540, 14935

4765, 4810

8836, 8836

7157, 7310

15076, 16119

1978, 2724

12338, 12359

4842, 5904

12432, 12442

8855, 9597

12464, 12866

12882, 13440

54,247

171,612

35512

Discharge summary

report

Admission Date: [**2121-6-10**] Discharge Date: [**2121-7-14**] Date of Birth: [**2048-1-25**] Sex: M Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:[**First Name3 (LF) 165**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Urgent Aortic valve replacement(21mm CE Magna Aortic Pericardial), Mitral valve replacement (27mm [**Company 1543**] Mosaic Mitral Porcine), coronary artery bypass grafting times three (LIMA to LAD, SVG to OM1, SVG to L PDA)[**2121-6-11**] Placement of Intraaorrtic Balloon tracheostomy [**2121-7-1**] percutaneous enterogastrostomy tube [**2121-7-1**] Bilateral closed thoracostomy tubes History of Present Illness: Mr. [**Known lastname 1124**] is a 73 year old gentleman with known coronary artery disease s/p PCI/stent to the LCX and presented to an outside hospital with dyspnea. He ruled in for a non-ST elevation MI. Therefore, he was transferred for pre-operative work-up for cardiac surgery. Past Medical History: Aortic stenosis mitral regurgitation coronary artery disease s/p coronary artery stent noninsulin dependent diabetes mellitus hypercholesterolemia h/o prostate cancer depression degenerative joint disease s/p bilateral knee replacements s/p transurethral resection of prostate s/p femeral rodding Social History: Patient lives with daughter, son and grandaughter. He is retired. He is a non smoker. Family History: non-contributory Physical Exam: Admission: Pulse: 82 SR Resp: 20 O2 sat: 96%-2LNP B/P Right: 140/83 Left: Height: 5'[**22**]" Weight: 129.3K General: NAD, lying in bed Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally []scattered rhonchi Heart: RRR [] Irregular [] Murmur 2/6 SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema none [x]Varicosities: None [x] Neuro: A&Ox3, MAE, follows commands. Grossly intact [x] Pulses: Femoral Right: cath site Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Pertinent Results: [**2121-7-13**] 01:18AM BLOOD WBC-9.5 RBC-2.81* Hgb-8.1* Hct-25.8* MCV-92 MCH-28.8 MCHC-31.4 RDW-16.5* Plt Ct-254 [**2121-7-12**] 02:08AM BLOOD WBC-8.4 RBC-2.87* Hgb-8.4* Hct-25.6* MCV-89 MCH-29.2 MCHC-32.7 RDW-17.7* Plt Ct-250 [**2121-7-13**] 01:18AM BLOOD Plt Ct-254 [**2121-7-13**] 01:18AM BLOOD PT-25.9* PTT-31.9 INR(PT)-2.5* [**2121-7-12**] 02:08AM BLOOD Plt Ct-250 [**2121-7-12**] 02:08AM BLOOD PT-21.6* PTT-30.6 INR(PT)-2.0* [**2121-7-11**] 03:44AM BLOOD Plt Ct-230 [**2121-7-11**] 03:44AM BLOOD PT-20.3* PTT-28.5 INR(PT)-1.9* [**2121-7-13**] 01:18AM BLOOD Glucose-143* UreaN-79* Creat-2.1* Na-144 K-3.6 Cl-103 HCO3-32 AnGap-13 [**2121-7-12**] 02:08AM BLOOD Glucose-145* UreaN-72* Creat-1.9* Na-143 K-3.5 Cl-103 HCO3-32 AnGap-12 [**2121-7-11**] 02:52PM BLOOD K-3.6 [**2121-7-11**] 03:44AM BLOOD Glucose-144* UreaN-68* Creat-1.8* Na-143 K-3.5 Cl-104 HCO3-30 AnGap-13 Brief Hospital Course: Mr. [**Known lastname 1124**] was admitted from an outside hospital to the cardiology service on [**2121-6-10**] for a pre-operative work-up and plavix wash-out. He was treated with antibiotics for a urinary tract infection. On [**6-11**] an intra-aortic balloon pump was placed in the cath lab for angina at rest, and then brought to the operative room where aortic valve replacement(21mm CE Magna Aortic Pericardial), mitral valve replacement (27mm [**Company 1543**] Mosaic Mitral Porcine), coronary artery bypass grafting times three (LIMA to LAD, SVG to OM1, SVG to L PDA) were performed. Please see operative note for details. He was transferred to the surgical intensive care unit with severe metabolic acidosis and hypoxia. He was atrial paced for an underlying junctional rhythm and occasional atrial fibrillation for which he was placed on amiodarone. He stabilized on multiple pressors and the acidosis resolved. He improved hemodynamically and pressors were slowly weaned and discontinued. On post-operative day three his balloon was removed. A dropping platelet leveldeveloped and a HIT panel was sent (which was positive) and he was placed on argatroban. He developed post-operative acute renal failure. Lightening of sedation on post-operative day four revealed arousability to voice and opening of eyes but not following commands. Tube feeds were begun on post-operative day five. The Hematology service was [**Company 4221**] and argatroban was started with coumadin overlap when his platelets recovered to 150,000. Coumadin was recommended for 3 months unless thrombosis was documented for which coumadin would be recommended for 6 months. Mr. [**Known lastname 1124**] was extubated on [**2121-6-20**] after aggressive diuresis, however, he developed a respiratory acidosis, became lethargic and confused and required reintubation. Tube feeds were resumed for nutritional support. He had a bump in his liver enzymes and his statin and tube feeds were held. An abdominal ultrasound was negative and his enzymes improved, allowing resumption of his tube feeds. Physical therapy was [**Date Range 4221**] to work with his range of motion and strength recovery. A large left pleural effusion was noted on chest x-ray and a chest tube was placed successfully draining 1600cc's for serousanguinous fluid. (Subsequently a right CT was placed for a 3liter effusion.) The wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] for early signs of a coccyx ulcer. Pressure relief measures were taken as well as skin barrier creams to protect skin from stool. Mr. [**Known lastname 1124**] was remained intolerant to several weaning attempts of his ventilator. The general surgery service was [**Known lastname 4221**] and on [**2121-7-1**] placed a tracheostomy and feeding tube at the bedside. He developed low grade fevers and a blood culture was significant for coagulase negative staph. Vancomycin and zosyn were started. A PICC line was placed in interventional radiology for access. Argatroban and Coumadin were restarted for atrial fibrillation and his HIT positive status. A right-sided chest tube was placed for a pleural effusion. He was seen in consultation by psychiatry after request by his daughter for depression. They recommended haldol as needed for anxiety and avoiding benzodiazepines and anticholinergics. With drainage of effusions and improved nutrritional status he began to tolerate brief periods of trach collar. Digoxin was added to his regimen for ventricular rate control and betablockers were added, amiodarone was continued. A digoxin level was 0.6 on [**7-12**]. His CXR on [**7-12**] demonstated well expanded lungs, without effusion. Vancomycin is to be continued through [**7-17**]. He was transferred to a rehabilitation facility for continued ventilator weaning and recovery. He remains neurologically intact with stable chemistries. Medications on Admission: Metformin 1000", Lisinopril 20', Atorvastatin 80', HCTZ25', Cartia XR 300', Ambien 10-hs, Paxil 40', Lorazepam 0.5 TID/prn, MVI, Glucosamine, Oxycodone 5 Q3hr/prn, Enoxaparin 30", colace 100", Senna 8.6", CaCarbonate 500-tid, Vit D Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 4. Docusate Sodium 50 mg/5 mL Liquid Sig: 10ml PO BID (2 times a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain for 4 weeks. 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Ranitidine HCl 15 mg/mL Syrup Sig: 10ml PO DAILY (Daily). 10. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for anxiety. 11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**4-21**] Puffs Inhalation Q4H (every 4 hours). 13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for off vent. 14. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 15. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for off vent. 17. Warfarin 1 mg Tablet Sig: as ordered Tablet PO DAILY (Daily): Approp dose will likely be 6mg daily INR target 2.5-3.0. 18. Paroxetine HCl 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 19. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gm Intravenous Q 24H (Every 24 Hours) for 4 days: through [**2121-7-17**]. 20. humalog Sig: see scale Injection AC & HS: AC & HS: 120-160:2units SQ 161-200:4 units SQ 201-240:6 units SQ 241-280:8 units SQ >280 [**Name8 (MD) 138**] MD. 21. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1) Intravenous PRN (as needed) as needed for K<4.4 and CR<2.0. 22. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML Injection PRN (as needed) as needed for line flush: Flush each lumen daily and prn. 23. Lantus 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous once a day. 24. picc line flushes Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen 25. lasix 20mg IV daily Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: aortic stenosis mitral regurgitation coronary artery disease s/p urgent mitral valve replacement,aortic valve replacement and coronary artery bypass acute renal failure postoperative respiratory failure s/p tracheostomy s/p percutaneous gastrostomy tube heparin induced thrombocytopenia noninsulin dependent diabetes mellitus hypercholesterolemia h/o prostate cancer depression degenerative joint disease s/p bilateral knee replacements s/p transurethral resection of prostate s/p femeral rodding Discharge Condition: deconditioned 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 Next INR check tomnorrow and daily until INR stable -goal 2-2.5 for afib. Take all medications as directed [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] (cardiac surgery) in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**First Name11 (Name Pattern1) 6330**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (PCP) in [**1-17**] weeks ([**Telephone/Fax (1) 18509**]) please call for appointment Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**] (cardiologist) in [**1-17**] weeks ([**Telephone/Fax (1) 5315**]) please call for appointment [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2121-7-15**]

[ "511.9", "276.2", "584.9", "401.9", "V10.46", "263.9", "998.0", "041.04", "289.84", "396.0", "E878.8", "427.31", "599.0", "458.29", "250.00", "E849.7", "V43.65", "V45.82", "518.81", "410.71", "416.8", "414.01" ]

icd9cm

[ [ [] ] ]

[ "31.1", "88.56", "37.61", "39.61", "36.12", "36.15", "37.23", "43.11", "35.23", "34.04", "96.04", "35.21", "97.44", "99.19", "96.72" ]

icd9pcs

[ [ [] ] ]

9789, 9861

3073, 6990

288, 679

10402, 10417

2176, 3050

10910, 11507

1433, 1451

7273, 9766

9882, 10381

7016, 7250

10441, 10887

1468, 2157

241, 250

707, 993

1015, 1313

1329, 1417

20,437

152,343

20822+20823

Discharge summary

report+report

Admission Date: [**2129-4-14**] Discharge Date: [**2129-4-26**] Date of Birth: [**2065-11-6**] Sex: M Service: [**Last Name (un) **] ADDENDUM: ADDITIONAL DISCHARGE MEDICATIONS: 1. Nifedipine 16 mg sustained release tablet q. day. 2. Clonidine .2 mg patch one patch to be worn for approximately five days and then patches can be discontinued. 3. Lasix 40 mg one p.o. q. day. 4. Theophylline 300 mg b.i.d. 5. Irbesartan 150 mg tablets, two tablets p.o. q. day. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Last Name (NamePattern1) 9178**] MEDQUIST36 D: [**2129-4-26**] 18:11:43 T: [**2129-4-26**] 18:18:27 Job#: [**Job Number 55488**] Admission Date: [**2129-4-14**] Discharge Date: [**2129-4-27**] Date of Birth: [**2065-11-6**] Sex: M Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: The patient is a 63 year old Creole speaking African American male with a history of hypertension, chronic renal insufficiency, who originally was admitted via the Emergency Department at [**Hospital6 **] on [**2129-4-13**], with epigastric pain originally thought to be secondary to myocardial infarction. He was immediately started on Heparin and subsequently had a hematocrit drop from 33.0 to 12.0. CT scan performed at that facility showed a large liver mass and hematoma adjacent to that. This was presumed to be the cause of the bleed. He was then transferred to [**Hospital1 69**] for further evaluation. PAST MEDICAL HISTORY: Hypertension. Asthma. Noninsulin dependent diabetes mellitus. Chronic renal insufficiency. Sleep apnea. Diverticulosis. Avascular necrosis. PAST SURGICAL HISTORY: The patient is status post hip operation of unknown type. MEDICATIONS ON ADMISSION: 1. Theophylline unknown dose. 2. Lasix unknown dose. 3. Nifedipine unknown dose. 4. Clonidine patch unknown dose. 5. Flovent unknown dose. 6. Albuterol unknown dose. 7. Protonix unknown disease. 8. Glyburide unknown dose. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies any tobacco or alcohol use. He lives with his wife and works as a laborer at one of the local care groups. PHYSICAL EXAMINATION: On presentation, temperature maximum was 98.6, pulse 110, blood pressure 139/74, respiratory rate 18, oxygen saturation 98 percent on two liters. In general, the patient is described as a moderately obese African American male in no acute distress. He is awake, alert and oriented times three. Head examination - The pupils are equal, round and reactive to light and accommodation bilaterally. Sclera nonicteric. Cranial nerves II through XII are grossly intact. There is no evidence of any lymphadenopathy in the anterior posterior lymph node chains. [**Last Name (un) 55489**] node is likewise noted to be noninflamed and nontender. Lungs are clear to auscultation bilaterally. Cardiac examination shows regular rate and rhythm. The abdomen is noted to be moderately distended with some diffuse tenderness. Extremities are warm and well perfused with no evidence of any edema or swelling. LABORATORY DATA: On presentation to the [**Hospital1 346**] are sodium 141, potassium 5.3, chloride 108, CO2 20, blood urea nitrogen 28, creatinine 3.5, glucose 160. Hematocrit at outside hospital was 12.6 and hematocrit at [**Hospital1 69**] was 32.2. Prothrombin time is 13.1 and partial thromboplastin time 26.0 with INR of 1.0. RADIOLOGY: CT scan performed at [**Hospital3 **] shows a large abdominal hemorrhage and a perihepatic hematoma. HOSPITAL COURSE: On [**2129-4-14**], the patient was taken to the operating room and underwent exploratory laparotomy, evacuation of abdominal hematoma, liver biopsy and ligation of common hepatic artery and replaced left hepatic artery. The procedure was said to have been well tolerated although fluid requirements were noted to be six units of packed red blood cells, two units of platelets and two units of fresh frozen plasma. Blood loss was estimated at 6000cc. The patient was transferred to the Intensive Care Unit still intubated but stable. Soon after surgery, a renal consultation was requested and this confirmed chronic renal insufficiency with hemodialysis not considered to be necessary at that time. Renal ultrasound performed showed no obstructive lesions or abnormalities in the kidneys During postoperative day number two, blood product requirements remained extremely large including nine units of packed red blood cells, multiple units of fresh frozen plasma and platelets. On postoperative day number two, Swan-Ganz catheter was placed. Soon after this, controlling hypertension became the main challenge with this patient delaying his extubation. Ultimately, hypertension would necessitate Nitroglycerin, Lopressor, Hydralazine, Clonidine and an ace inhibitor. On postoperative day number two, the patient was started on TPN. On postoperative day number three through six, unit care was further complicated by the development of a pneumonia confirmed by x-ray. Cultures of the sputum showed pansensitive Klebsiella and the patient was started on Levofloxacin originally 500 mg p.o. once daily and ultimately titrated down to 250 mg p.o. once daily given renal insufficiency. By postoperative day number eight, blood pressure was finally controlled with a Nipride drip and the patient was successfully extubated. On postoperative day number nine, Dicarbine had been weaned off and the patient was transferred out of the Intensive Care Unit to the floor. On the floor, the patient's TPN was gradually weaned off. His diet was then advanced from sips to clear and on to a regular diet. On postoperative day number ten, examination of the patient's surgical wound showed a small area of drainage at the apex of the wound. Four surgical staples were removed and the area was packed with a dry gauze sponge. No large amounts of purulent material or wound breakdown were ever found. On postoperative day number ten and eleven, the patient was evaluated by physical therapy team. The patient's conditioning was good up to the time and it was felt that the patient was a good candidate for acute rehabilitation following discharge from the [**Hospital1 188**]. On postoperative day number eleven after evaluation by Dr. [**First Name (STitle) **] and the rest of the surgical team, it was deemed that the patient was fit for discharge to rehabilitation. While final pathology was not available at the time of this dictation, preliminary pathology and operative findings were consistent with unresectable primary hepatocellular carcinoma. These findings and the prognosis were shared with the patient and his family. DISCHARGE DIAGNOSES: Hepatocellular carcinoma unresectable. Status post laparotomy and liver resection. Hypertension. Asthma. Noninsulin dependent diabetes mellitus. Chronic renal insufficiency. Sleep apnea. Diverticulosis. Avascular necrosis. FOLLOW UP: The patient should follow-up with Dr. [**First Name (STitle) **] in two to three weeks to have his staples removed and wound check. The transplant coordinating nurse will contact him at rehabilitation to set this up. Physical therapy as directed. The abdominal wound should be repacked twice a day with dry gauze. MEDICATIONS ON DISCHARGE: 1. Albuterol 90 mcg aerosol one to two puffs q6hours. 2. Salmeterol Xinafoate 50 mcg per dose, one q12hours. 3. Fluticasone 110 mcg two puffs twice a day. 4. Heparin 5000 units q8hours. 5. Albuterol 90 mcg one to two puffs q4-6hours p.r.n. 6. Ipratropium Bromide 18 mcg q6hours p.r.n. shortness of breath. 7. Lansoprazole 30 mg p.o. once daily. 8. Glipizide 5 mg p.o. once daily. 9. Verapamil 240 mg slow release p.o. once daily. 10. Hydralazine 75 mg p.o. q6hours. 11. Colace 100 mg p.o. three times a day. 12. Levofloxacin 250 mg one p.o. q24hours for ten additional days after discharge. 13. Percocet one to two tablets p.o. q4-6hours p.r.n. pain. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Last Name (NamePattern1) 9178**] MEDQUIST36 D: [**2129-4-26**] 18:08:45 T: [**2129-4-26**] 19:23:28 Job#: [**Job Number 55490**]

[ "287.4", "584.5", "459.0", "573.8", "155.0", "276.0", "593.9", "401.9", "482.0" ]

icd9cm

[ [ [] ] ]

[ "50.29", "38.93", "99.15", "99.04", "38.86", "89.64", "50.12" ]

icd9pcs

[ [ [] ] ]

6791, 7023

199, 911

7379, 8329

1836, 2098

3634, 6769

1751, 1810

7035, 7353

2266, 3616

940, 1557

1580, 1727

2115, 2243

13,718

167,292

20143

Discharge summary

report

Admission Date: [**2139-1-14**] Discharge Date: [**2139-1-21**] Date of Birth: [**2078-12-31**] Sex: F Service: NEUROSURGERY HISTORY OF THE PRESENT ILLNESS: The patient is a 60-year-old woman status post a colostomy for perforated colon cancer on [**2138-11-24**] at [**Hospital 8**] Hospital. The patient had an uneventful hospital course. She was readmitted on [**2139-1-5**] for wound dehiscence. A workup for fistula at that time was negative, although she had developed progressively worse ataxia and mental status changes. She was transferred here from [**Hospital 8**] Hospital for a workup. MRI before transfer showed right cerebellar hemisphere metastasis and she was transferred here for further management. She was awake and alert, not oriented to place or date. Speech was fluent. Naming was intact. Following complex commands. The pupils were equal, round, and reactive to light. EOMs were full. She had nystagmus in left lateral gaze. No diplopia, Gaze was conjugate. Face was symmetric. Palate was symmetric. Positive gag. No drift. Grasp and IPs were full strength. Reflexes were 2+. Toes were downgoing bilaterally. HOSPITAL COURSE: She was taken to the OR for craniotomy for excision of this cerebellar metastatic lesion and was monitored in the Surgical ICU postoperatively. Her vital signs were stable postoperatively. She was transferred to the regular floor on postoperative day number one. Postoperatively, she was alert and oriented. EOMs were full. She had no nystagmus. She had no drift. Face was symmetric. No diplopia. Dysmetria on the right. Left-sided was intact. IPs were full bilaterally. The dressing had minimal drainage. She had a postoperative MRI scan which showed good excision of tumor. She was out of bed, transferred to the floor. She had a physical therapy consult. She was found to be safe for discharge to home with two to three days of treatment. Occupational Therapy felt the same. She was seen by the [**Hospital 9341**] nurse [**First Name (Titles) **] [**Last Name (Titles) 9341**] care and training. She and her husband were trained how to change the colostomy bag. She was discharged to home in stable condition with staples to be removed on postoperative day number 14 with follow-up in the Brain [**Hospital 341**] Clinic on [**2139-2-2**] at 4:00 p.m. The patient is to follow-up with Dr. [**Last Name (STitle) 1327**] on [**2139-2-3**] at 3:00 p.m. CONDITION ON DISCHARGE: Stable at the time of discharge. DISCHARGE MEDICATIONS: 1. Decadron tapering down to 2 mg p.o. b.i.d. over ten days. 2. Metoprolol 50 mg p.o. b.i.d. 3. Famotidine 20 mg p.o. b.i.d. 4. Percocet one to two tablets p.o. q. four hours p.r.n. 5. Colace 100 mg p.o. b.i.d. 6. The patient was given prescriptions also for all of her [**Year (4 digits) 9341**] supplies. FOLLOW-UP: She will follow-up with Dr. [**Last Name (STitle) 54156**] at [**Hospital 8**] Hospital for her postsurgical check for her [**Hospital 9341**] next week. Her condition was stable at the time of discharge. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2139-1-21**] 11:44 T: [**2139-1-24**] 15:43 JOB#: [**Job Number 54157**]

[ "197.0", "401.9", "331.4", "V10.05", "V44.3", "198.3" ]

icd9cm

[ [ [] ] ]

[ "01.59", "38.91" ]

icd9pcs

[ [ [] ] ]

2542, 3337

1189, 2460

2485, 2519

32,436

156,815

45160+58791

Discharge summary

report+addendum

Admission Date: [**2130-7-15**] Discharge Date: [**2130-8-4**] Date of Birth: [**2060-11-1**] Sex: M Service: MEDICINE Allergies: Flomax / Shellfish Derived / Fish Product Derivatives / Zolpidem / Ativan Attending:[**First Name3 (LF) 3918**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: [**First Name3 (LF) 13241**] History of Present Illness: Mr. [**Known lastname 69629**] is a 69 y.o. Spanish-speaking male with multiple myeloma, ESRD on HD, history of right PICA CVA, HTN who presents with worsened mental status per his family members. Apparently he was doing fine 1 day prior to admission. Of note he received chemotherapy (cytoxan) on [**2130-7-3**] and his blood counts are decreasing. He is overall a poor historian despite use of a Spanish interpreter on the phone. . He did make it to [**Date Range 13241**] today on his own, but was slightly confused there and sent home from HD by taxi. His son then brought him to [**Name (NI) **] because he "wasn't acting right." Initial VS in the ED: T 97.3, BP 173/76, HR 104, 87%RA, up to 100% 3L NC. Emperically given vanco/ceftriaxone for possible infection. He does not complain of respiratory symptoms (cough, SOB). His temperature subsequently went up to 100.6 in the ED. CT head negative for acute process. CXR negative. CTA chest pursued given his h/o PE (although INR 6.0), and revealed RUL consolidation consistent with pneumonia. Azithromycin also given to cover atypical organisms. Blood cultures drawn prior to antibiotics. In addition his serum calcium was 12.2 (has h/o hypercalcemia of malignancy) and he was given 500cc bolus of normal saline only given his h/o [**Name (NI) **] failure on HD. Troponin elevated at his baseline given his ESRD. . While in ED, his SBP rose into the 200s when he was aggitated waiting for CT scan and other tests. This was not treated given concern for possibility he may decline clinically and become septic. The SBP come down to 180 spontaneously after the studies. . ROS: Denies chest pain, SOB, cough, chills, abdominal pain, N/V. Does admit to "total body pain" which on further characterization seems to be muscle pain, predominately in the legs and head. He admits to chronic leg pain at baseline. Past Medical History: IgA Multiple myeloma s/p 11 cycles velcade/dex -- received first dose cytoxan on [**2130-7-3**] for disease progression on velcade ESRD [**2-27**] to MM - Tu/Th/Sa R PICA CVA [**5-27**] - ataxic @ baseline PAF PE [**9-2**] Mild-mod AR Mod MR [**Name13 (STitle) **] TR C. diff Strep pneumo PNA PCP PNA HTN Hyperlipidemia Diverticulosis H. pylori gastritis Anemia of B12/Fe-deficiencies, CKD Anxiety and depression Social History: Formerly worked at [**Hospital1 **] and [**Hospital6 **]. Married, 3 children. Son is HCP. Wife has [**Name2 (NI) 499**] CA. 20 pack-year smoking hx. Drinks ETOH socially. Family History: Mother and father died of lung CA. Physical Exam: VS: T 99.4, BP 194/97, HR 106, RR 18, 95%3L NECK: supple LUNGS: Scattered rhonchi and wheezes, L>R HEART: tachy, regular, [**3-31**] late systolic murmur, best at apex ABD: soft, ND/NT EXT: LE edema, R>L (chronic per patient) NEURO: answers questions appropriately, no focal deficit Pertinent Results: ADMISSION LABS: [**2130-7-15**] 07:02PM WBC-3.0* RBC-2.58* HGB-8.8* HCT-26.8* MCV-104* MCH-33.9* MCHC-32.6 RDW-17.7* [**2130-7-15**] 07:02PM NEUTS-82.9* LYMPHS-10.8* MONOS-3.1 EOS-2.8 BASOS-0.3 [**2130-7-15**] 07:02PM PLT COUNT-141* [**2130-7-15**] 07:02PM PT-53.7* PTT-60.3* INR(PT)-6.0* [**2130-7-15**] 07:02PM GLUCOSE-98 UREA N-12 CREAT-4.1*# SODIUM-137 POTASSIUM-4.1 CHLORIDE-94* TOTAL CO2-28 ANION GAP-19 [**2130-7-15**] 07:02PM CALCIUM-12.2* PHOSPHATE-4.1 MAGNESIUM-2.0 . Portable Chest x-ray: no acute process . CTA chest [**2130-7-15**]: 1. Right upper lobe consolidation, likely infectious. 2. No PE or acute aortic process. 3. Emphysema. 4. Interval resolution of bilateral pleural effusions and left lower lobe pneumonia. . CT head (non-contrast) [**2130-7-15**]: IMPRESSION: No acute intracranial process. . ECG: Sinus tachycardia @ 104. 1mm downsloping ST depressions V4-V6 (new) Brief Hospital Course: Mr. [**Known lastname 69629**] is a 69 y.o. man with multiple myeloma and ESRD on [**Known lastname 2286**] who presented with altered mental status and was found to have a right upper lobe pneumonia and hypercalcemia. . # RUL pneumonia. The patient was found to have a right upper lobe pneumonia on CT scan. He was treated with vancomycin, zosyn, and azithromycin for hospital acquired PNA. He was hypoxic on admission. His O2 requirement worsened in the setting of volume overload. Pt had rigors and low grade temps on HD2. Blood and sputum cultures were negative. A bronchoscopy was performed on [**7-24**] and the BAL was negative. He was discharged breathing comfortably on room air. . # hypercalcemia/ altered mental status: The patient's altered mental status likely due to a combination of his infection (pneumonia) and metabolic derangements (hypercalcemia). The patient's hypercalcemia was thought to be secondary to his multiple myeloma. He has been on weekly pamidronate. He was treated with pamidronate, calcitionin, decadron, and [**Month/Year (2) 2286**] to decrease his calcium level. . # right back pain: The patient developed excruciating right back pain during this admission. Multiple imaging modalities were negative for any pathological fractures, but there was a question of left sided ilio-psoas bursitis which did not correlate with his clinical presentation. His pain was managed with Dilaudid throughout his admission. He was transitioned to oral Dilaudid prior to discharge. . # End-stage [**Month/Year (2) 2793**] Disease: The patient is on HD with ESRD secondary to his multiple myeloma. The [**Month/Year (2) **] team was consulted and the patient was treated with HD during this hospitalization. The patient is basically anuric so his hypercalcemia and volume status was dependent on HD. The patient had to undergo HD daily in order to manage his hypercalcemia. . # Pancytopenia: The patient was supported with blood transfusions during this hospitalization. He was transfused to keep his hematocrit greater than 25. He also receives epogen at [**Month/Year (2) 2286**]. . # Atrial Fibrillation: The patient has been anticoagulated for paroxsymal atrial fibrillation. He was in sinus rhythm on admission. The patient was supratherapeutic on admission. His INR was 6.0. He was reversed with Vitamin K and anticoagulation was held as patient was thought to be at high risk of bleeding given his likely uremic platelets. Of note, the patient had a history of PE in [**9-2**], but completed a 6 month treatment course with warfarin and repeat CTA was negative for residual clot. It was decided that the risks of anticoagulation outweigh the benefits at this point and it was discontinued. . # Hypertension: The patient's antihypertensive medications were initially held due concern that he might be developing sepsis physiology; however, he developed HTN with SBP 200. His metoprolol was restarted and he was treated with hydralazine IV PRN. . # ST depressions: The patient was noted to have ST depressions on EKG most likely secondary to demand ischemia. He did not have any symptoms of chest pain or pressure. His troponin was elevated in the setting of [**Date Range **] failure and missed [**Date Range 2286**], but his CK was flat. . # Multiple myeloma: The patient has end stage multiple myeloma. His was treated with Cytoxan on [**2130-7-3**] in an effort to help control his disease and hypercalcemia. He was started on Rituxan as an inpatient and will follow-up with Dr. [**Last Name (STitle) 410**] (oncology) for further treatment. Orthopedic oncology was consulted and it was determined that no intervention for his back pain would be indicated at this time. Medications on Admission: Albuterol Inhaler - 1-2 puffs Q4-6H prn Allopurinol - 100 mg every other day B COMPLEX-VITAMIN C-FOLIC ACID [[**Last Name (STitle) **] CAPS] - 1 mg Capsule Daily Calcitonin 200 unit/dose Aerosol, Spray - Epogen - 10,000 unit/mL daily Fexofenadine 60 mg Daily Folic Acid - 1 mg Daily Lactulose - 10 gram/15 mL Solution - one TSP PO daily prn constipation Metoprolol 100mg TID Midodrine 2.5 mg PO 20 minutes prior to the end of [**Last Name (STitle) 2286**] Pantoprazole - 40 mg PO daily Sevelamer [RENAGEL] - 1600 mg TID with meals Trazodone 50mg PO QHS Bactrim 400mg-80mg, 1 tab daily Warfarin 4mg daily Acetaminophen prn B12 1000mcg po daily Benadryl 25mg IV during HD Ferrous Sulfate 325 mg (65 mg Iron) PO daily Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection Injection ASDIR (AS DIRECTED): Given at HD. 3. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*15 Tablet(s)* Refills:*2* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Capsule(s) 12. Renagel 800 mg Tablet Sig: Two (2) Tablet PO three times a day. Disp:*180 Tablet(s)* Refills:*2* 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 14. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-27**] puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 * Refills:*0* 15. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Tablet(s) Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: Right upper lobe and aspiration pneumonia, hypercalcemia of malignancy Secondary diagnoses: - ESRD on [**Location (un) 13241**] Tuesday/Thursday/Saturday - depression/anxiety - multiple myeloma - history of pulmonary embolus - hyperlipidemia - diverticulosis - H. pylori gastritis - paroxysmal atrial fibrillation Discharge Condition: stable, afebrile, no oxygen requirement, ambulatory Discharge Instructions: You were admitted to [**Hospital1 **] Hospital with confusion, increased calcium levels, and a right upper lobe pneumonia. Your confusion was caused by the combination of your pneumonia and increased calcium levels. Your high calcium was treated with [**Hospital1 2286**], pamidronate, calcitonin, and dexamethasone. You also completed a course of antibiotics for your pneumonia. Please follow-up with your outpatient [**Hospital1 4314**] with Dr. [**Last Name (STitle) 410**] and for [**Last Name (STitle) 2286**]. Please seek medical care if you experience any concerning symptoms including [**Last Name (STitle) 5162**], chills, night sweats, pain not responsive to medication, difficulty breathing, or chest pain. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Please follow-up with all of your outpatient [**Name8 (MD) 4314**] listed below: 1. Provider: [**Name10 (NameIs) **],[**Name10 (NameIs) **] SCHEDULE [**Name10 (NameIs) **] UNIT Date/Time:[**2130-8-5**] 12:00 2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2130-8-7**] 11:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**] Date/Time:[**2130-8-7**] 11:30 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**] Name: [**Known lastname 15333**],[**Known firstname **] Unit No: [**Numeric Identifier 15334**] Admission Date: [**2130-7-15**] Discharge Date: [**2130-8-4**] Date of Birth: [**2060-11-1**] Sex: M Service: MEDICINE Allergies: Flomax / Shellfish Derived / Fish Product Derivatives / Zolpidem / Ativan Attending:[**First Name3 (LF) 7221**] Addendum: On [**2130-7-25**] the patient had an increased oxygen requirement and a CTA to rule out PE was performed. A small subsegmental acute PE was found in the left lower lobe and the patient was put on a heparin drip for about 4 days to maintain a PTT between 60-80. Over this time period, his oxygen requirement was slowly weaned to room air. Given his history of GI bleed, pancytopenia, and intent on continuing chemotherapy for his multiple myeloma, it was felt that the risks of anticoagulation outweighed the benefits and all anticoagulation was discontinued once the patient was satting well on room air. Discharge Disposition: Extended Care Facility: [**Location (un) 176**] of [**Location (un) 177**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 7222**] Completed by:[**2130-8-24**]

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icd9cm

[ [ [] ] ]

[ "39.95", "33.24" ]

icd9pcs

[ [ [] ] ]

13535, 13733

4223, 4947

355, 385

10927, 10981

3292, 3292

11871, 13512

2936, 2972

8721, 10468

10589, 10661

7982, 8698

11005, 11848

2987, 3273

10682, 10906

294, 317

413, 2293

3308, 4200

4962, 7956

2315, 2730

2746, 2920

81,342

167,453

5260

Discharge summary

report

Admission Date: [**2121-7-8**] Discharge Date: [**2121-7-11**] Date of Birth: [**2062-12-17**] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Pollen Extracts Attending:[**First Name3 (LF) 905**] Chief Complaint: fever Major Surgical or Invasive Procedure: History of Present Illness: This is a 58 year old female with history of SLE, left sialolithiasis s/p ENT removal of stone who presents today with high spiking fevers of 1 day's duration up to 104. She states that she went to her ENT Dr.[**Name (NI) 18353**] office yesterday for increased swelling and pain of her left submandibular region. During that office visit Dr. [**First Name (STitle) **] massaged a 2mm sialolith out of her [**Location (un) 21511**] duct and expressed a small amount of pinkish tinged pus. She has a history of submandibular MRSA cellulitis, and as such was started on Bactrin DS. . However, once she returned home, she developed frank rigors and fever up to 104. She also had N/V x4, after which she developed right sided chest and back pain which she attributes to the retching. She has had this pain in the past. She also states however that she has had a headache over this same period with some neck pain associated. The pain is worse with neck flexion and she had some relief with tylenol. With neck flexion she also has some lumbar pain. She also describes pain behind her eyes, although she denies photophobia or sound sensitivity. She states that while she has had fevers in the past with SLE flares along with generalized body pain and weakness, she has never had a headache in the past. Of note, she has been on immunosuppresive drugs in the recent past, with MMF being stopped only on [**6-23**]. She was also on prednisone as recently as [**5-27**]. . On day of admission, she continued to complain of left mandibular swelling and tenderness, although her main complaints are primarily the fever as well as the headache. Of note, she states that she had been feeling well since her submandibular gland resection in early [**Month (only) 205**], but as recently as last week had diaphoresis and the feeling of generalized malaise. . In the ED, initial vs were: T 102.8 P 87 BP 139/73 R 20 O2 sat. 99% on RA. Patient was given tylenol, vancomycin, unasyn and 3L of NS . On the floor, patient had neck stiffness and lower bck pain. Givent concern for [**Last Name (LF) 21514**], [**First Name3 (LF) **] LP was planned. INR was 2.6 from coumadin and she was giving FFP, with a goal INR < 1.5. She got 5 units, while procedure service was on call. On the fifth unit, she had a desaturation to 82 % on RA. She got a neb treatment for diffuse wheezing. She was briefly on a non-rebreather, but quickly improved and was [**Doctor Last Name 21515**] 98% on room air on evaluation. . (+) Per HPI. No dizziness, no SOB, no abdominal pain, diarrhea or constipation. Past Medical History: -Systemic lupus erythematosus with antiphospholipid syndrome on chronic anticoagulation-status post pulmonary embolism, renal vein thrombosis. IVC filter placed 10 years ago. -Stage V membranous glomerulonephritis Nephrotic syndrome, now stage 3. -Depression -Obstructive sleep apnea -hypertension -hyperlipidemia Social History: The patient does not smoke any cigarettes, but she does drink two to three alcoholic beverages per week. She is married and works as a real estate [**Doctor Last Name 360**] and has one child who is healthy. Family History: NC Is notable for diabetes mellitus, and she does have one cousin who did have lupus and was deceased of complications with therapy. Physical Exam: Vitals: per medivision General: Alert, oriented x 3, in mild distress HEENT: Sclera anicteric, MMM, PERRL, EOMI. Tenderness to palpation along left mandible Neck: supple, JVP not elevated, no LAD. Mild lower back pain with neck flexion. Otherwise normal range of motion. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mildly tender in epigastric region, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. No splinter hemorrhages. Right knee pain, right knee is warm Pertinent Results: Micro: [**2121-5-14**] 9:46 am SWAB Source: submandibular drainage. GRAM STAIN (Final [**2121-5-14**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2121-5-17**]): [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. RARE GROWTH. [**2121-5-12**] 9:10 pm SWAB LEFT SUBMANDIBULAR GLAND ABSCESS. GRAM STAIN (Final [**2121-5-13**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final [**2121-5-17**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. MODERATE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES) CONSISTENT WITH OROPHARYNGEAL FLORA. ANAEROBIC CULTURE (Final [**2121-5-17**]): NO ANAEROBES ISOLATED. . Blood cultures pending . Images: Portable chest, (prelim read, [**2121-7-8**]): overall increased opacity of left hemithorax likely technical as it extends into soft tissues. no focal consolidation, no evidence of pulmonary edema. cannot evaluate for PE on CXR. cardiac silhouette likely unchanged on this portable study. . CT NECK W/CONTRAST ([**2121-7-8**]) 1. Study is slightly limited by extensive streak artifact, but previous area of inflammation in the left submandibular gland has signfiicantly decreased and there is no discrete fluid collection identified. The previously seen sialolith is not identified on this study but may be obscured by artifacts. assessment limited due to artifacts. 2. Borderline lymph nodes, particularly in the submandibular region. . EKG: NSR @ 80s, S1Q3T3, but old; TWI V1-2 . At admission: [**2121-7-8**] 12:10AM BLOOD WBC-6.1# RBC-3.98* Hgb-10.8* Hct-34.0* MCV-85 MCH-27.2 MCHC-31.9 RDW-14.2 Plt Ct-221# [**2121-7-8**] 12:10AM BLOOD Neuts-83.0* Lymphs-13.2* Monos-2.1 Eos-1.5 Baso-0.2 [**2121-7-8**] 12:10AM BLOOD PT-26.8* PTT-28.8 INR(PT)-2.6* INR decreased to 1.9 during admission [**2121-7-8**] 12:10AM BLOOD ESR-31* [**2121-7-8**] 12:10AM BLOOD Glucose-107* UreaN-24* Creat-1.3* Na-140 K-4.5 Cl-107 HCO3-22 AnGap-16 Cr decreased to 1.1 during admission [**2121-7-8**] 12:10AM BLOOD ALT-18 AST-21 LD(LDH)-236 AlkPhos-101 TotBili-0.2 [**2121-7-9**] 04:35AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.6 [**2121-7-8**] 12:10AM BLOOD C3-115 C4-20 [**2121-7-8**] 07:24PM BLOOD Type-ART pO2-83* pCO2-35 pH-7.48* calTCO2-27 Base XS-2 [**2121-7-8**] 12:28AM BLOOD Lactate-1.2 K-4.2 Lactate decreased to 0.8 during admission Brief Hospital Course: 58 F with h/o SLE and saliolithiasis who presented to the ED with fevers spiking to 104 and vomiting x2 after expression of saliolith and pus from left [**Location (un) 21511**] duct. . # Meningismus: The patient upon transfer to the floor endorsed neck stiffness, headache and lumbar pain on neck flexion. ENT was consulted and direct spread from a submandibular abscess was deemed unlikely. She was started empirically on ceftriaxone, flagyl and vancomycin, and the decision to LP was made. However, the patient was anticoagulated and FFP was given to transiently decrease the INR to make the procedure safe. The patient's INR did not drop sufficiently, and after 5 units of FFP became transiently hypoxic. She was transferred to the MICU, where she was stabilized and given vitamin K. ID was consulted, and after further discussion it was decided that LP would still yield helpful information even if the cultures would be negative, as a fully negative LP would allow stoppage of the antibiotics. LP was performed which showed slightly elevated WBCs. Therefore the patient was discharged with a PICC and home infusion of ceftriaxone and vancomycin . # Transient hypoxia: The patient developed transient hypoxia after administration of FFP. Related either to changes in VQ matching with blood product administration or to transient opening of a PFO, given the very short duration of hypoxemia. Both cardiogenic and noncardiogenic pulmonary edema related to FFP (i.e. TACO or TRALI) generally have longer durations before resolution. Regardless, quickly resolved. . # Fever - Likely source of fever is bacteremia following manipulation of abscess. Meningitis is a secondary possiblity. See above meningeal signs. . # SLE - The patient states that some of her symptoms are typical to her SLE flares. She may be having an SLE flare that is precipitated by an infection currently. These quickly resolved, and it was rheumatology's opinion that this was not an SLE flare. . # hypertension - BP meds held given possible infection. She was restarted on these prior to discharge. . # anticoagulation - the patient was discharged on coumadin and a lovenox bridge. Medications on Admission: fluoxetine 40qd hydroxychloroquine 200 [**Hospital1 **] lisinopril 40 qd mom[**Name (NI) 6474**] 110 2 puffs qd omeprazole 20mg qd coumadin 6mg qd tylenol prn pain, fever Discharge Medications: 1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 6 days: From [**2121-7-12**] to [**2121-7-17**]. Disp:*12 12* Refills:*0* 2. Ceftriaxone 2 gram Piggyback Sig: One (1) Intravenous twice a day for 6 days: From [**2121-7-12**] to [**2121-7-17**]. Disp:*12 doses* Refills:*0* 3. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous twice a day for 6 days: You need to take this medication till your warfarin's blood thinning level (INR) is appropriate. Your primary care doctor will let you know when to stop. Disp:*12 doses* Refills:*0* 4. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 5. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet 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. Coumadin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day for 2 days: From [**2121-7-11**] to [**2121-7-12**]. Disp:*6 Tablet(s)* Refills:*0* 8. Coumadin 6 mg Tablet Sig: One (1) Tablet PO once a day: From [**2121-7-13**] onwards. Your primary care doctor (or covering doctor) will adjust the dose as needed. 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Mom[**Name (NI) 6474**] 110 mcg (30 doses) Aerosol Powdr Breath Activated Sig: Two (2) puffs Inhalation once a day as needed for shortness of breath or wheezing. 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 unit* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Therapies Discharge Diagnosis: Primary: Fever, most likely due to recurrent sublingual gland infection or meningitis . Secondary: Systemic lupus erythematosus Membranous glomerulonephritis Antiphospholipid syndrome Discharge Condition: Afebrile and hemodynamically stable. Discharge Instructions: You were admitted to [**Hospital1 69**] with fevers. Your fevers are most likely due to transient worsening of your infection in your cheek or meningitis (infection of the spinal fluid). You are being treated with a 10 day course of antibiotics. Your symptoms improved prior to discharge. We offered a acute nursing care facility for you in order to get your antibiotics, however you wanted to go home. You will finish your antibiotics at home by taking them for another six days. . Please take the medications as written. You will need to take Vancomycin 1 gram every 12 hours and Ceftriaxone 2 gram every 12 hours for six more days for a total ten day course. You will need to take Warfarin (Coumadin) 7.5 mg for the next two days and then take 6 mg daily. Your primary care doctor's office will check the INR as below and make adjustments. You will need to take Enoxaparin (Lovenox) shots till your warfarin's blood thinning levels are appropriate. Your primary care doctor will let you know when to stop this medication. You are started on Albuterol Inhaler as needed for wheezing or shortness of breath. . Please take all medications as directed. Thechanges to your medications are as above. . Please keep all of the follow up appointments. . If you develop fevers, chills, neck pain, weakness of any other concerning symptoms, please call your primary care doctor or go to the nearest Emergency Department. Followup Instructions: You have an appointment at your primary care doctor's office with Dr.[**Last Name (STitle) **] (covering for Dr.[**Last Name (STitle) 3306**]) [**Telephone/Fax (1) 21516**] on Monday [**7-14**], at 3:45 PM. Please discuss your stay here with her. Please ask her to check INR during this visit. Your Vancomycin level will also need to be checked during this visit. I have updated your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3306**] regarding your care here and she will let Dr.[**Last Name (STitle) **] know about the upcoming visit. Please ask for the final culture results. Your PICC (IV) line needs to be removed once you finish your antibiotics. Please discuss this with your primary care doctor. . Rheumatology follow up: Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 3538**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2121-8-7**] 11:00 . Other previously scheduled appointments are: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2121-7-31**] 4:00 Provider: [**First Name8 (NamePattern2) 1141**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 4775**] Date/Time:[**2121-8-4**] 3:00 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2121-7-17**]

[ "581.9", "710.0", "999.89", "401.9", "799.02", "327.23", "V12.51", "795.79", "780.60", "787.01", "V45.89", "311", "583.1", "527.2", "272.0", "322.9", "493.90", "E879.8", "530.81" ]

icd9cm

[ [ [] ] ]

[ "03.31", "99.07", "38.93" ]

icd9pcs

[ [ [] ] ]

11263, 11332

7269, 9441

303, 303

11560, 11599

4333, 7246

13070, 13840

3483, 3617

9663, 11240

11353, 11539

9467, 9639

11623, 13047

3632, 4314

13851, 14477

256, 263

331, 2902

2924, 3240

3256, 3467

53,474

177,016

35126

Discharge summary

report

Admission Date: [**2131-1-11**] Discharge Date: [**2131-1-21**] Date of Birth: [**2085-12-16**] Sex: M Service: ORTHOPAEDICS Allergies: Zoloft / Effexor / Atenolol Attending:[**First Name3 (LF) 64**] Chief Complaint: L knee pain Major Surgical or Invasive Procedure: [**2131-1-11**] Left total knee arthroplasty History of Present Illness: I met with [**First Name8 (NamePattern2) **] [**Known lastname **] today. He earlier in the day had met with Dr. [**First Name (STitle) **] [**Name (STitle) 7376**] to consider whether or not any additional procedures can and should be done to his left knee, which has been persistently problem[**Name (NI) 115**] and painful despite many operations over many years. He has been told that nonsurgical management is best. As for his ipsilateral left knee, which Dr. [**Last Name (STitle) **] has referred to me for treatment, it will be best served with a total knee arthroplasty. I refer to the note from [**2130-11-9**], which extensively outlines their conversation six weeks ago and his referral in my direction. Basically, this patient has had eight different arthroscopic procedures performed on the left knee. He originally had discoid meniscus, subsequently developed osteoarthritis, and at this point has had no improvement with the most recent couple of meniscectomies/chondroplasties. This is not, however, his only problem. [**Name (NI) **] is disabled for the past several years with a combination of ankle pain and knee pain. He is status post lumbar surgeries with radicular symptoms and polyneuropathy. He has also had cervical spine operations in the past. Past Medical History: Diabetes, HTN, high cholesterol, chronic pain, disability, neck pain Social History: He lives in [**State 1727**] Family History: N/C 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: [**2131-1-12**] 06:40AM BLOOD WBC-9.5 RBC-3.98* Hgb-11.9* Hct-35.0* MCV-88 MCH-29.8 MCHC-34.0 RDW-13.4 Plt Ct-191 [**2131-1-13**] 07:36AM BLOOD WBC-10.6 RBC-3.54* Hgb-10.6* Hct-31.5* MCV-89 MCH-29.9 MCHC-33.7 RDW-13.4 Plt Ct-163 [**2131-1-14**] 06:35AM BLOOD WBC-9.8 RBC-3.51* Hgb-10.3* Hct-31.2* MCV-89 MCH-29.2 MCHC-32.9 RDW-13.4 Plt Ct-184 [**2131-1-15**] 03:30PM BLOOD WBC-7.6 RBC-3.10* Hgb-9.2* Hct-27.8* MCV-90 MCH-29.8 MCHC-33.3 RDW-13.4 Plt Ct-207 [**2131-1-16**] 06:38AM BLOOD WBC-6.8 RBC-2.86* Hgb-8.4* Hct-25.6* MCV-90 MCH-29.4 MCHC-32.8 RDW-13.6 Plt Ct-246 [**2131-1-17**] 04:17AM BLOOD WBC-7.5 RBC-3.02* Hgb-8.7* Hct-26.8* MCV-89 MCH-29.0 MCHC-32.6 RDW-13.5 Plt Ct-239 [**2131-1-18**] 04:28AM BLOOD WBC-8.6 RBC-2.96* Hgb-8.8* Hct-25.7* MCV-87 MCH-29.7 MCHC-34.3 RDW-13.7 Plt Ct-241 [**2131-1-19**] 08:10AM BLOOD WBC-12.6* RBC-3.15* Hgb-9.3* Hct-27.0* MCV-86 MCH-29.6 MCHC-34.5 RDW-13.6 Plt Ct-272 [**2131-1-20**] 07:35AM BLOOD WBC-11.5* RBC-3.08* Hgb-9.4* Hct-26.5* MCV-86 MCH-30.5 MCHC-35.5* RDW-13.5 Plt Ct-270 [**2131-1-21**] 07:05AM BLOOD WBC-12.7* RBC-3.37* Hgb-10.0* Hct-28.9* MCV-86 MCH-29.6 MCHC-34.4 RDW-13.2 Plt Ct-306 [**2131-1-12**] 06:40AM BLOOD Glucose-182* UreaN-18 Creat-1.1 Na-136 K-4.4 Cl-102 HCO3-28 AnGap-10 [**2131-1-15**] 06:25AM BLOOD Glucose-136* UreaN-56* Creat-3.0*# Na-138 K-5.4* Cl-100 HCO3-31 AnGap-12 [**2131-1-15**] 03:30PM BLOOD Glucose-192* UreaN-55* Creat-2.0* Na-138 K-5.1 Cl-100 HCO3-32 AnGap-11 [**2131-1-16**] 06:38AM BLOOD Glucose-168* UreaN-45* Creat-1.5* Na-141 K-5.3* Cl-107 HCO3-28 AnGap-11 [**2131-1-16**] 03:59PM BLOOD Glucose-169* UreaN-40* Creat-1.2 Na-143 K-4.2 Cl-106 HCO3-31 AnGap-10 [**2131-1-17**] 04:17AM BLOOD Glucose-154* UreaN-27* Creat-1.0 Na-144 K-4.5 Cl-105 HCO3-31 AnGap-13 [**2131-1-18**] 04:28AM BLOOD Glucose-160* UreaN-17 Creat-1.0 Na-142 K-4.4 Cl-104 HCO3-33* AnGap-9 [**2131-1-19**] 08:10AM BLOOD Glucose-209* UreaN-14 Creat-0.9 Na-136 K-4.1 Cl-100 HCO3-29 AnGap-11 [**2131-1-20**] 07:35AM BLOOD Glucose-175* UreaN-13 Creat-0.8 Na-138 K-3.9 Cl-99 HCO3-29 AnGap-14 [**2131-1-21**] 07:05AM BLOOD Glucose-172* UreaN-15 Creat-0.9 Na-138 K-3.8 Cl-99 HCO3-29 AnGap-14 [**2131-1-21**] 07:05AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.1 [**2131-1-13**] - xrays of L knee show good hardware alignment without complication [**2131-1-13**] - CXR - no acute cardiopulmonary changes [**2131-1-13**] - CT PE IMPRESSION: No evidence of large central filling defects within the pulmonary arteries. However, given suboptimal contrast administration, more distal pulmonary emboli within the segmental and subsegmental arterial branches cannot be excluded. Repeat study could be performed if clinically indicated. [**2131-1-16**] - ECHO The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size is normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve 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. Normal left ventricular cavity sizes with preserved global systolic function. [**2131-1-16**] - LE doppler IMPRESSION: No evidence of DVT. [**2131-1-17**] - CXR FINDINGS: The monitoring and support devices are in unchanged position. The right upper lobe is now better ventilated than on the previous radiograph. The size of the cardiac silhouette is unchanged. The remaining lung parenchyma has identical appearance. Small retrocardiac areas of hypoventilations, but no newly appeared focal parenchymal opacities suggestive of pneumonia. The left costophrenic sinus is not completely depicted, costophrenic sinus is without signs of pleural effusion. [**2131-1-17**] - CT PE 1. Limited study for the evaluation of pulmonary embolism due to body habitus, breathing motion artifact, and poor opacification of the pulmonary artery. No evidence of central or lobar pulmonary embolism. Although the study is sub-optimal, the previously described questionable filling defect in the left lower lobe branch of the pulmonary artery are not confirmed in this study. 2. Endotracheal tube terminates at 2.6 cm above the carina. 3. Bilateral small upper lobe atelectasis, right greater than left. 4. Fatty liver. [**2131-1-18**] - CXR Moderate cardiomegaly is unchanged. There are low lung volumes. Biapical medial atelectases are unchanged. There are no pleural effusions. Left IJ catheter tip is in the left brachiocephalic vein. Brief Hospital Course: The patient was admitted on [**2131-1-11**] and, later that day, was taken to the operating room by Dr. [**Last Name (STitle) **] for L TKA without complication. Please see operative report for details. Postoperatively the patient did well. 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 patient was placed in a CPM machine with range of motion that started at 0-45 degrees of flexion before being increased to 90 degrees as tolerated.*** 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. 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 rehabilitation in a stable condition. The patient's weight-bearing status was WBAT in [**Doctor Last Name 6587**] brace. ***The patient is to continue using the CPM machine advancing as tolerated to 0-100 degrees.*** Patient developed asymptomatic hypoxia post-op day #1 ([**1-13**]). Chest CTA was negative for PE. Patient was noted to be more somnolent on [**1-14**]; ABGs showed respiratory acidosis and severe hypercarbia. He was treated with CPAP and his mental status improved. Routine labs on [**1-15**] showed a creatinine of 3.0, up from 1.1 on admission. Medical consult was called to evaluate him, and decision was made in light of the acute renal failure, hypoxemia and hypercarbia, and altered mental status to transfer him to medicine. He subsequently was admitted to the MICU and intubated. He remained intubated for 3 days and was again ruled out for a PE with a CT scan. He was extubated, renal failure improved and he was transferred back to the orthopedic service. He spiked to 103 and 102 on [**1-18**] and [**1-19**] respectively. Vanco and Zosyn were restarted for a likely Hospital acquired pneumonia. He is to finish a 10 day course of vanco and zosyn. # Acute renal failure: Several possibilities exist. Patient may have decreased renal perfusion from hypovolemia and the combination of ACEI and NSAIDS (patient was kept on his home lisinopril and post-operatively was given toradol and naproxen for 3 days). AIN was less likely, given lack of culprit medications. Contrast nephropathy is a possibility, as is obstructive uropathy (patient had urinary retention of 1 liter). Renal ultrasound, urine electrolytes are pending. ACEI, NSAIDs should be D/C'd, and lovenox should be renally dosed. # Hypoxemia/hypercarbia: Multifactorial from post-op atelectasis with underlying restrictive lung disease from obesity and obstructive sleep apnea predisposing to hypercarbia. No evidence of pneumonia, CHF or PE. Patient has responded to daytime CPAP, and this may need to be re-initiated. He was started on Vanco/Zosyn while in the ICU but this was d/c'ed after second CT-PE showed no PE or consolidation. However when he was transferred back to the floor, he spiked again to 103 and again to 102 so he was started back on the vanco and zosyn. He will complete a 10 day course. # Somnolence: Multifactorial from narcotic medications and hypercarbia. Patient was given narcan x 4 with some improvement. # DM2 uncontrolled with complications: Elevated BS. He was controlled on long acting and sliding scale insulin. # s/p TKR: stable post-operatively. Medications on Admission: Celebrex 200'', diazepam 5''', Cymbalta 20', Lidoderm patches, Perocet, Novolog 70/30, Levemir 85 units qa.m., Actos 45', Protonix 40', oxycontin 80'', lipitor 80', ASA 81', androgel 50mg/5gm, Discharge Disposition: Extended Care Facility: Marshwood Skilled Nsg Center Discharge Diagnosis: L knee osteoarthritis Discharge Condition: Stable Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1953**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2131-2-9**] 9:00 CC:[**Numeric Identifier 80201**] Completed by:[**2131-1-21**]

[ "250.02", "997.5", "E937.8", "293.0", "278.01", "530.81", "716.50", "327.23", "997.39", "486", "518.0", "507.0", "278.8", "584.5", "300.4", "518.89", "276.52", "715.36", "518.5", "E878.1" ]

icd9cm

[ [ [] ] ]

[ "96.71", "33.23", "38.93", "81.54" ]

icd9pcs

[ [ [] ] ]

11011, 11066

6806, 10768

303, 350

11132, 11141

1976, 6783

11164, 11426

1815, 1820

11087, 11111

10794, 10988

1835, 1957

252, 265

378, 1661

1683, 1753

1769, 1799

15,553

198,509

24589

Discharge summary

report

Admission Date: [**2148-4-28**] Discharge Date: [**2148-4-30**] Date of Birth: [**2128-6-6**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 293**] Chief Complaint: SSRI overdose Major Surgical or Invasive Procedure: None History of Present Illness: 19 yo female with h/o depression (on lexapro for 4 months, no previous suicide attempts) who presents after an overdose of Lexapro (100-150 mg), demerol (amount unknown), and EtOH. She had reportedly just had a break-up with her boyfriend, and was found teary and with slurred speech by her friends -> 911 was called. She was never unresponsive. In the ED she was tachycardic and somnolent and received Narcan 0.4 mg IV x4, ativan 1 mg, and charcoal. Toxicology was consulted for possible mild serotonin syndrome, and recommended treatment with benzodiazepines as needed for tachycardia and anxiety. She has no known h/o previous suicide attempts, sexual abuse, rape, eating disorders, or drug use. Past Medical History: Depression - on lexapro for 4 months. No past history of suicide attempts h/o broken left arm Social History: [**Known firstname 2110**] is a sophomore at BU. She currently lives with five girls. Denies tobacco use. She describes social alcohol use, with occasional blackouts after drinking only ~4 drinks on occasion. She denies any other drug use. Family History: No family history of depression or suicidality Physical Exam: VS: 98.6 112/76 - 90 - 12 - 100% GEN: alert, oriented x 3, soft speech, no diaphoresis HEENT: supple neck, no LAD, MMM, OP clear, anicteric CV: tachycardic, no m/r/g RESP: CTA bilaterally ABD: soft, NT, ND EXT: no edema; 2+ DP pulses NEURO: pupils 4-5mm -> 3mm with light. CN II-XII bilaterally. Pertinent Results: [**2148-4-29**] 12:20PM BLOOD WBC-8.0 RBC-4.05* Hgb-12.6 Hct-35.0* MCV-87 MCH-31.0 MCHC-35.9* RDW-12.9 Plt Ct-225 [**2148-4-29**] 12:20PM BLOOD Plt Ct-225 [**2148-4-29**] 06:01AM BLOOD Glucose-104 UreaN-3* Creat-0.7 Na-141 K-3.6 Cl-108 HCO3-27 AnGap-10 [**2148-4-29**] 06:01AM BLOOD LD(LDH)-155 TotBili-0.6 [**2148-4-29**] 06:01AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.6 [**2148-4-29**] 06:01AM BLOOD Hapto-49 [**2148-4-28**] 04:30AM BLOOD ASA-NEG Ethanol-151* Acetmnp-17.4 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ---- ECG:Sinus tachycardia. Otherwise, without diagnostic abnormality. Brief Hospital Course: 19yo woman with history of depression and recent stressors/break up with boyfriend found to have overdosed on about 150mg of lexapro in total, etoh, and unknown quantity of demerol. . 1. OVERDOSE: Initial EtOH level was 151 and remainder of tox screen was negative, including opiates and benzos. Initially confused, but then her mental status cleared. No evidence of serotonin syndrome throughout her stay. She received Narcan in ED, but did not require this in ICU. She had stable vitals throughout her stay. She had a 1:1 sitter. No signs of rigidity, diarrhea, flushing, and diaphoresis. Her Lexapro was held and she was only given tylenol prn. Psychiatry was consulted, saw her, and recommended inpt stay due to suicide attempt and depression. . 2. DEPRESSION: Pt on lexapro as an outpatient. Did not restart this here after she overdosed on it. As above, seen by psych and will be transferred to psychiatric unit for treatment. . 3.Anemia:She was slightly anemic on labs. Can have this followed as outpt. No obvious source of bleeding. Medications on Admission: lexapro 10mg qd ocp Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Discharge Diagnosis: SSRI overdose Discharge Condition: Stable. Eating normally. Vitals stable. Ambulating Discharge Instructions: Please tell the psychiatry staff if you have any dizziness, shortness of breath, chest pain, or fevers. -Take your medications as you are directed by the psychiatrists. Followup Instructions: Follow-up as the psychiatry physicians arrange for you.

[ "995.83", "969.0", "305.00", "285.9", "E967.7", "V62.89", "E950.0", "965.09", "301.83", "E950.3", "427.89", "296.90" ]

icd9cm

[ [ [] ] ]

[ "94.49", "94.65" ]

icd9pcs

[ [ [] ] ]

3682, 3697

2447, 3498

335, 341

3755, 3807

1846, 2424

4025, 4084

1466, 1514

3568, 3659

3718, 3734

3524, 3545

3831, 4002

1529, 1827

282, 297

369, 1074

1096, 1191

1207, 1450

8,772

199,828

22975

Discharge summary

report

Admission Date: [**2184-1-1**] Discharge Date: [**2184-1-7**] Date of Birth: [**2115-1-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14037**] Chief Complaint: mental status changes Major Surgical or Invasive Procedure: Intubation History of Present Illness: Mr. [**Known lastname **] is a 68 year old nursing home resident with a history of mulit-infarct dementia, alcohol abuse, pulmonary hypertension, and CAD who was admitted to the [**Hospital Unit Name 153**] on [**2184-1-2**] for acute mental status changes. He has dementia but is very alert at baseline. On the date of admission, he was unable to be aroused by RN. Head CT done in the emergency department was negative, LP was negative, but chest x-ray demonstrated bilateral pneumonia. CT/angiogram showed left lower lobe pneumonia, no pulmonary embolism, 1cm B hilar lymphnodes, as well as severe emphysema. Was seen by PCP with plans to return to [**Hospital1 1501**] on Abx, but he had progressive deterioration in his mental status. He was admitted to the [**Hospital Unit Name 153**] and required intubation for airway protection on [**1-2**]. With the patient stabilized, MRI was performed but did not demonstrate a new stroke. The patient was extubated on [**1-5**], had improved mental status. The thought was that the patient's decline was due to his pneumonia. At baseline pt speaks, although sometimes has word finding problems, uses [**Name2 (NI) **], dresses and feeds himself. Past Medical History: Dementia (multi-infarct) s/p CVA - has residual L hemiparesis [**2180**] Pulm HTN EtOH abuse CAD h/o UTI's Social History: Resident of Provident NH since a CVA in [**2180**]. He has a history of alcohol abuse and unknown tobacco use history. Family History: Non-contributory Physical Exam: VS: T 98.9 BP 177/74 HR 86 RR 86 Sat 95% on cool neb GEN: Man in bed in NAD HEENT: PERRL, NC/AT, MMM, CV: RRR nl S1/S2, II/VI systolic murmur PUL: scant crackles at left base. ABD: NT, +BS, no rebound/guarding EXT: no LE edema, RP/DP 2+ b/l Neuro: A&Ox person, month, day, "hospital". CNII-XII intact, Motor [**4-1**] right. [**4-1**] LUE, 4+/5 LLE. Pertinent Results: [**1-3**]: EKG: Sinus arrhythmia Borderline first degree AV block Right bundle branch block P-R interval 0.21 Since previous tracing, sinus tachycardia absent and axis change seen MRI/MRA Head: No evidence of acute infarct. Chronic infarcts in the brain stem and posterior fossa with severe changes of small vessel disease in the periventricular white matter with multiple lacunes in the white matter. No midline shift or hydrocephalus. MRA: The head MRA demonstrated normal flow signal within the arteries of anterior and posterior circulation. No evidence of vascular occlusion or high grade stenosis is seen. Echo ([**1-2**]): Symmetric left ventricular hypertrophy with hyperdynamic systolic function and mild resting mid-cavity gradient. Moderate pulmonary artery systolic hypertension. No definite 2D or Doppler evidence for endocarditis identified (does not exclude if clinically suggested). CT head: No evidence of intracranial hemorrhage or cerebral edema. Note that MRI with diffusion weighted imaging is a more sensitive evaluation for detection of acute stroke. CT chest: 1) No pulmonary embolism. 2) Left lower lobe infiltrate, likely pneumonia. 3) Bilateral emphysematous changes. 4) 1 cm nodular density along right major fissure. This could be infectious in etiology, but f/u chest CT recommended in 3 months. 5) Hilar and medistinal lymphadenopathy, which could be infectious in origin. 6) Apparent tracheobronchial thickeening which could represent chronic bronchitis or mucous. [**2184-1-1**] 09:30PM CK(CPK)-487* [**2184-1-1**] 09:30PM CK-MB-7 cTropnT-<0.01 [**2184-1-1**] 09:25PM AMMONIA-27 [**2184-1-1**] 05:33PM LACTATE-3.3* [**2184-1-1**] 04:07PM TYPE-ART PO2-40* PCO2-44 PH-7.38 TOTAL CO2-27 BASE XS-0 INTUBATED-NOT INTUBA [**2184-1-1**] 04:07PM O2 SAT-71 [**2184-1-1**] 12:03PM TYPE-ART PO2-65* PCO2-40 PH-7.40 TOTAL CO2-26 BASE XS-0 [**2184-1-1**] 12:03PM LACTATE-3.1* [**2184-1-1**] 12:03PM O2 SAT-92 CARBOXYHB-1.0 MET HGB-0.5 [**2184-1-1**] 12:03PM freeCa-1.26 [**2184-1-1**] 11:32AM TYPE-ART PO2-26* PCO2-56* PH-7.31* TOTAL CO2-30 BASE XS--1 [**2184-1-1**] 11:32AM LACTATE-4.3* [**2184-1-1**] 11:32AM O2 SAT-34 CARBOXYHB-1.3 MET HGB-0.5 [**2184-1-1**] 11:32AM freeCa-1.34* [**2184-1-1**] 08:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-41 GLUCOSE-72 [**2184-1-1**] 08:30AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-2* POLYS-4 LYMPHS-96 MONOS-0 [**2184-1-1**] 08:30AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-2* POLYS-0 LYMPHS-0 MONOS-0 [**2184-1-1**] 05:30AM URINE HOURS-RANDOM MAGNESIUM-10.2 [**2184-1-1**] 05:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2184-1-1**] 05:30AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2184-1-1**] 05:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2184-1-1**] 03:30AM GLUCOSE-121* UREA N-19 CREAT-1.1 SODIUM-140 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14 [**2184-1-1**] 03:30AM ALT(SGPT)-24 AST(SGOT)-19 CK(CPK)-204* ALK PHOS-43 AMYLASE-80 TOT BILI-0.4 [**2184-1-1**] 03:30AM LIPASE-26 [**2184-1-1**] 03:30AM cTropnT-<0.01 [**2184-1-1**] 03:30AM CK-MB-3 [**2184-1-1**] 03:30AM VIT B12-541 [**2184-1-5**] 04:11AM BLOOD WBC-8.2 RBC-4.00* Hgb-11.5* Hct-34.7* MCV-87 MCH-28.8 MCHC-33.2 RDW-14.0 Plt Ct-172 [**2184-1-5**] 04:11AM BLOOD Plt Ct-172 [**2184-1-5**] 04:11AM BLOOD Glucose-132* UreaN-11 Creat-0.8 Na-143 K-3.6 Cl-109* HCO3-29 AnGap-9 [**2184-1-5**] 04:11AM BLOOD Calcium-8.8 Phos-2.2* Mg-2.0 [**2184-1-3**] 04:21AM BLOOD Cortsol-8.7 [**2184-1-1**] 03:30AM BLOOD TSH-1.2 ECG: nl axis at 72bpm, w/ RBBB vs ICD [**2184-1-5**] 04:11AM BLOOD WBC-8.2 RBC-4.00* Hgb-11.5* Hct-34.7* MCV-87 MCH-28.8 MCHC-33.2 RDW-14.0 Plt Ct-172 [**2184-1-5**] 04:11AM BLOOD Plt Ct-172 [**2184-1-5**] 04:11AM BLOOD Glucose-132* UreaN-11 Creat-0.8 Na-143 K-3.6 Cl-109* HCO3-29 AnGap-9 [**2184-1-5**] 04:11AM BLOOD Calcium-8.8 Phos-2.2* Mg-2.0 [**2184-1-2**] 11:31PM BLOOD Lactate-1.6 [**2184-1-1**]: UCx neg BCx NGTD Sputum O/P flora; Cx NGTD Brief Hospital Course: 68 yo NH resident w/ h/o CVA and multi-infarct dementia who presents with MS changes in setting of pna. # MS changes: Etiology of altered MS was most likely secondary to his infection/ sepsis, as LP and initial head CT were negative and vit B12, RPR, TSH were nl. Neurology was consulted and recommended MRI, which showed no evidence of stroke. Pt's neuro exam continued to improve with improvement of his PNA and oxygenation. He was talking and increasingly oriented and found stable for transfer to the floor. Aricept, thiamine, folate were continued and sedatives meds/narcotics were avoided. . # PNA with hypoxia: Pt was noted to be and hypoxic in the ED, CXR showed impressive bilat PNA and pt required intubation for airway protection. He was treated with ceftriaxone and azithro. His PNA improved, lactate decreased and he was extubated [**1-5**]. Sputum revealed moderate growth of oropharyngeal flora; no pathogens were isolated. He received aggressive suctioning and chest PT. He will continue antibiotic treatment with levaquin, 500mg PO x10days. . #COPD: Poor air movement on exam and O2 sats in the 89-92 range on 2L. Likely pt has severe emphysema at baseline. He was on supplemental O2 with goal sats 89-92% and received RTC nebs as well as 5 days of prednisone 50mg PO daily (day [**1-3**] on discharge), with no taper. . # CAD: Pt was noted to have ST depressions in lateral leads on EKG. Unfortunately, there was no prior EKG for comparison. Card mkrs were cycled and he ruled out for MI. ASA was continued and lopressor and captopril were added and titrated up to achieve goal SBP 120s-130s. . # DM: Likely steroid-induced. Pt was kept on reg insulin sliding scale while on prednisone. This may be discontinued in 3 days, once he is off prednisone. . # Abnormal CT finding: 1 cm nodular density along right major fissure. This could be infectious in etiology, but f/u chest CT recommended in 3 months. . # FEN: Speech and swallow was consulted and recommended pureed solids and nectar-thickened liquids. . #Oustanding issues needing f/u: Abnormal CT finding (see above). Pt will need f/u CT in 3 months. Currently on insulin sliding scale while on prednisone, but insulin may be stopped once prednisone discontinued. . #Dispo: Pt was d/c'ed back to [**Hospital1 789**] House once acute issues were resolved. He will follow-up with Dr.[**Last Name (STitle) 5762**] in [**6-6**] days after discharge. Medications on Admission: Meds: ASA 81 Lasix 30 qd Lopressor 12.5 qd Aricept 5 qd Folate 1 qd NTG prn MVI Thiamine Imdur 30 qd Milk of mag . NKDA Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q2-3H (every 2-3 hours) 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. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) inj Subcutaneous ASDIR (AS DIRECTED) for 3 days: please continue while on prednisone . 9. Prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 11. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Discharge Disposition: Extended Care Facility: Provident Skilled Nursing Center - [**Location (un) 583**] Discharge Diagnosis: Bilateral pneumonia Altered mental status Hypoxia dementia COPD Hypertension Discharge Condition: stable--at baseline Discharge Instructions: Please call your doctor and return to the hospital for incresing confusion, lethargy, fever, chills, shortness of breath, or any other concerning symptoms you may have. Followup Instructions: Please follow-up with Dr.[**Last Name (STitle) 5762**] in [**6-6**] days after discharge. Please have outpatient CT done in 3 months to evaluate findings on prior CT.

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icd9cm

[ [ [] ] ]

[ "96.04", "03.31", "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

10184, 10269

6386, 8807

335, 347

10390, 10411

2272, 3174

10629, 10800

1859, 1877

8978, 10161

10290, 10369

8833, 8955

10435, 10606

1892, 2253

274, 297

375, 1576

3183, 6363

1598, 1706

1722, 1843

9,954

157,205

52832

Discharge summary

report

Admission Date: [**2164-12-7**] Discharge Date: [**2164-12-11**] Service: MEDICINE Allergies: Sulfonamides / Codeine / Hydrochlorothiazide / Ace Inhibitors Attending:[**First Name3 (LF) 2751**] Chief Complaint: Abdominal pain/nausea x24 hours Major Surgical or Invasive Procedure: None. History of Present Illness: This is a [**Age over 90 **]-year-old female with a past medical history of hypertension, hypothyroidism, GI bleed in [**8-/2164**] who presents from home with abdominal pain, [**9-15**] and intermittent nausea, for the past 24 hours. Upon arrival in ED, patient was febrile to 101.7, and elevated LFTs were concerning for cholangitis. A CTA of the abdomen demonstrated a dilated CBD with a stone obstructing the ampula. Patient was tachycardic to 120-130s, and was given IV fluids and cipro, flagyl, unasyn. Crackles were heard at her lower lung bases, and IVF were eventually discontinued. ERCP was consulted, and during the course of a long discussion with ERCP fellow, family, and geriatrics fellow, it was felt that surgical intervention (i.e. ERCP) would not be in accordance with patient's wishes as she is DNR/DNI. The decision was made to treat patient with antibiotics and symptomatically, and she was transferred to the [**Hospital Unit Name 153**] for further work-up. Upon transfer to the [**Hospital Unit Name 153**], vitals were: VS: 101.7 129/59 128 24 96% 4L. An extensive note in the chart by ERCP fellow documents entirety of this conversation. Upon arrival in the [**Hospital Unit Name 153**], patient complained of abdominal discomfort and missing her daughter. She also complained of thirst. Vitals on arrival were: T: 98.8, BP: 108/43, RR: 28, SP02 92% on 2L. ROS: Patient is a poor historian. But she denies headache, chest pain, shortness of breath, dysuria, or change in bowel habits. Past Medical History: - Left Temporal Infarct [**2157**] with resulting expressive aphasia - TIAs - Asthma - GERD - Osteoporosis - Htn - Left hip fracture status post left hemiarthroplasty [**12-12**] - Traumatic subdural hematoma status post exploratory - Hypothyroidism - Basal cell carcinoma, left auricle status post excision [**11-11**] - Osteoarthritis - L2 compression fracture - [**5-/2164**] - Syncopal episode - [**5-/2164**] - GI Bleed - [**8-/2164**] Social History: Widowed, lives independently with some driving assistance. Former smoker but quit in [**2123**]. One shot of vodka nightly. Family History: Non-Contributory. Physical Exam: T: 98.8, BP: 108/43, RR: 28, SP02 92% on 2L. GENERAL: Pleasant, confused, complains of abdominal pain HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. CARDIAC: Regular rhythm, rate is tachy to 120s, no murmurs, rubs, or gallops. LUNGS: Crackles at bases bilaterally ABDOMEN: +BS, hyper-resonant, diffusely tender, no organomegally EXTREMITIES: Warm and dry, 2+ dorsalis pedis pulses NEURO: Patient thinks that it's [**2098**] and she is in surgery. Knows that it's the first of the year. Patient is confused, agitated, and keeps asking for her daughter. Pertinent Results: [**2164-12-7**] 12:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG [**2164-12-7**] 12:25PM URINE RBC-0 WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0 [**2164-12-7**] 11:52AM LACTATE-3.6* [**2164-12-7**] 11:45AM ALT(SGPT)-72* AST(SGOT)-235* CK(CPK)-40 ALK PHOS-226* TOT BILI-3.2* [**2164-12-7**] 11:45AM LIPASE-[**Numeric Identifier 68795**]* [**2164-12-7**] 11:45AM WBC-9.9 RBC-4.30 HGB-13.8 HCT-40.7 MCV-95 MCH-32.1* MCHC-33.8 RDW-15.0 [**2164-12-7**] 11:45AM NEUTS-72.1* LYMPHS-26.0 MONOS-0.5* EOS-0.7 BASOS-0.6 [**2164-12-7**] 11:45AM PLT COUNT-174 [**2164-12-7**] 11:45AM PT-13.7* PTT-26.8 INR(PT)-1.2* [**2164-12-7**] 12:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 CTA Abdomen [**2164-12-7**] 1. Patent mesenteric vasculature with no evidence of mesenteric ischemia. 2. Pronounced dilatation of the common bile duct measuring up to 17 mm, with moderate intrahepatic biliary ductal dilatation. Dilated CBD extends to the ampulla, which bulges into the duodenum. There is associated ventral pancreatic ductal dilatation. Precontrast images demonstrate a stone at the ampulla. 3. Patchy hypoenhancing areas in the liver, most extensive in the left lateral segment, raising concern, in the overall context, for hepatobiliary infection, although the infiltrative appearance is in itself non-specific. 4. Dilated main pancreatic duct with widespread peripancreatic fluid consistent with pancreatitis. Ill-defined fluid and edema are also extensive along the portal tracts, hepatic hilum and gallbladder. 3. Distended gallbladder with echogenic layering material and pericholecystic fluid, but most likely secondary to surrounding inflammation and biliary obstruction, although coinciding cholecystitis cannot be entirely excluded. 4. Compression of the T11 vertebral body, new since [**2161**], with mild retropulsion of the superior portion of the vertebral body into the spinal canal. 5. Extensive colonic diverticulosis without diverticulitis. 6. Extensive atherosclerotic disease. [**2164-12-9**] 04:43AM BLOOD WBC-24.8* RBC-4.54 Hgb-14.4 Hct-43.3 MCV-95 MCH-31.7 MCHC-33.2 RDW-15.1 Plt Ct-132* [**2164-12-9**] 04:43AM BLOOD Glucose-72 UreaN-19 Creat-0.7 Na-145 K-3.3 Cl-112* HCO3-21* AnGap-15 [**2164-12-9**] 04:43AM BLOOD ALT-97* AST-138* LD(LDH)-196 AlkPhos-171* TotBili-2.1* [**2164-12-9**] 04:43AM BLOOD Calcium-8.1* Phos-2.4* Mg-2.6 Brief Hospital Course: This is a [**Age over 90 **]-year-old lady with choledocholithiasis vs. cholangitis who presents from home with a 24-hour history of abdominal pain and nausea with CT abdomen suggestive of distal CBD obstruction with stone and pancreatitis, and bacteremia. . CBD OBSTRUCTION/PANCREATITIS: Patient is bacteremic with gram negative rods, likely source being biliary tract - possibly stone vs ampullary mass. After long discussions with family, ERCP team, and geriatrics, the decision was made not to pursue ERCP and to keep patient comfortable. The family is aware that patient could pass away from overwhelming infection, but they do not believe that invasive procedures and/or intubation would be in accordance with her wishes. Although the obstruction looked like it could be a ampullary mass on initial read of CT, radiology attending asserted that it was most likely a stone. Pt received Zosyn for empiric gram negative coverage and IVF as tolerated by respiratory status, though prior to transfer to medical floor, comfort measures were instituted as per family wishes, and antibiotics were discontinued on [**2164-12-9**]. Pain was controlled with morphine. Palliative care, Geriatric PCP, [**Name10 (NameIs) **] case management saw patient in ICU and on medical floor. Family was interested in setting up home hospice care, and arrangements were made. Prior to discharge, 48 hours without treatment, she was improving, decreased pain and agitation and eating. It is very possible the stone has passed. Her PCP was made aware, and if patient does well at home, can follow up with patient -- 11R geriatric coordinator alerting clinic to make sooner follow-up. . TACHYCARDIA: Sinus tachy. Most likely a combination of pain, anxiety, fever, and infection. Pt's underlying infection was treated with antibiotics as above. Agitation was treated with zyprexa prn, and pain was controlled with morphine. . HYPOTHYROIDISM: Continued home levothyroxine dose, but this was discontinued when CMO measures instituted. Can be followed by PCP (have alerted her)if she survives this. . HYPERTENSION: Hold off on home anti-hypertensive medications, as patient had SBPs in the 80s-90s. If she does well at home with no demise, can re-institute as outpatient if she survives this - PCP [**Name Initial (PRE) 12309**]. . AGITATION / DELERIUM: Likely secondary to ICU delerium, underlying infection and pain. Patient required restraints and IV Haldol overnight in ICU. Patient refused to take PO meds, and all possible meds were changed to IV. IV Haldol was continued on the medical floor but restraints not needed. This was transitioned to PO Haldol. IV morphine 1 mg standing and 1-4mg q2-4hr instituted for pain control. She will have SL morphine with hospice care. Her delerium improved slightly between [**12-9**] and [**2164-12-11**] and she was moved to all oral medications. GERD: Discontinued PPI. Can be followed by PCP (have alerted her)if she survives this. Support given to family. . Medications on Admission: MEDS (PER OMR) Furosemide 20mg PO daily Levothyroxine 112 mcg Tablet PO Daily Nifedipine [Nifediac CC] 30mg PO Daily Ranitidine HCl 150mg PO BID Risedronate [Actonel] 35mg QSunday Valsartan [Diovan] 320mg PO Daily Zolpidem [Ambien] 2.5mg PO QHS PRN Insomnia Acetaminophen 325mg PO Q4H PRN Pain Aspirin 81mg PO Daily (? Compliance) Calcium Carbonate-Vitamin D3 600 mg-400mg PO BID Psyllium Powder 1 tbsp PO Daily PRN Vitamin A-Vitamin C-Vit E-Min [Ocuvite] Dosage Uncertain Discharge Medications: 1. morphine sulfate Sig: 2-20 mg (20mg/ml) Sublingual Q 1 hr prn: give 30ml. Disp:*1 1 bottle* Refills:*0* 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever: [**Month (only) 116**] give per rectum if unable to take orally. 3. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for delerium. Discharge Disposition: Home With Service Facility: Circle of [**Hospital 108962**] hospice of the Good [**Last Name (un) 3952**] Discharge Diagnosis: Cholangitis w/ CBD and PD Dilatation Gram Negative Rod Bacteremia Delerium Discharge Condition: Mental Status:Confused - sometimes Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted with cholangitis and bacteria in your blood. You were admitted to ICU and treated with antibiotics and IV fluids. Surgical evaluation was done, and ERCP was recommended to further evaluate the cause of this infection based on Cat Scan findings. This is a life threatening illness. After discussion with the ICU team, you and your family decided to make comfort measure the goal of therapy. Antibiotics were discontinued, further evaluation of cause of infetion was not pursued, but every attempt to make you comfortable and pain free were made. You have and are experiencing delerium - likely related to underlying infection, hospital stay and pain. Pain medication and a mild sedative was started. You were seen and evaluated by the Geriatrics team and Palliative care services. Arrangements were made to help you transition to home Hospice Care. Followup Instructions: Hospice Care

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9568, 9676

5590, 8590

302, 309

9795, 9795

3125, 5567

10869, 10884

2485, 2504

9113, 9545

9697, 9774

8616, 9090

9974, 10846

2519, 3106

231, 264

337, 1862

9809, 9950

1884, 2327

2343, 2469

26,557

150,536

12948

Discharge summary

report

Admission Date: [**2101-2-4**] Discharge Date: [**2101-2-7**] Date of Birth: [**2044-10-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 134**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization [**2101-2-4**]: Cypher stent to left main coronary artery Bare metal stent to left anterior descending artery History of Present Illness: The patient is a 56 year old smoker with heavy EtOH use, CAD s/p emergent CABG in [**2088**] (SVG->RCA, OM, LIMA->LAD) who presented to his primary care physician today on [**2101-2-4**] with the chief complaint of increasing rest substernal angina for the past few weeks. The patient states the pain is only [**12-6**] and is substernal and unlike his anginal equivalent in [**2088**] when he had his first heart attack. At that time, he experienced bilateral arm pain and no substernal chest pain. For the past few days, the patient has had increasing frequency and intensity rest substernal chest pain that was associated with shortness of breath, no diaphoresis, radiating pain to arm, jaw or back, or nausea/vomiting over the past few weeks. As a result, the patient underwent an exercise stress test 3 weeks ago at [**Hospital1 **] which was reportedly negative. The patient saw his PCP on the day of admission who took an EKG which showed new ST elevations and was thus transferred immediately to [**Hospital1 **] where his EKG showed 3-[**Street Address(2) 1755**] elevations in V1-V5 with TWI in V5-V6, I and avL with [**Street Address(2) 4793**] depressions in II, III and avF. There is no baseline EKG in the chart. There is no documented troponin or CK. He was transferred from [**Hospital3 4107**] to [**Hospital1 18**] for cath which showed the following: right-dominant system LMCA 90% ostial lesion, heavily calcified LAD 90% proximal-mid after high diagonal Moderate ramus LCX totally occluded RCA totally occluded mid lesion, collaterals to ramus SVG -> RCA patent, OM patent LIMA->LAD occluded, very small vessel distally and LAD not visualized through LIMA LVEDP 16 Cypher to left main, unable to deploy Taxus to LAD with resulting major dissection and thus bare metal stent to the LAD to cover the dissection ROS: Positive for shortness of breath with chest pain, able to exercise up 2 flights of stairs without difficulty, no orthopnea, lower extremity edema or recent weight gain or loss. Denies any blood in stool/urine. Past Medical History: CAD s/p emergent CABG in [**2088**] (SVG->RCA, OM and LIMA->LAD) Hyperlipidemia Heavy EtOH use (10-14 beers/day for 15 years) Heavy tobacco use (2-2.5 ppd x 35 years) Social History: The patient is a retired firefighter and now works as a carpenter. He admits to heavy tobacco use with 2-2.5 ppd for at least 35 years and his wife states he last smoked the day before admission. He also drinks 10-14 beers/day for 15 years and last drank EtOH the day before admission. He denies any history of DTs, seizures, or alcohol withdrawal. He also denies any history of IV drug use, cocaine, or other illicit drug use. Family History: Father - MI with CABG at 83 Mother - with heart problems Siblings - [**Name2 (NI) **] medical problems Physical Exam: Tc=98 P=70 BP=157/77 RR=16 97% on RA Gen - NAD, AOX3 HEENT - PERLA, no JVD, no carotid bruits bilaterally Heart - Holosystolic murmur best heard at left upper sternal border not radiating to carotids, regular rate and rhythm Lungs - CTAB (anteriorly) Abdomen - Soft, NT, ND + BS no bruits Ext - no C/C/E, right groin no hematoma/bruits, +2 d. pedis bilaterally Pertinent Results: ECHO Study Date of [**2101-2-7**] Left Ventricle - Ejection Fraction: 30% to 35% (nl >=55%) Conclusions: 1. The left atrium is normal in size. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed. Resting regional wall motion abnormalities include apical, distal [**11-29**] of the LV, and mid-septal akinesis with mid anterior wall hypokinesis.. 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. At least moderate (2+) mitral regurgitation is seen. 6.There is no pericardial effusion. Cardiology Report ECG Study Date of [**2101-2-4**] 5:41:20 PM Sinus rhythm. Since the previous tracing of [**2101-2-4**] the ST segment elevations in leads V1-V3 are less apparent and T wave inversions are less prominent suggesting evolution of anterior myocardial infarction. C.CATH Study Date of [**2101-2-4**] COMMENTS: 1. Selective native coronary angiography of this right dominant system revealed left main and severe three vessel CAD. The LMCA was heavily calcified with a 90% ostial stenosis. The LAD was diffusely diseased in it proximal-to-mid segment up to 90% until the takeoff of the first high diagonal branch. It too was heavily calcified. The LCx was occluded proximally. There was a medium caliber ramus intermedius branch that had moderate diffuse disease up to 70% in the mid-portion of the vessel. The RCA was a dominant vessel that had proximal diffuse disease and was occluded in its mid-portion. Distal competitive filling via the SVG was seen distally. 2. Graft and conduit angiography revealed a patent SVG-OM, with retrograde filling of a small portion of the circumflex and a second obtuse marginal branch. The SVG-dRCA was likewise patent and supplied a mildly diffusely diseased PDA and PL branch. The LIMA-LAD was distally atretic, and appeared to be occluded at the anastamotic site. 3. Limited resting hemodynamic measurements revealed normal systemic arterial pressures, with normal left sided filling pressures (LVEDP was 16-18 mm Hg). Left ventriculography and left ventricular pullback was not performed. 4. Successful PTCA/stenting of the LMCA with a 3.5x13mm Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] with a 4.0mm balloon followed by PTCA/stenting of the proximal/mid LAD with a with a 2.25mmx18mm Pixel bare metal stent. Final angiography revealed a 20% residual stenosis in the LMCA, none in the LAD stent but residual diffuse disease proximal and distal to the stent up to 30%, TIMI-3 flow (see PTCA comments). FINAL DIAGNOSIS: 1. Severe three vessel and left main coronary artery disease. 2. Patent SVG-OM, SVG-dRCA, and occluded LIMA-LAD. 3. PCI of the LMCA. 4. PCI of the LAD. Brief Hospital Course: The patient is a 56 year old male with a significant smoking and alcohol history, severe 3 vessel disease s/p emergent CABG in [**2088**] (LIMA->LAD, SVG->RCA, SVG->OM) who presented to his PCP with an [**Name9 (PRE) **] with a more than 3 week history of increasing rest angina. 1. CAD - The patient had a Cypher placed to the left main and a failed attempt at a Taxus stent to his LAD which was complicated by a coronary dissection ameliorated with a bare metal stent on [**2101-2-4**]. - The patient states he took Lopressor 50 mg QD at home with aspirin and lipitor 10 mg. We increased his lipitor to 40 mg and started Lopressor 12.5 TID and changed this to Toprol XL 50 mg on discharge with aspirin and plavix x 9 months. We started Captopril 6.25mg TID for better BP control and changed this to Lisinopril 5 mg in the setting of an acute MI. - His lipid panel showed an LDL of 105 with an HDL of 64. His LFTs were within normal range. - The patient had an echocardiogram on [**2101-2-7**] which showed an EF of 30-35% with apical, distal [**11-29**] of the LV, and mid-septal akinesis with mid anterior wall hypokinesis. The decision to anticoagulate this patient rested on his history of heavy daily EtOH use. We decided against using coumadin as he drinks a large amount. This may be readdressed with the patient's primary cardiologist. 2. Heavy EtOH Use - The patient drinks up to 15 beers a day with his last drink of similar amount the day prior to admission. He denies ever having had delirium tremens or signs of alcohol withdrawal. However, he was placed on a CIWA protocol in the ICU but did not require any diazepam. He showed no signs of alcohol withdrawal and was encouraged to cut down significantly on his alcohol intake. 3. Heavy tobacco use - The patient also has a history of heavy current tobacco use. He did not wish to start a nicotine patch. We discussed the risks and benefits of continued smoking and his higher risk for coronary artery disease if he continues to smoke and he understands these risks. 4. Hypertension - The patient was titrated to Toprol XL 50 mg and Lisinopril 5 mg with no difficulty. Medications on Admission: Atorvastatin 10 mg Aspirin Lopressor 50 mg PO QD 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). Disp:*30 Tablet(s)* Refills:*9* 3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 6. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as needed as needed for chest pain: Place one tablet under the tongue as needed for chest pain up to three doses 5 minutes apart. If your chest pain persists, please call 911. Disp:*30 30* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: ST elevation myocardial infarction Discharge Condition: Stable. Discharge Instructions: Please return to the ER or call 911 if you experience any recurrent chest pain. You MUST take your plavix every day for the next 9 months. Failure to do so may result in another heart attack or even death. Followup Instructions: Provider: [**Name10 (NameIs) **],[**First Name3 (LF) 251**] T [**Telephone/Fax (1) 4475**] Appointment should be in [**6-5**] days Please follow up with your cardiologist at [**Hospital1 **] in 4 weeks.

[ "998.2", "401.9", "276.1", "305.1", "V70.7", "410.81", "E870.6", "305.00", "V45.81", "272.0" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.07", "36.05", "36.06", "37.22", "99.20" ]

icd9pcs

[ [ [] ] ]

9788, 9794

6658, 8797

324, 460

9873, 9882

3697, 6464

10137, 10346

3193, 3297

8897, 9765

9815, 9852

8823, 8874

6481, 6635

9906, 10114

3312, 3678

274, 286

488, 2541

2563, 2732

2748, 3177

16,265

151,953

54222+59588

Discharge summary

report+addendum

Admission Date: [**2103-7-18**] Discharge Date: [**2103-8-3**] Date of Birth: [**2048-8-9**] Sex: M Service: MED HISTORY OF PRESENT ILLNESS: A 53-year-old male Ethiopian with history of intracerebral hemorrhage most likely from hypertension in the cerebellar region near the fourth ventricle one month ago, [**2103-6-19**], that presents with decreased energy and emesis times one week at rehab. The patient currently in rehab and was here in the Emergency Department one day prior to admission and diagnosed with a urinary tract infection and treated with Levaquin. CT of the abdomen showed gallstone but no other pathology. The patient states he vomits up everything he eats including medications. It is green and he occasionally has blood. He complains of dizziness that feels like the room is spinning. The patient worsens after food intake. No fever or upper respiratory infection. No diarrhea. PAST MEDICAL HISTORY: Back pain status post fall with back and neck injuries [**2103-5-10**]; status post cerebellar hemorrhage [**2103-6-19**]; status post ventricular drain; hypertension. MEDICATIONS: Reglan 25 b.i.d., Levaquin 500 q. day, citalopram 20 q. day, Megace 40 b.i.d., milk of magnesia, bisacodyl, captopril 75 t.i.d., nicardipine 20 q. 8h., metoprolol 75 b.i.d., heparin 5000 subcutaneous b.i.d., Tylenol q. 6h., Percocet q. 6h. as needed. SOCIAL HISTORY: Worked as [**Doctor Last Name **] at the airport but has been in rehab for a month. No alcohol, no tobacco personally. FAMILY HISTORY: Two brothers had cholecystic disease. PHYSICAL EXAMINATION: 98.8, 164/110, 84, 18, 98 percent on room air. No apparent distress. Alert and oriented times three. Cachectic appearing. Moist mucus membranes. Oropharynx moist. Regular rate without murmur. Clear to auscultation bilaterally. Soft, diffusely tender, no guarding, no rigidity, faint bowel sounds. No clubbing, cyanosis or edema. Warm. Dorsalis pedis's 2 plus. RADIOLOGY: CT of the abdomen and kidneys showed gallstone, mild ascending colon dilation. LABORATORY: Urinalysis was completely normal. No signs of infection. White count 4.6, hematocrit 37.3, platelet count 374,000. Electrolytes were unremarkable. Liver function tests were within normal limits except for an alk phos of 134. HOSPITAL COURSE: Nausea and emesis: Neurology and Neurosurgery were consulted. It was felt that the nausea and emesis were due to irritation of the edema and blood that stills surrounds the fourth ventricle which is near the chemotactic area. The patient had a repeat MRI and CT scan which showed no further hydrocephalus. The patient was transferred for one day to the Neurosurgery Intensive Care Unit for a ventricular drainage which showed an opening pressure of 13-14 cm which was within normal limits. They also drained some fluid with only modest improvement in nausea and dizziness. The patient slowly recovered. He was treated with ondansetron and Ativan to try to alleviate the nausea. He has been slowly improving his oral intake and is taking nectar, thick liquids and soft solids. Each day the patient seems to have modest improvements. Neurology also wanted the patient to be on glycerine one ounce four times a day to try to decrease the swelling surrounding that fourth ventricle which is near the chemotactic area. Hypertension: The patient has very difficult hypertension to manage. He is currently taking atenolol and captopril. He may need increases in these doses with goal systolic blood pressures around 140. Vertigo: The patient has sort of difficulty tracking things with his eye movements. The neurologist felt that this was not vertigo, however, and that is all related to the intracerebellar hemorrhage. Urinary tract infection: There were no signs of UTI in the old UA or the new one so the Levaquin was discontinued. DISPOSITION: The rest of this discharge summary will be dictated when the patient is discharged. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 27875**] Dictated By:[**Last Name (NamePattern1) 14382**] MEDQUIST36 D: [**2103-7-31**] 11:30:19 T: [**2103-7-31**] 11:53:48 Job#: [**Job Number **] Name: [**Known lastname 18235**],[**Known firstname 18236**] G. Unit No: [**Numeric Identifier 18237**] Admission Date: [**2103-7-18**] Discharge Date: [**2103-8-3**] Date of Birth: [**2048-8-10**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1775**] Chief Complaint: nausea and vomiting Major Surgical or Invasive Procedure: TBI/ICH one month ago ([**2103-6-19**]), s/p Ventricular Drainage History of Present Illness: HPI: 53 YO male ethiopian with Hx of TBI/ICH 1 month ago ([**2103-6-19**]) that presents with decreased energy and emesis x1 week. CT of abdomen showed Gallstone but no other pathology. Pt states vomits up everything he eats including meds. Vomit is "green" and occasionally has blood. He c/o dizziness that feels like room spinning. Pt worsens after food intake. No fever, URI, no diarrhea. Past Medical History: PMH: Back pain s/p fall with back and neck injury 4/32/04 s/p cerebellar hemorrhage [**2103-6-19**] s/p ventricular drain. hypertension Brief Hospital Course: Due to the patients persistent nausea and green-tinged emesis, an MRCP was performed to rule out biliary etiology. MRCP demonstrated a large gallstone, but no other pathology. There was no evidence of cholecystitis or biliary duct obstruction. His nausea/emesis has slowly improved over the course of this hospitalization. However, he still requires IV anti-emetic therapy for control of his symptoms. Discharge Medications: 1. Ondansetron 8 mg IV TID 2. Lorazepam 0.5 mg IV QID nausea 3. Glycerin 50 % Solution Sig: One (1) ounce PO QID (4 times a day). 4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 5. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 8. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal QD (once a day) as needed. Suppository(s) 10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for for pain. 11. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for GI upset Discharge Disposition: Extended Care Facility: [**Hospital3 14**] & Rehab Center - [**Hospital1 15**] Discharge Diagnosis: Nausea with Emesis Discharge Condition: Nausea/emesis improved on IV anti-emetics, Blood pressure stable. No pain concerns. Discharge Instructions: Please notify your physician if your nausea or vomiting worsens, if you vomit up blood, if you have abdominal pains or headaches, or if you develop a fever. Followup Instructions: F/U with PCP regarding Nausea control with oral agents, and continued Blood pressure control. The facility listed above is incorrect. The patient was discharged to [**Hospital3 **] in [**Location (un) 177**]. [**First Name11 (Name Pattern1) 1034**] [**Last Name (NamePattern1) 1778**] MD [**MD Number(2) 1779**] Completed by:[**2103-8-2**]

[ "401.9", "V12.59", "285.9", "E928.9", "574.20", "276.5", "331.4", "853.00", "787.01" ]

icd9cm

[ [ [] ] ]

[ "45.13", "02.2", "99.15" ]

icd9pcs

[ [ [] ] ]

6719, 6800

5375, 5778

4697, 4765

6862, 6947

7152, 7525

1542, 1581

5801, 6696

6821, 6841

2328, 4621

6971, 7129

1604, 2310

4638, 4659

4793, 5193

5215, 5352

1404, 1525

20,238

162,171

4469

Discharge summary

report

Admission Date: [**2156-8-7**] Discharge Date: [**2156-10-6**] Date of Birth: [**2110-10-13**] Sex: F Service: [**Doctor First Name 147**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Acute renal failure Major Surgical or Invasive Procedure: [**2156-9-2**] Tracheostomy [**2156-9-16**] Open G-tube placement [**2156-9-28**] Replacement of fenestrated tracheostomy tube with non-fenestrated tube History of Present Illness: This is a 45 year old female with end-stage renal disease secondary to diabetes mellitus (on hemodialysis since [**46**]) and now status-post a cadaveric renal transplant in [**2149**] presenting as a transfer from [**Hospital3 **] Healthcare for worsening renal function. The patient's baseline Creatinine of 1.4-1.6 after her transplant was recently elevated to 2.8. She was transferred with other ongoing issues, including Bilateral pleural infiltrates (left greater than the right) thought to be secondary to pneumonia or posisbly congestive heart failure and severe diabetic gastroparesis with persistant nausea and vomiting limiting PO intake. On an admission in [**2156-7-23**] she was shown to have bilateral lung infiltrates and was started on Unasyn; she was readmitted with exacerbation of shortness of breath on [**2156-8-5**] and drainage of pleural fluid from the level yielded 900 cc. She had an EGD for her persistant nausea on [**8-5**] which demonstrated esophagitis. On transfer to [**Hospital1 18**] [**2156-8-7**] she was expressing shortness of breath but denied chest pain or abdominal pain. She was not febrile and denied chills or rigors. She expressed some nausea. Past Medical History: IDDM for 36 yrs ESRD on HD since '[**46**] and s/p CRT 98' HTN Hip replacement MI Total abdominal hysterectomy, R salpingo-oophorectomy Gastroparesis Neuropathy Anxiety/depression Grade 2 Esophagitis Social History: Patient is a non-smoker now but has a prior tobacco history. She lives at home with family. She denies any alcohol usage. Family History: non-contributory for renal disease Physical Exam: On admission: V/S: 98.8, pulse 97, BP 129/69, RR 22, 94% on 2L General: AAO times 3, anxious CV: RRR S1+S2 no murmurs Pulm: Bilat crackles [**12-27**] to 1/2 up the lung fields L>R, increased work of breathing Abdomen: Soft, NT/ND BS normoactive, small peri-umbilical hernia easily reducible; RLQ graft non-tender, no bruit Neuro: no astericis, 2+ bilateral biceps reflexes\ Derm: no rash Extrem: no LE edema Pertinent Results: MICROBIOLOGY: [**8-9**] Blood Culture: Negative [**8-9**] LYME Serology: Negative [**8-9**] CMV Viral Load: CMV Not detected [**8-13**] Catheter Tip Culture: Negative BLOOD SEROLOGY: CRYPTOCOCCAL ANTIGEN (Final [**2156-8-13**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. [**2156-8-13**] 5:09 pm BRONCHOALVEOLAR LAVAGE: RESPIRATORY CULTURE (Final [**2156-8-15**]): OROPHARYNGEAL FLORA ABSENT. YEAST. SPARSE GROWTH. LEGIONELLA CULTURE (Final [**2156-8-24**]): NO LEGIONELLA ISOLATED. IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final [**2156-8-16**]): PNEUMOCYSTIS CARINII NOT SEEN. FUNGAL CULTURE (Final [**2156-8-27**]): [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION, OF TWO COLONIAL MORPHOLOGIES. ACID FAST SMEAR (Final [**2156-8-16**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. DIRECT INFLUENZA A ANTIGEN TEST (Final [**2156-8-16**]): Negative for Influenza A viral antigen. DIRECT RSV ANTIGEN TEST (Final [**2156-8-16**]): Negative for Respiratory Syncytial viral antigen. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2156-8-16**]): NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN. VIRAL CULTURE (Final [**2156-9-13**]): NO VIRUS ISOLATED. FUNGAL CULTURE (Final [**2156-8-27**]): [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. OF TWO COLONIAL MORPHOLOGIES. DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final [**2156-8-17**]): POSITIVE FOR VARICELLA-ZOSTER VIRUS. [**8-16**] Blood Culture: Negative [**8-17**] URINE CULTURE : YEAST. 10,000-100,000 ORGANISMS/ML Direct Antigen Test for Herpes Simplex Virus Types 1 & 2 (Final [**2156-8-17**]): Herpes Simplex Virus Types 1 and 2 not detected.. [**8-18**], [**8-19**] Stool C. Diff: Negative [**2156-8-25**] 03:29PM CEREBROSPINAL FLUID (CSF) WBC-233 RBC-4* Polys-1 Lymphs-97 Monos-2 [**2156-8-25**] 03:29PM CEREBROSPINAL FLUID (CSF) WBC-216 RBC-2* Polys-0 Lymphs-98 Monos-2 [**2156-8-25**] 03:29PM CEREBROSPINAL FLUID (CSF) TotProt-88* Glucose-55 [**8-28**], [**8-30**] Stool C. Diff: Negative [**8-30**] MRSA Screen: Negative [**9-1**] BLood Culture: Coag Negative Staph Aureus [**9-6**] VRE Swab: Negative [**9-6**] MRSA Screen: Negative VARICELLA-ZOSTER CULTURE (Final [**2156-9-14**]): NO VIRUS ISOLATED. [**2156-9-17**] URINE URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA-- pan-sensitive} [**2156-9-19**] SPUTUM GRAM STAIN-Negative ; RESPIRATORY CULTURE-Negative ; FUNGAL CULTURE-FINAL {YEAST}; ACID FAST SMEAR-Negative [**2156-9-19**] BLOOD CULTURE: Negative [**2156-9-19**] URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA-- pan-sensitive} [**2156-9-17**] BLOOD CULTURE: Negative [**10-4**] CMV Antibody level: POSITIVE FOR CMV IgG ANTIBODY BY EIA. 111.0 AU/ML. [**10-18**] Blood Culture: Negative [**10-20**] CMV Antibody level: POSITIVE FOR CMV IgG ANTIBODY BY EIA. 101.0 AU/ML. [**10-22**] Urine Culture: Negative RADIOLOGY/CARDIOLOGY: CHEST (PORTABLE AP) [**2156-8-8**] 1:14 AM IMPRESSION: Bilateral pleural effusions, with bilateral opacities, right greater than left, consistent with air space disease. CHEST (PORTABLE AP) [**2156-9-12**] 1:27 AM COMMENTS: Portable AP radiograph is reviewed, and compared with previous study of [**2156-9-10**]. The tracheostomy tube is seen in place. The right subclavian IV catheter terminates in the superior vena cava. The feeding tube is coiled within the stomach. The previously identified congestive heart failure has been improving. There is continued mild cardiomegaly. There is no evidence for pneumothorax. ECHO Study Date of [**2156-8-9**] Conclusions: 1. The left atrium is moderately dilated. The left atrium is elongated. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 3.Right ventricular chamber size and free wall motion are normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 5.The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. 6.There is a small to moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. MR CONTRAST GADOLIN [**2156-8-22**] 2:40 PM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN IMPRESSION: 1. No focal areas of restricted diffusion noted to suggest acute infarct. 2. Small vessel disease as described above. MR CONTRAST GADOLIN [**2156-8-27**] 2:58 PM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN CONCLUSION: New right thalamic hemorrhage with extension into the posterior limb of the internal capsule and into the cerebral peduncle. This most likely represents a hypertensive hemorrhage. Mastoid and paranasal sinus opacification. CT HEAD [**2156-8-28**]: Stable right thalamic hemorrhage. CT HEAD W/O CONTRAST [**2156-9-6**] 11:37 AM CT HEAD WITHOUT CONTRAST: There has been slight interval reduction in size of the right thalamic hemorrhage with surrounding edema. The ventricles are stably enlarged. No new areas of hemorrhage are present. Differentiation of the grey/white matter is otherwise preserved. There is opacification of the left sphenoid sinus and left ethmoid air cells. Additionally there is opacification of both mastoid air cells Neurophysiology Report EEG Study Date of [**2156-9-6**] IMPRESSION: This is an abnormal portable EEG due to the presence of a slow background rhythm in the theta frequency range with bursts of both generalized and independent 3 Hz delta frequency slowing in the right and left hemispheres. These findings are consistent with a mild to moderate encephalopathy. No epileptiform abnormalities were seen. [**9-10**] Left Upper Extremity Ultrasound: No evidence of deep vein thrombosis. [**9-13**] Fluorscopy: Under fluoroscopic guidance, a nasojejunal catheter was placed. Confirmatory spot radiographs demonstrate the tip within the proximal jejunum. [**9-18**] CT Head: Evolution of the right thalamic hemorrhage with slight decreased mass effect. No new areas of hemorrhage. [**9-19**] CXR: 1. Tracheostomy tube in satisfactory position. 2. Worsening pulmonary edema. [**9-20**] Left Upper Extremity Venogram: Successful left upper extremity venogram demonstrating patent subclavian and brachiocephalic veins. [**9-23**] CT Airways: High grade focal subglottic stenosis above the level of the tracheostomy tube, with an associated dominant 8 mm diameter polypoid opacity arising from the left lateral wall of the airway and resulting in high grade coronal narrowing, with near complete occlusion during expiratory phase of respiration. Diffuse severe tracheobronchomalacia below level of tracheostomy tube. Persistent diffuse bilateral alveolar process, which now appears asymmetric, affecting the right lung to a greater degree than the left. This is most likely due to asymmetrical pulmonary edema, but it is difficult to exclude other process such as a component of infection or aspiration in the right lung. [**9-26**] CXR: Extensive bilateral alveolar opacities, with worsened consolidation when compared to the prior film of [**9-19**]. [**9-27**] CXR: Progression of diffuse marked air space opacities. The differential includes edema and diffuse infection. ARDS is a possible etiology. [**9-30**] CXR: Continued cardiomegaly and bilateral patchy opacities, slightly better compared to the prior study of [**2156-9-28**]. Continued left lower lobe opacity, which may represent atelectasis vs. pneumonia [**9-30**] Left Lower Extermity Ultrasound: There is no evidence of DVT. [**9-30**] Video Swallow Study: 1) Slow oral transit. 2) Mild penetration of thin consistencies into the laryngeal vestibule, with probable trace aspiration of thin liquid, although only when given as a mixed consistency. Please see the report of the speech pathologist for further details. COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2156-10-4**] 05:20AM 6.5 3.31* 9.9* 30.3* 92 29.9 32.6 17.7* 544* [**2156-10-3**] 09:45AM 8.0 3.34* 10.3* 30.8* 92 30.8 33.4 17.7* 596* [**2156-10-2**] 06:21AM 6.2 3.25* 9.9* 30.3* 93 30.6 32.8 17.8* 581* [**2156-10-1**] 06:15AM 5.9 3.31* 10.2* 31.1* 94 30.8 32.7 17.6* 540* [**2156-9-30**] 03:03AM 6.8 3.42* 10.5* 31.9* 93 30.8 33.0 17.6* 548* [**2156-9-29**] 05:40AM 9.2 3.22* 10.0* 29.8* 93 31.1 33.7 17.7* 468* [**2156-9-28**] 03:13AM 8.7 3.55* 11.0* 32.1* 90 30.9 34.2 17.9* 486* [**2156-9-27**] 04:04AM 8.3 2.86* 8.8* 26.2* 92 30.8 33.7 18.6* 465* [**2156-9-26**] 11:14PM 10.0 2.95* 9.1* 26.9* 91 31.0 33.9 18.7* 488* [**2156-9-25**] 06:55AM 10.0 2.96* 9.3* 27.4* 93 31.4 33.8 19.1* 424 [**2156-9-24**] 07:00AM 8.2 3.17* 9.8* 29.5* 93 31.0 33.3 19.1* 459* [**2156-9-23**] 07:10AM 8.0 3.24* 10.4* 31.1* 96 32.2* 33.5 19.0* 406 [**2156-9-22**] 06:40AM 7.8 3.26* 10.1* 31.4* 96 30.8 32.1 19.3* 402 [**2156-9-21**] 06:45AM 6.5 3.27* 10.2* 30.4* 93 31.0 33.4 19.1* 339 [**2156-9-20**] 06:37AM 7.5 3.61* 10.9* 33.5* 93 30.3 32.6 19.2* 353 [**2156-9-18**] 06:10AM 8.3 3.35* 10.6* 31.4* 94 31.6 33.7 19.9* 283 [**2156-9-17**] 06:45AM 10.1 3.51* 10.9* 32.7* 93 31.0 33.3 19.5* 296 [**2156-9-16**] 06:45AM 8.3 3.44* 11.0* 32.2* 94 31.9 34.1 20.0* 304 [**2156-9-13**] 05:00AM 8.3 3.72* 11.8* 34.5* 93 31.6 34.0 20.0* 384 [**2156-9-12**] 05:00AM 9.2 3.64* 11.1* 33.9* 93 30.6 32.9 19.7* 383 [**2156-9-11**] 05:00AM 8.6 3.71* 11.6* 34.9* 94 31.2 33.2 19.9* 413 [**2156-9-10**] 09:52AM 9.5 3.67* 11.5* 33.4* 91 31.4 34.4 20.1* 401 [**2156-9-10**] 04:06AM 9.8 3.66* 11.2* 33.2* 91 30.7 33.9 19.6* 416 [**2156-9-9**] 05:45AM 9.7 3.66*# 11.2*# 32.9* 90 30.6 34.0 19.6* 418 [**2156-9-8**] 04:37AM 9.0 2.89* 8.9* 26.4* 91 30.6 33.6 21.2* 431 [**2156-9-7**] 03:39AM 8.7 3.04* 9.1* 27.6* 91 29.9 33.0 20.8* 431 [**2156-9-6**] 03:03AM 7.8 2.99* 9.1* 26.9* 90 30.3 33.8 20.5* 384 [**2156-9-5**] 03:10AM 9.2 3.39* 9.6* 29.8* 88 28.5 32.3 20.0* 409 [**2156-9-4**] 03:56AM 9.4 3.10* 9.2* 27.4* 89 29.8 33.7 20.0* 379 [**2156-9-3**] 02:58AM 13.3* 3.17* 9.4* 27.8* 88 29.6 33.8 19.4* 385 [**2156-9-2**] 03:50AM 11.6* 3.00* 9.0* 26.5* 88 29.9 33.8 17.9* 325 [**2156-9-1**] 03:01AM 13.0* 3.11* 9.3* 26.9* 87 29.8 34.4 17.1* 312 [**2156-8-31**] 03:22AM 12.1* 3.16* 9.2* 27.3* 86 29.3 33.9 16.7* 293 [**2156-8-30**] 04:00AM 13.5* 3.08* 8.9* 26.6* 86 28.8 33.4 16.4* 329 [**2156-8-29**] 04:15AM 14.2* 3.45* 9.7* 29.1* 84 28.1 33.3 16.4* 357 [**2156-8-28**] 03:30AM 16.8* 3.77* 10.6* 30.9* 82 28.2 34.3 15.8* 369 [**2156-8-27**] 03:15AM 18.1* 4.13*# 11.6*# 34.6* 84 28.2 33.7 16.1* 407 [**2156-8-26**] 03:19AM 19.6* 3.24* 8.9* 27.4* 85 27.5 32.4 16.8* 452* [**2156-8-25**] 02:51AM 20.0* 3.56* 10.0* 30.5* 86 28.1 32.8 16.7* 400 [**2156-8-24**] 03:03AM 17.0* 4.25# 12.0# 35.7*# 84 28.2 33.5 16.3* 425 [**2156-8-23**] 03:22PM 13.0* 3.20* 8.7* 26.8* 84 27.3 32.6 15.9* 400 [**2156-8-22**] 03:49AM 15.4* 3.60* 10.0* 29.6* 82 27.9 33.9 15.7* 417 [**2156-8-21**] 03:03PM 14.7* 3.81* 10.8* 30.6* 80* 28.3 35.2*# 15.7* 429 [**2156-8-20**] 03:21AM 16.9* 3.66* 10.0* 29.8* 82 27.4 33.6 15.9* 377 [**2156-8-19**] 04:20PM 19.7* 3.76* 10.4* 30.2* 80* 27.7 34.5 15.6* 357 [**2156-8-18**] 03:10AM 15.3* 3.30* 9.3* 28.4* 86 28.1 32.7 14.5 329 [**2156-8-17**] 07:45PM 15.9* 3.33* 9.4* 28.4* 85 28.3 33.2 14.5 313 [**2156-8-16**] 02:50AM 11.5* 3.56* 10.0* 29.9* 84 28.1 33.5 14.2 307 [**2156-8-15**] 02:42PM 9.5 3.50* 9.8* 29.0* 83 28.1 33.9 14.2 323 [**2156-8-14**] 03:06PM 11.4* 3.82* 10.8* 30.7* 80* 28.3 35.2* 14.0 316 [**2156-8-13**] 03:46AM 15.8* 3.62* 10.2* 30.2* 84 28.2 33.8 14.1 338 [**2156-8-12**] 04:45AM 13.4* 3.65* 10.4* 29.8* 82 28.4 34.8 14.1 375 [**2156-8-11**] 06:15AM 15.3* 3.18* 9.0* 26.7* 84 28.4 33.9 14.2 430 [**2156-8-10**] 06:00AM 16.0* 2.93* 8.0* 25.3* 86 27.4 31.7 14.0 527* [**2156-8-9**] 04:50AM 14.3* 2.96* 8.1* 24.3* 82 27.4 33.3 14.0 466* [**2156-8-8**] 11:25AM 14.3*# 3.21* 8.6*# 26.6*# 83# 26.7* 32.2 14.0 503* HEMATOLOGIC calTIBC Ferritn TRF [**2156-9-9**] 05:45AM 217* 167* [**2156-9-7**] 03:39AM 209* 229* 161* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2156-10-4**] 05:20AM 119* 37* 0.8 138 4.0 97 32* 13 [**2156-10-3**] 09:45AM 211* 33* 0.9 140 3.8 99 31* 14 [**2156-10-2**] 06:21AM 113* 31* 0.8 141 3.7 102 30* 13 [**2156-10-1**] 06:15AM 108* 29* 0.8 140 4.1 102 29 13 [**2156-9-30**] 03:03AM 63* 26* 0.8 142 3.8 101 32* 13 [**2156-9-29**] 05:40AM 276* 25* 0.9 139 3.6 98 30* 15 [**2156-9-28**] 03:13AM 130* 25* 0.8 140 4.1 100 29 15 [**2156-9-27**] 04:04AM 113* 30* 0.9 141 3.8 98 31* 16 [**2156-9-26**] 11:14PM 51* 31* 0.9 140 3.8 99 32* 13 [**2156-9-25**] 06:55AM 86 27* 0.9 137 4.2 98 30* 13 [**2156-9-24**] 07:00AM 223* 24* 0.9 134 4.0 95* 28 15 [**2156-9-23**] 07:10AM 231* 22* 0.9 133 4.3 95* 26 16 [**2156-9-22**] 06:40AM 141* 16 0.9 133 4.2 97 28 12 [**2156-9-21**] 06:45AM 249* 13 0.9 131* 4.0 98 30* 7* [**2156-9-20**] 06:37AM 134* 12 0.8 134 3.8 97 27 14 [**2156-9-18**] 06:10AM 107* 14 0.8 134 3.5 97 24 17 [**2156-9-17**] 06:45AM 75 18 0.8 136 3.9 101 24 15 [**2156-9-16**] 06:45AM 250* 28* 1.0 136 4.1 99 25 16 [**2156-9-13**] 05:00AM 175* 24* 1.1 137 4.0 104 23 14 [**2156-9-12**] 05:00AM 212* 28* 1.2* 136 3.6 100 24 16 [**2156-9-11**] 05:00AM 196* 26* 1.2* 136 4.0 99 26 15 [**2156-9-10**] 09:52AM 89 27* 1.1 138 3.7 97 31* 14 [**2156-9-10**] 04:06AM 145* 28* 1.1 136 3.4 97 27 15 [**2156-9-9**] 05:45AM 151* 28* 1.0 137 3.9 98 29 14 [**2156-9-8**] 04:37AM 74 24* 0.9 140 3.9 102 29 13 [**2156-9-7**] 03:39AM 101 26* 0.9 137 4.2 105 27 9 [**2156-9-6**] 03:03AM 169* 28* 0.9 139 3.9 105 26 12 [**2156-9-5**] 03:10AM 51* 36* 1.0 138 3.9 102 25 15 [**2156-9-4**] 03:56AM 38*1 42* 1.1 141 3.9 108 26 11 [**2156-9-3**] 02:58AM 91 44* 1.1 142 3.8 108 24 14 [**2156-9-2**] 11:52AM 74 49* 1.1 142 3.8 108 24 14 [**2156-9-2**] 03:50AM 94 49* 1.1 141 3.8 111* 23 11 [**2156-9-1**] 06:51PM 94 143 3.6 110* [**2156-9-1**] 03:01AM 88 56* 1.1 140 3.7 109* 22 13 [**2156-8-31**] 03:22AM 71 69* 1.2* 139 4.2 107 23 13 [**2156-8-30**] 04:00AM 187* 76* 1.4* 133 4.5 103 23 12 [**2156-8-29**] 04:15AM 63* 74* 1.4* 134 3.8 102 23 13 [**2156-8-28**] 03:30AM 91 71* 1.4* 136 3.8 102 25 13 [**2156-8-27**] 03:05PM 136* 68* 1.3* 140 4.1 103 27 14 [**2156-8-27**] 03:15AM 114* 65* 1.2* 143 3.6 105 28 14 [**2156-8-26**] 03:25PM 237* 66* 1.3* 145 3.8 108 29 12 [**2156-8-26**] 03:19AM 308* 65* 1.4* 145 3.6 107 27 15 [**2156-8-25**] 09:59PM 98 149* 3.3 [**2156-8-25**] 06:21PM 150* [**2156-8-25**] 01:29PM 151*1 [**2156-8-25**] 05:50AM 154*1 [**2156-8-25**] 02:51AM 89 55* 1.3* 153*1 3.1* 114* 29 13 [**2156-8-24**] 04:00PM 151*1 [**2156-8-24**] 12:00PM 109* 50* 1.3* 153*1 3.8 112* 32* 13 [**2156-8-24**] 03:03AM 197* 42* 1.3* 152*1 3.4 110* 28 17 [**2156-8-23**] 03:22PM 144* 38* 1.2* 152*1 3.7 109* 33* 14 [**2156-8-23**] 03:32AM 199* 41* 1.4* 149* 3.4 106 31* 15 [**2156-8-22**] 02:01PM 150* 36* 1.5* 148* 3.8 106 34* 12 [**2156-8-22**] 03:49AM 198* 33* 1.6* 146* 4.0 106 28 16 [**2156-8-21**] 09:46PM 229* 31* 1.6* 146* 2.7*1 105 24 20 [**2156-8-21**] 03:03PM 108* 29* 1.7* 144 2.5*1 103 30* 14 [**2156-8-21**] 04:01AM 365* 28* 2.0* 1391 3.7 96 19* 28* [**2156-8-20**] 03:46PM 183* 24* 2.3* 141 3.1* 99 21* 24 [**2156-8-20**] 03:21AM 77 24* 2.6* 138 3.4 98 24 19 [**2156-8-19**] 04:20PM 142* 24* 2.8* 138 3.7 99 21* 22* [**2156-8-19**] 03:56AM 102 23* 3.1* 136 4.0 97 23 20 [**2156-8-18**] 03:00PM 135* 23* 3.4* 138 3.6 97 22 23* [**2156-8-18**] 03:10AM 116* 21* 3.4* 136 3.2* 98 22 19 [**2156-8-17**] 05:04PM 219* 19 3.3* 136 4.3 97 23 20 [**2156-8-17**] 02:45AM 226* 17 3.3*#1 136 4.1 98 22 20 [**2156-8-16**] 02:10PM 74 30* 4.7* 134 3.6 93* 24 21* [**2156-8-16**] 02:50AM 229* 31* 4.8* 132* 3.5 92* 22 22 [**2156-8-15**] 02:42PM 83 30* 4.5* 133 3.9 95* 22 20 [**2156-8-15**] 03:11AM 280* 29* 4.4* 134 3.9 96 25 17 [**2156-8-14**] 10:30PM 344* 29* 4.3* 134 4.3 95* 24 19 [**2156-8-14**] 03:06PM 79 27* 4.0* 136 3.8 97 25 18 [**2156-8-14**] 03:46AM 178* 27* 3.8* 135 3.8 96 26 17 [**2156-8-13**] 06:46PM 123* 27* 3.8* 137 3.7 98 26 17 [**2156-8-13**] 03:46AM 451*1 21* 3.1* 134 4.3 95* 23 20 [**2156-8-12**] 05:59PM 175* 20 2.7*#1 141 3.9 99 28 18 [**2156-8-12**] 04:45AM 169* 35* 3.8* 137 4.0 97 24 20 [**2156-8-11**] 06:15AM 433* 46* 4.5*#1 1342 5.3*1 92*1 16*1 31* [**2156-8-10**] 01:30PM 110* 64* 6.0* 135 5.2* 97 23 20 [**2156-8-10**] 06:00AM 420* 58* 6.0* 130* 6.2*1 92* 20* 24* [**2156-8-9**] 04:50AM 285* 53* 5.5* 134 5.3* 95* 23 21* [**2156-8-8**] 11:25AM 287* 49* 5.0*# 137 5.4* 97 27 18 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2156-10-4**] 05:20AM 11.1* 2.9 2.6 [**2156-10-3**] 09:45AM 11.6* 2.7 2.6 LINE: R CVL [**2156-10-2**] 06:21AM 11.0* 2.5* 2.5 [**2156-10-1**] 06:15AM 10.9* 2.6* 2.6 [**2156-9-30**] 02:28PM 10.7* 2.5* 2.4 [**2156-9-30**] 03:03AM 3.2* 10.9* 2.8 2.5 [**2156-9-29**] 05:40AM 2.9* 10.8* 2.8 2.3 [**2156-9-28**] 03:13AM 11.0* 2.9 2.4 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2156-9-30**] 03:03AM 12 13 230 135* 0.2 [**2156-9-29**] 05:40AM 12 15 132* 26 0.2 [**2156-9-13**] 05:00AM 31 29 216 197* 22 0.3 [**2156-9-12**] 05:00AM 26 27 202* 22 0.2 [**2156-9-10**] 03:44AM 25*1 [**2156-8-22**] 03:49AM 15 14 118* 0.2 [**2156-8-21**] 04:01AM 18 14 109 0.3 [**2156-8-20**] 09:20PM 18 14 105 20 0.3 [**2156-8-18**] 03:10AM 23 31 115 28 0.1 [**2156-8-17**] 02:45AM 19 27 116 0.1 [**2156-8-14**] 03:06PM 11 13 107 0.2 [**2156-8-8**] 11:25AM 16 11 113 0.1 TOXICOLOGY, SERUM AND OTHER DRUGS FK506 [**2156-9-28**] 03:13AM LESS THAN 1 [**2156-9-12**] 05:00AM LESS THAN 1 [**2156-9-8**] 04:37AM LESS THAN [**2156-9-7**] 08:34AM LESS THAN 1 [**2156-9-4**] 07:41AM 3.4*1 [**2156-9-2**] 07:21AM 4.6*1 [**2156-9-1**] 08:01AM 4.4*1 [**2156-8-31**] 08:00AM 2.2*1 [**2156-8-31**] 03:22AM 2.2* [**2156-8-30**] 07:44AM 3.7*1 [**2156-8-29**] 07:55AM 5.41 [**2156-8-28**] 07:39AM 6.11 [**2156-8-27**] 08:42AM 8.21 [**2156-8-26**] 08:50AM 4.6*1 [**2156-8-25**] 07:40AM 8.31 [**2156-8-24**] 06:45AM 5.11 [**2156-8-23**] 03:32AM 4.1*1 [**2156-8-22**] 03:49AM 3.0*1 [**2156-8-21**] 07:31AM 3.8*1 [**2156-8-20**] 07:10AM 2.4*1 [**2156-8-19**] 08:49AM 2.7*1 [**2156-8-19**] 03:56AM 3.1*1 [**2156-8-18**] 03:10AM 3.7*1 [**2156-8-17**] 02:45AM 7.01 [**2156-8-16**] 02:50AM 23.2* [**2156-8-15**] 03:11AM 50.8*1 ] [**2156-8-14**] 03:46AM 83.6*1 [**2156-8-13**] 03:46AM 90.4*1 [**2156-8-12**] 04:45AM 73.2*1 [**2156-8-11**] 06:15AM 87.6*1 [**2156-8-10**] 06:00AM 93.2*1 [**2156-8-9**] 04:50AM 87.9*1 [**2156-8-8**] 03:36PM 92*1 [**2156-8-8**] 11:25AM 88.2*1 Rapamycin Levels: [**10-1**]: 15.1 [**9-30**]: 20.5 [**9-27**]: 7.5 [**9-24**]: 11.8 [**9-23**]: 7.6 [**9-22**]: 11.4 Brief Hospital Course: This is a 45 year old woman who was admitted with presumed immunosuppressant toxicity causing acute renal failure; her admission creatinine level was 3.6 and her cyclosporine level was 88. In addition, her hospital course was complicated by a hemorrhagic stroke and respiratory complications. A brief summary of her hospital course by systems is as follows: RENAL: Renal was asked to consult this patient on admission regarding her acute increase in creatinine and assessed that she had acute renal failure secondary to Prograf toxicity. She required several hemodialysis treatments for elevated serum creatinine and potassium. She was held from Prograf and started on Rapamycin for immunosuppression; cyclosporine was restarted when serum levels were lower after several days from admission, but this medication was ultimately withdrawn when the patient's Rapamycin levels were therapeutic. Her creatinine showed continued improvement and was at normal levels after hospital day 16. She was discharged with Rapamycin and Cellcept (which was started on hospital day 27) for immunosuppression. She has a follow-up appointment with the transplant nephrologist scheduled for [**10-28**]. NEURO: ON hospital day 15 the patient was noted to have an acute change in mental status, with an episode of decreased responsiveness and decreased movement of extremities on the afternoon of [**2156-8-26**]. She had an MRI of the head on [**2156-8-27**] which showed a new right thalamic hemorrhage involving the Right internal capsule (per report, findings likely secondary to hypertension); this hemorrhage was stable on subsequent imaging studies. She had a lumbar puncture which showed CSF lymphocytic pleocytosis. Her CSF cultures from [**2156-8-25**] were negative for bacteria, fungi, cryptococcus, or viruses. However given the location of her bleed, the CSF hematologic findings, and her VZV from sputum culture, the presumed diagnosis was VZV meningoencephalitis. She had an EEG performed on [**2156-9-6**] for continued slow mentation and drowsiness which demonstrated mild to moderate encephalopathy; no epileptiform abnormalities were seen. After her stroke, she had decreased ability to move her left lower and upper extremities, and decreased sensation on her left side. These findings on her exam remained unchanged following her stroke and were her findings on discharge. From a mental status standpoint, she continued to demonstrated improvement in the weeks following her stroke and resolution of presumed VZV meningoencephalitis, and was alert and oriented x 3 for several days before discharge. PULMONARY: The patient was intubated and transferred to the intensive care unit on [**8-12**] for worsening respiratory problems since her transfer and serial chest x-rays suspicious for ARDS. She was started on Bactrim impirically for presumed PCP but this was discontinued when an [**8-13**] bronchoalveolar lavage was negative. She was also Acyclovir was started for VZV cultures grown from sputum culture of [**2156-8-17**]. She was successfully extubated on [**2156-8-20**]. However, she was re-intubated on [**2156-8-27**] as a precautionary measure for decreased responsiveness secondary to her hemorrhagic event and encephaltiis. She had a tracheostomy placed on [**2156-9-2**] for continued ventilation dependence. Her respiratory function improved with Lasix diuresis. She had her fenestrated tracheostomy tube replaced on [**2156-10-8**] with a non-fenestrated tracheostomy tube after a CT of her airways revealed subglottic granulation tissue felt to be secondary to having the fenestrated tube. She was noted to breath adequately through this new trach tube and was able to tolerate several hours a day speaking with the Passy Muir valve in place after this procedure. Following replacement of her trach tube she demonstrated normal work of breathing with good O2 saturation for several days on trach-mask breathing before discharge. INFECTIOUS DISEASE: The patient was started on a ten-day course of Meropenum on [**9-20**] for Urine culture on [**9-17**] demonstrated Pseudomonas. As mentioned above, she also received a month's course of Acyclovir for presumed VZV pneumonia and VZV meningoencephalitis. Bronchoalveolar lavage for evaluation of severe pneumonia/ARDS on [**2156-8-13**] demonstrated only VZV; all other cultures from the lavage were negative. All blood cultures during her hospitalization were negative. She was tested for Babesiosis because of her leukocytosis with anemia; this was negative. Her anemia was thought to be secondary to chronic renal failure and she require several blood transfusions; her hematocrit remained in the 28-33 range for several weeks before discharge. She remained afebrile over a week prior to discharge and was not discharged on any antibiotics. GI: The patient was started on tube-feeding after it was determined that she could not tolerate PO intake; her G-tube was placed on [**2156-9-16**]. TPN was also started after 2 weeks of admission, but was discontinued after tube feeding was increased to goal. She had a speech and swallow evaluation with video swallow study on [**2156-9-30**] and was started on a pureed soft diet which she tolerated well, but continued to be dependent on tube-feeding for adequate nutritional intake by day of discharge. PSYCH: The patient was evaluated by psychiatry for anxiety and depression. She was initially held from her pre-admission regimen of ativan, but restarted on this as a non-standing treatment for occasional anxiety symptoms. Medications on Admission: On admission: Reglan 10 mg PO or IV BID Celexa 40 mg Daily Prograf 1.5 mg [**Hospital1 **] Rapamune 2.5 mg daily Protonix 40 mg [**Hospital1 **] Amitriptyline 25 mg QHS Norvasc 2.5 mg daily Erythromycin 250 mg PO TID NPH insulin 10 units qam Humalog sliding scale coverage Ativan 0.5 mg PO Q6H prn Carafte 1 g one hour before meals Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-26**] Puffs Inhalation Q4H (every 4 hours) as needed. 3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QD (once a day). 4. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 5. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution Sig: Five (5) PO BID (2 times a day). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 7. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Hydralazine HCl 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 9. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO once a day. 10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 11. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution Sig: One (1) PO BID (2 times a day). 12. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QD (once a day). 13. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO QD (once a day). 14. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-26**] Puffs Inhalation Q4H (every 4 hours) as needed. 15. Insulin Lantus 8 u QHS AND: Regular Insulin Sliding Scale (61-130) 0 units, (131-160) u units, (161-200) 4 un, 201-240) 6u, 241-280 (8 u), 281-320 (10 u), 321-360 (12 u), 351-400 (14 units). Check Q6h fingersticks 16. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed. 17. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. 18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: (1) s/p renal transplant '[**49**] (2) Prograf toxicity (3) L thalamic/L internal capsule Hemorrhagic stroke (4) Gastroparesis with tube-feeding dependence (5) VZV meningoencephalitis (6) Pseudomonas UTI (7) Anemia of chronic disease (8) Hypertension (9) Diabetes Melitus Discharge Condition: Stable Discharge Instructions: Take all medications as prescribed. Please call the Transplant office or return to the ER if any increased pain, swelling, tenderness, nausea and vomitting, chest pain, shortness of breath, significant weight gain or weight loss, or fevers. Please check Q6h fingerstick blood sugars. Please check weekly CBC, Chem 10, and serum Rapamycin levels and have results faxed to the [**Hospital1 18**] transplant center at [**Telephone/Fax (1) 697**] Followup Instructions: Provider: [**Name10 (NameIs) 970**],[**Name11 (NameIs) 971**] TRANSPLANT CENTER-MEDICINE Where: TRANSPLANT CENTER-MEDICINE Date/Time:[**2156-11-9**] 10:10 [**Last Name (LF) **], [**Name8 (MD) **] M.D., [**Last Name (un) **] DIABETES CENTER, [**2156-10-25**], 3 pm [**Last Name (LF) **], [**Name8 (MD) 177**], MD, [**Telephone/Fax (1) 7732**], [**2156-11-19**] , 1:15 pm, [**Street Address(2) 19149**], ENT [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2156-10-6**]

[ "041.7", "250.41", "428.0", "052.0", "996.81", "052.1", "518.5", "438.20", "584.5", "536.3", "078.5", "519.02", "599.0", "250.61", "285.21", "431", "E933.1" ]

icd9cm

[ [ [] ] ]

[ "03.31", "99.04", "38.93", "33.24", "43.19", "39.95", "96.04", "99.15", "88.67", "96.72", "96.6", "31.1", "97.23" ]

icd9pcs

[ [ [] ] ]

29701, 29813

21989, 27543

353, 508

30129, 30137

2587, 3489

30630, 31197

2106, 2142

27925, 29678

29834, 30108

27569, 27569

30161, 30607

2157, 2157

3525, 8707

294, 315

536, 1728

8716, 21966

27583, 27902

1750, 1951

1967, 2090

17,574

159,694

595

Discharge summary

report

Admission Date: [**2196-3-5**] Discharge Date: [**2196-4-20**] Date of Birth: [**2127-1-18**] Sex: M Service: [**Last Name (un) **] CHIEF COMPLAINT: Fevers, chills, abdominal pain in the right upper quadrant, worsening shortness of breath x1 day, pleuritic like chest pain and nausea. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old male with a history of polycystic kidney disease, status post cadaveric renal transplant in [**2190**], on Rapamune, prednisone and Gengraf. The patient has a history of polycystic liver disease with recent cyst infections treated with IV antibiotics recently, presents with 2 week history of fevers up to 101, chills, malaise and shortness of breath with increasing abdominal distention and right upper quadrant pain. The patient saw Dr. [**First Name (STitle) **] in the clinic the week prior and was instructed to go to the hospital for further evaluation. The patient felt worse, however, and came to the emergency department for evaluation and workup. The patient complained of malaise and shortness of breath but denied chest pain. He denied any anorexia or urinary symptoms or new bowel changes. He did complain of nausea and some dry heaves. The patient has a history of polycystic kidney disease with also polycystic liver disease with multiple large liver cysts, one of which became infected secondarily with a pansensitive pseudomonas following episode of ERCP induced cholangitis and bacteremia in [**2195-8-20**]. At that time, he was initially treated with PIP/TAZO, followed by recurrence of fevers and persistence of the abscess. He was drained in [**2195-10-20**], and treated with 6 weeks of Cipro plus 2 weeks of Augmentin for an unidentified gram positive cocci through late [**Month (only) 404**]. He did well through [**2196-2-17**], when he had recurrent low fevers and malaise. Repeat MRI showed enlargement of the left lateral liver abscess that was impinging on the diaphragm and pericardium. He was started on oral Cipro as an outpatient. He continued to have low grade fevers. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: Polycystic kidney disease, hypertension, GERD, endstage renal disease, status post cadaveric renal transplant in [**2190**], CHF, biliary stones, diverticulosis, chronic pancreatitis, cholestasis. PAST SURGICAL HISTORY: Cadaveric renal transplant in [**2190**], biliary stenting and an AV fistula. MEDICATIONS: At home, prednisone 5 mg, Lopressor 75 mg p.o. b.i.d., cyclosporin 25 mg b.i.d., doxazosin, Rapamune 1 mg p.o. daily, Protonix, allopurinol 50 mg p.o. b.i.d., Lasix 20 mg p.o. daily, and Bactrim single strength daily. The patient was admitted to the transplant service. Full labs were sent off. A KUB and chest x-ray were done that demonstrated massive cardiomegaly and pericardial effusion. Blood cultures and urine cultures were sent. These were subsequently negative. PHYSICAL EXAMINATION: On admission, temperature was 99.7, heart rate 89, blood pressure 133/68, respiratory rate 24, O2 saturation 96% in room air. He was mildly uncomfortable, appeared uncomfortable. No scleral icterus. EOMI. Respiratory rate regular. Lungs were decreased on the left base with end expiratory crackles at base. He was tachypneic especially when supine. Heart: Regular rate and rhythm, no murmurs, but distant sounds. Abdomen moderately distended, tender over right upper quadrant. He was tympanitic, no rebound, no guarding. Extremities: Warm, no clubbing, cyanosis, 1+ edema, no calf tenderness. GU: Enlarged prostate, normal rectal tone, guaiac positive. Neurologically, he was [**4-22**] for strength throughout. Cranial nerves II through XII grossly intact. Alert and oriented. HOSPITAL COURSE: He was started on IV Zosyn and vancomycin renally dosed with IV hydration and cardiology was consulted. After a right subclavian catheter was inserted, chest x-ray confirmed placement. The patient was transferred to the SICU, surgical intensive care unit. Cardiology was consulted for cardiac tamponade. He was found to have purulent pericarditis with pseudomonas, likely from translocation of bacteria from the abscess in the pericardium. A pericardiocentesis was done and he was drained for approximately 2-3 liters of fluid and culture was positive for pansensitive pseudomonas and second gram negative organism was not identified. He was started on IV vancomycin and Zosyn on admission. Cipro was also added for double coverage while the sensitivities of the pseudomonas and the ID of the gram negative rods were pending. The patient went to the operating room for a pericardial window and resection of the liver abscess on [**3-10**]. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], assisted by resident [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], as well as Dr. [**First Name (STitle) **] [**Doctor Last Name **]. The patient underwent left lateral segmental resection of the liver including the offending cyst which was found to be densely adherent to the undersurface of the diaphragm with frank perforation through the parietal pericardium. Please see operative report for further details. The patient was transferred to the surgical intensive care unit postoperatively with chest tubes, intubated. He remained in the surgical intensive care unit for a prolonged period of time during which time he received CVVHD for fluid overload. He also experienced atrial fibrillation and required an amiodarone drip. He was converted to a sinus rhythm and started on digoxin. He had an abdominal J-P and was draining large amounts of serosanguineous fluids as high as 1.5 liter per day. This was sent off for culture and was negative. Thoracic followed the patient for most of this hospital course. Repeat chest x-rays demonstrated no pneumothorax. His chest tubes were removed on [**3-14**], and [**3-15**]. Repeat chest x-ray demonstrated right basilar atelectasis and left effusion. He was gradually weaned from CVVHD and intermittent hemodialysis was initiated although he experienced some drops in his blood pressure. Nephrology followed the patient throughout this hospital course. During this time, he was maintained on his regularly scheduled prednisone dose. He experienced a rise in his creatinine from a baseline of 2.2 up to a high of 4. Gengraf was held as well as Rapamune in the immediate postoperative period to prevent over immunosuppression. Gengraf was resumed at 25 mg p.o. b.i.d. and Rapamune was eventually resumed at 1 mg per day. This was adjusted to 0.5 mg per day for a level of 14.4. Rapamune was later diminished to 0.5 mg once a day. He was eventually weaned from the ventilator and was stable on nasal cannula O2. His O2 saturations were satisfactory. He was eventually transferred out of the surgical intensive care unit where he was then sent down to the medical surgical unit where he had a prolonged stay for postoperative pancreatitis. His amylase and lipase increased to a high of 652 for amylase and lipase of 1403 around postoperative day 17. His liver function tests increased during this hospital course. Pancreatitis etiology was unclear. A MRCP was done. This was negative and an endoscopic ultrasound was done that showed no evidence of sludge or stones. During this time, the patient was NPO and was maintained on IV TPN. He remained on this. His diet was gradually advanced. He experienced a rise in his Amylase and Lipase. His diet was downgraded to low fat. It was felt that possibly the TPN was worsening his liver function. He was switched to postpyloric feeding tube and enteral feedings were started. Nutrition was consulted and he was initially maintained on half strength Nepro. During this time, he experienced bouts of diarrhea and some abdominal discomfort. Multiple stools were sent off for culture and C. Diff. All of these were subsequently found to be negative. His liver enzymes continued to remain elevated with an AST of 268, ALT of 112, alkaline phosphatase of 788, total bilirubin of 0.7, albumin of 2.2, his amylase and lipase trended down. His [**Location (un) 1661**]-[**Location (un) 1662**] was sent off and was negative for [**Doctor First Name 4663**]. The [**Location (un) 1661**]-[**Location (un) 1662**] was eventually removed and the site was sutured without further incident. Zosyn was continued for a total of 39 days. Vancomycin had been stopped previously given finalization of cultures which revealed pseudomonas pansensitive. Vancomycin was also stopped at the time the patient was found to be VRE positive by rectal swab. He was MRSA negative. All stool cultures were finalized and negative. Abdominal CT on [**2196-3-22**], demonstrated no evidence of pancreatitis, multiple low attenuation lesions of the liver, many of which represented cysts, but could not exclude abscesses without IV contrast. Polycystic kidneys were noted and unchanged. A pericardial and pleural effusion with subcutaneous stranding with free fluid was found to be consistent with anasarca. New air pockets were noted with surrounding soft tissue density anterior to the bladder. This was felt to be due to recent catheterization. A liver ultrasound demonstrated no gallstones, no gallbladder wall thickening. The patient remained in sinus rhythm and TTE demonstrated a moderate loculated pericardial effusion and no tamponade on [**2196-4-1**]. He also underwent a retroperitoneal ultrasound that demonstrated no evidence of biliary dilatation. The pancreas was poorly visualized on that exam. A portable KUB demonstrated feeding tube terminating in the distal duodenum without any bowel obstruction. Also during this hospital course, he had a renal transplant duplex that demonstrated patent renal vasculature with no hydronephrosis or perinephric fluid collection. His creatinine gradually decreased to a low of 2.5. Throughout this time on the medical surgical unit, he was afebrile. His blood pressure remained stable. He continued to be fluid overloaded. Hemodialysis was stopped. He was treated with IV torsemide with mild response. His weight continued to remain around 84.3 kilograms. He demonstrated some upper extremity edema. He did have a known right subclavian thrombus. His left arm appeared edematous and it was noted that he had a left IJ central line in place. On [**4-19**], he underwent an ultrasound of the left upper extremity that demonstrated no left upper limb deep venous thrombosis. In summary, the patient is a 69-year-old male with complicated hospital course, status post pericardiocentesis and left segmentectomy, complicated by postoperative pancreatitis and renal insufficiency. His nutritional status was of concern. He remained in hospital pending a rehabilitation bed for enteral nutrition. Physical therapy followed the patient and felt the patient would benefit from continuation of physical therapy to increase endurance and strength. He was ambulating in the hallway with supervision. His lungs were diminished on the left lower lobe and bibasilar crackles. Heart rate was regular. Abdomen was soft, positive bowel sounds, abdominal incision had a small open area with a 2 x 2 normal saline dressing that was changed daily and that wound was healing. Old J-P site was clean and dry as well as the old chest tube sites were well healed. He continued with 3+ bilateral edema in his legs to his knees. Labs: White count 7.5, hematocrit 27.9. His hematocrit was relatively stable. Platelet count 214,000. Sodium 136, potassium 3.5, chloride 97, CO2 of 25, BUN 65, creatinine 2.5, glucose 109. His glucoses were in the of 109 to 168. The plan is to send the patient to rehabilitation for continuation of postpyloric feeding tube feedings using Peptamen full strength with banana flakes being cycled from 6:00 p.m. to 6:00 a.m. with a goal rate of 100 cc per hour. The patient was maintained on IV heparin until Coumadin reached a therapeutic goal range of between 2 and 3. Heparin was stopped. INRs were therapeutic at 2.6 to 2.7. DISCHARGE MEDICATIONS: Tylenol 650 mg p.o. p.r.n. q.4-6 hours, albuterol 1-2 puffs MDI p.r.n. q.6 hours, Atrovent 1-2 puffs p.r.n. q.6 hours, Anzemet 12.5 mg IV q.8 hours p.r.n., Gengraf 25 mg p.o. b.i.d., prednisone 5 mg p.o. daily, Rapamune 0.5 mg p.o. daily, Dilaudid 0.5 mg p.o. p.r.n. q.6 hours, Imodium 2 mg p.o. p.r.n. b.i.d., insulin sliding scale p.r.n. q.6 hours, Phenergan 12.5 mg p.r.n. q.8 hours if no result from Anzemet, torsemide 80 mg p.o. daily, Coumadin 5 mg p.o. daily alternating with 7.5 mg p.o. every other day, Ambien 5-10 mg p.o. p.r.n. at bedtime, Protonix 40 mg p.o. daily, nitroglycerin 0.3 mg SL p.r.n. chest pain, metoprolol 37.5 mg p.o. b.i.d. DISCHARGE DIAGNOSES: 1. Polycystic liver disease. 2. Cardiac tamponade. 3. Pericardial effusion. 4. Status post cadaveric renal transplant in [**2190**], complicated by chronic renal insufficiency, pancreatitis, atrial fibrillation, right internal jugular nonocclusive thrombus, occlusive right subclavian thrombus. 5. Malnutrition. 6. Pseudomonas pericardial fluid infection treated with Zosyn. CONDITION ON DISCHARGE: Stable. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Name8 (MD) 4664**] MEDQUIST36 D: [**2196-4-19**] 17:41:54 T: [**2196-4-19**] 21:34:52 Job#: [**Job Number 4665**]

[ "518.5", "420.99", "263.9", "577.0", "751.62", "997.4", "584.9", "427.31", "996.81", "573.8", "995.92", "038.9", "423.9", "998.59" ]

icd9cm

[ [ [] ] ]

[ "37.12", "38.95", "37.21", "45.13", "50.29", "38.93", "37.0", "39.95", "96.72", "34.09", "96.6" ]

icd9pcs

[ [ [] ] ]

12727, 13125

12053, 12706

3741, 12029

2355, 2921

2944, 3723

171, 308

337, 2110

2133, 2331

13150, 13411

65,002

127,453

38611

Discharge summary

report

Admission Date: [**2136-2-11**] Discharge Date: [**2136-2-12**] Date of Birth: [**2078-7-28**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2763**] Chief Complaint: transfer for cirrhosis Major Surgical or Invasive Procedure: intubation, a line placement History of Present Illness: 57-year old man with PMH of alchoholic cirrhosis with portal hypertensive gastropathy and esophagitis who initially presented on [**2136-1-28**] to [**Hospital6 2561**] with weakness and lightheadedness who is now presenting with worsening liver failure, renal failure, hypotension and encephalopathy. Briefly, at the OSH, he was admitted for above. He was also acting confused and had epistaxis. He was newly jaundiced and had pain in his R shoulder and R knee. During his hospitalization he was found to have MSSA bacteremia, probable endocarditis, with septic emboli to brain, ARF, and worsening bilirubinemia. First, respiratory-wise, he was intubated on [**2-3**] for an AC joint washout. He was diuresed and extubated. His respiratory status stayed stable. As for his infection, he was started on azithro/ceftriaxone for PNA initially. Then blood cx on [**1-28**] grew MSSA. He was switched to vanco. Then again switched to oxacillin/levoflox for eye penetration of his vitreous infection. Ophtho followed. A TTE was performed and showed no vegetation, and a TEE was deferred because of risks and the mortality of cardiac surgery would be so high, that the management would not change. He did have a shoulder washout with cultures that grew MSSA. His WBC trended upward. He had worsening pancytopenia and multiple transfusions while at OSH. He also had worsening ARF. He became oliguric and the thought was that it was secondary to NSAIDs and sepisis. He was dialyzed once and his Cr improved and his urine output increased. Over the last few days, his BUN and Cr have continued to rise again. He also was thought to have septic emboli to his brain. He had asterixis but was conversational until the day of transfer when his lethargy worsened. On the floor, initial vs were T 98.6, P 90, BP 119/42, R 12, O2 sat 97% on 2L. Patient was intubated for airway protection as he was gurgling and not responding. He was posturing. He withdrew to pain only minimally. He was continued on his levofed gtt. Propofol was tried for sedation, but not tolerated because of hypotension. Fentanyl and versed was started for sedation. Unable to obtain ROS. Past Medical History: ETOH cirrhosis with ascites Portal Gastropathy HTN Social History: married, 3 children and works as police detective. - Tobacco: none - Alcohol: hx of etoh abuse, quit [**8-2**] after detox at [**Hospital 7301**], was drinking approximately - Illicits: none Family History: non-contributory, unable to obtain, per report no liver dx in family Physical Exam: Vitals: T: BP: 97/53 P: 97 R: 15 O2: 95% @ 50% General: Unarousable HEENT: Sclera severely icteric, MMM Lungs: coarse crackles and rhonchorous noises in all fields bilaterally CV: RRR, almost unable to hear over coarse breath sounds Abdomen: soft, non-tender, distended, hyperactive bowel sounds Ext: 4+ pitting edema bilaterally Skin: bright yellow, sporadic spider angiomas across upper torso Pertinent Results: LABS: [**2136-2-11**] 11:56PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2136-2-11**] 11:56PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-NEG PH-5.5 LEUK-TR [**2136-2-11**] 11:56PM URINE RBC-81* WBC-9* BACTERIA-MOD YEAST-NONE EPI-0 [**2136-2-11**] 11:56PM URINE GRANULAR-1* [**2136-2-11**] 10:39PM TYPE-CENTRAL VE PO2-50* PCO2-23* PH-7.38 TOTAL CO2-14* BASE XS--9 [**2136-2-11**] 10:39PM LACTATE-2.4* NA+-127* K+-4.2 [**2136-2-11**] 10:39PM freeCa-1.08* [**2136-2-11**] 10:22PM GLUCOSE-91 UREA N-138* CREAT-4.5* SODIUM-126* POTASSIUM-4.4 CHLORIDE-94* TOTAL CO2-12* ANION GAP-24* [**2136-2-11**] 10:22PM estGFR-Using this [**2136-2-11**] 10:22PM ALT(SGPT)-21 AST(SGOT)-48* CK(CPK)-27* ALK PHOS-101 TOT BILI-23.7* [**2136-2-11**] 10:22PM CK-MB-NotDone cTropnT-0.25* [**2136-2-11**] 10:22PM ALBUMIN-2.2* CALCIUM-8.0* PHOSPHATE-9.1* MAGNESIUM-2.5 [**2136-2-11**] 10:22PM WBC-20.7* RBC-2.82* HGB-8.4* HCT-23.8* MCV-84 MCH-29.6 MCHC-35.2* RDW-18.7* [**2136-2-11**] 10:22PM NEUTS-91.3* LYMPHS-5.1* MONOS-2.9 EOS-0.4 BASOS-0.2 [**2136-2-11**] 10:22PM PLT COUNT-117* [**2136-2-11**] 10:22PM PT-37.7* PTT-107.9* INR(PT)-3.9* CT HEAD: Large intraventricular and probable left thalamic hemorrhage with moderate hydrocephalus. Brief Hospital Course: 57M with EtOH cirrhosis and worsening liver failure, encephalopathy, renal failure, leukocytosis and known MSSA septic emboli transferred from [**Hospital1 18**]. # ETOH cirrhosis/acute liver failure: has liver failure with new encephalopathy, jaundice, and coagulopathy. Not improving. Per liver consult the patient is not a transplant candidate. Initially treated with with octreotide, midodrine, blood products and lactulose. Individual problems discussed below. # Hypotension: likely septic shock in the setting of rising WBC. Transferred on low dose levofed and tolerating well. Did not tolerated propofol because of hypotension. Levofed gtt started initially. Infectious workup as below. # Hyperbilirubinemia: [**12-27**] liver failure. # Coagulopathy: worsening coagulopathy and is oozing from nose and NG tube. INR is 3.9 and PTT over 100. Initially given FFP and vitamin K via NGT. # Altered mental status: ICH found on CT. Possibly also with encephalopathy from liver failure and contribution from uremia. Patient intubated for airway protection. Extubated as discussed below. # Acute Renal Failure: has worsening renal failure with rising BUN and Cr. Likely has uremia, although electrolytes are stable. Was dialyzed once at OSH. Is not oliguric. Initially treated with IVFs/levofed for kidney perfusion. Renal consulted, however patient not considered suitable candidate for HD line and dialysis. # Anion Gap Acidosis: likely from combination of renal failure and lactic acidosis. Would not benefit from HCO3 because worsens encephalopathy when broken down across the BBB. # Leukocytosis/MSSA bactermia: rising leukocytosis and known MSSA bactermia. [**Month (only) 116**] have new source of infection. Etiologies could be line infection, SBP, or c. diff. Cultures pending. Initially started on broad antibiotics which were stopped given decision to make patient CMO. # Hyponatremia: Likely from hypervolemic hyponatremia in the setting of cirrhosis and ascites. # GI Bleeding: Ongoing bleeding from NG tube, guiac positive. Hemodynamically stable on night of admission. Initially transfused with RBCs and FFP. # Respiratory Failure: intubated for altered mental status and inability to protect his airway. Patient terminally extubated after decision to make CMO as discussed below. # CODE STATUS/GOALS OF CARE: Family meeting on second day of hospitalization to discuss poor prognosis. Patient has intracranial bleed, end stage liver and renal failure. Family made aware that he will not recover from these illnesses. Decision was made to become comfort measures. Dr. [**Last Name (STitle) **] was present for the meeting, as was a social worker and the patient??????s nurse [**Last Name (Titles) **]. The family will visit right now and plan for extubation later today. The patient was extubated in the early afternoon of [**2-12**] and he slowly became bradycardic, hypotensive, bradypneic, and expired at 16:05. Medications on Admission: Calcium Acetate Capsule 1334mg Oxacillin Sodium 2gm Hydromorphone Lansoprazole 30mg [**Hospital1 **] Norephinephrine 4mg per criteria Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Terminal Extubation Liver Failure Intraventricular Hemorrhage Discharge Condition: Pt. expired Discharge Instructions: Pt. expired Followup Instructions: Pt. expired [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]

[ "444.89", "401.9", "276.2", "449", "431", "530.10", "038.11", "518.81", "785.52", "789.59", "331.4", "276.1", "286.9", "584.9", "571.2", "570", "578.9", "572.2", "537.89", "995.92", "572.3", "303.93" ]

icd9cm

[ [ [] ] ]

[ "96.04" ]

icd9pcs

[ [ [] ] ]

7820, 7829

4664, 5570

319, 349

7935, 7949

3329, 4540

8009, 8116

2827, 2897

7792, 7797

7850, 7914

7633, 7769

7973, 7986

2912, 3310

257, 281

377, 2527

4549, 4641

5585, 7607

2549, 2602

2618, 2811

79,846

133,107

54971

Discharge summary

report

Admission Date: [**2106-5-28**] Discharge Date: [**2106-6-5**] Date of Birth: [**2037-10-29**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: Coronary artery bypass grafting times three (LIMA>LAD, SVG>OM, SVG>PDA) [**6-1**] History of Present Illness: Mr. [**Known lastname 112250**] is a 68 year old male with multiple cardiac risk factors who presents with multi-vessel coronary artery disease on catheterization. He sought cardiac evaluation after his brother unexpectedly required coronary bypass surgery. He is quite active baseline, swimming [**12-14**] mile every day without any problems. A stress test showed normal exercise tolerance but a fixed anterior defect on perfusion study, and catheterization revealed three vessel coronary artery disease. He is transferred for surgical evaluation. Past Medical History: Hypertension Coronary Artery Disease Hyperlipidemia Diabetic Kidney Disease Diabetes Mellitus, Type II Erectile Dysfunction Social History: Mr. [**Known lastname 112250**] [**Last Name (Titles) **] from customer relations for [**Company **]. He denies having smoked or used illicit drugs. Family History: Mr. [**Known lastname 112251**] two older brothers with had myocardial infarctions at greater than 65 years of age. Physical Exam: Pulse: 68 Resp: 20 O2 sat: 98% RA B/P Right: 163/78 Left: Height: 5'[**04**]" Weight: 182 lbs Five Meter Walk Test #1_______ #2 _________ #3_________ General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: p Left: p DP Right: p Left: p PT [**Name (NI) 167**]: p Left: p Radial Right: p Left: p Carotid Bruit Right: NO Left: NO Discharge Exam: VS: T 98.8 HR: 47-63 SB SBP: 116-130/50 Sats: 98% RA BS 167/178/184 Wt: 85.3 General: 68 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR normal S1,S2 no murmur Resp: diminished breath sounds at base otherwise clear GI: benign Ext: warm 2+ edema Incision: sternal clean, dry, intact, no erythema or click. RLE VV site clean dry intact Neuro: awake, alert oriented Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 4075**] [**Hospital1 18**] [**Numeric Identifier 112252**] (Complete) Done [**2106-6-1**] at 9:10:14 AM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 18**] - Department of Cardiac S [**Last Name (NamePattern1) 439**], 2A [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2037-10-29**] Age (years): 68 M Hgt (in): 70 BP (mm Hg): 107/58 Wgt (lb): 180 HR (bpm): 54 BSA (m2): 2.00 m2 Indication: Abnormal ECG. Chest pain. Coronary artery disease. Hypertension. Mitral valve disease. ICD-9 Codes: 745.5, 402.90, 786.51, 424.0 Test Information Date/Time: [**2106-6-1**] at 09:10 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 #: 2012AW3-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Left Ventricle - Stroke Volume: 83 ml/beat Left Ventricle - Cardiac Output: 4.49 L/min Left Ventricle - Cardiac Index: 2.24 >= 2.0 L/min/M2 Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: 3.5 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm Aorta - Ascending: 3.3 cm <= 3.4 cm Aorta - Arch: 2.6 cm <= 3.0 cm Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 9 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 5 mm Hg Aortic Valve - LVOT VTI: 24 Aortic Valve - LVOT diam: 2.1 cm Findings LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH. Normal LV cavity size. Mild regional LV systolic dysfunction. Low normal LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. No atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate ([**12-14**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the patient. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Resting bradycardia (HR<60bpm). Results were Conclusions for post-bypass data Conclusions PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the apex and apical segments. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-14**]+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at time of surgery. POST-BYPASS: The patient is atrially paced. The patient is on a phenylephrine infusion. Biventricular function is unchanged. Mitral regurgitation is now mild (1+). The aorta is intact post-decannulation. CXR: [**2106-6-5**]: Small left lower lobe effusion with bilateral atelectasis Labs: [**2106-6-4**] WBC-7.9 RBC-2.70* Hgb-8.6* Hct-25.4* MCV-94 MCH-31.8 MCHC-33.8 RDW-12.2 Plt Ct-202 [**2106-5-28**] WBC-10.0 RBC-4.36* Hgb-13.4* Hct-41.6 MCV-95 MCH-30.8 MCHC-32.3 RDW-12.1 Plt Ct-410 [**2106-6-4**] Glucose-167* UreaN-29* Creat-1.1 Na-136 K-4.4 Cl-101 HCO3-29 [**2106-5-28**] Glucose-204* UreaN-24* Creat-1.5* Na-135 K-4.7 Cl-100 HCO3-26 [**2106-5-28**] ALT-35 AST-42* LD(LDH)-213 CK(CPK)-110 AlkPhos-45 Amylase-62 TotBili-0.3 [**2106-5-28**] Lipase-74* [**2106-5-28**] %HbA1c-6.0* eAG-126* [**2106-6-1**] MRSA SCREEN (Final [**2106-6-3**]): No MRSA isolated. Brief Hospital Course: The patient was brought to the Operating Room on [**6-1**] where the patient underwent a coronary artery bypass grafting times three (LIMA to LAD, SVG to OM, SVG to PDA). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. post-operative day one found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. His metformin was restarted along with a insulin sliding scale to maintain blood sugars <150. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on post-operative day four the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from outside record. 1. Finasteride 5 mg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Amlodipine 5 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. fenofibrate micronized *NF* 200 mg Oral daily 6. Rosuvastatin Calcium 10 mg PO DAILY 7. LeVITRA *NF* (vardenafil) 20 mg Oral daily prn erectile dysfunction Discharge Medications: 1. Finasteride 5 mg PO DAILY 2. MetFORMIN (Glucophage) 1000 mg PO BID 3. Acetaminophen 650 mg PO Q4H:PRN pain/fever 4. Aspirin EC 81 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. fenofibrate micronized *NF* 200 mg Oral daily 7. LeVITRA *NF* (vardenafil) 20 mg Oral daily prn erectile dysfunction 8. Rosuvastatin Calcium 10 mg PO DAILY 9. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 Tablet(s) by mouth once a day Disp #*5 Tablet Refills:*0 10. Potassium Chloride 20 mEq PO DAILY Hold for K+ > 4.5 RX *Klor-Con M20 20 mEq 1 20 mEq by mouth once a day Disp #*5 Tablet Refills:*0 11. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg 1 Tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 12. Metoprolol Succinate XL 12.5 mg PO DAILY RX *metoprolol succinate 25 mg 0.5 (One half) Tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 13. Oxycodone-Acetaminophen (5mg-325mg) [**12-14**] TAB PO Q4H:PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg [**12-14**] Tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Coronary artery disease Hypertension Hyperlipidemia Diabetic Kidney Disease Diabetes Mellitus, Type II Erectile Dysfunction Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call the office [**Telephone/Fax (1) 170**] for a wound check in 1 week Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2106-7-8**] at 1:15pm in the [**Hospital **] Medical Building [**Last Name (NamePattern1) **] [**Apartment Address(1) **] A Cardiologist Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 5424**] [**2106-6-24**] at 1:30pm Please call to schedule the following: Primary Care Dr.[**Last Name (STitle) 50167**] in [**3-18**] weeks ([**Telephone/Fax (1) 91791**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2106-6-5**]

[ "424.0", "V58.67", "403.90", "584.9", "272.4", "583.81", "V17.3", "414.01", "250.40", "585.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10643, 10718

7916, 9144

323, 407

10886, 11042

2643, 7893

11914, 12684

1322, 1440

9586, 10620

10739, 10865

9170, 9563

11066, 11891

1455, 2165

2181, 2624

271, 285

435, 990

1012, 1138

1154, 1306

12,937

179,216

47255

Discharge summary

report

Admission Date: [**2185-9-21**] Discharge Date: 08/23-24/[**2185**] (pending rehab placement) Service: HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old female with known coronary artery disease documented in [**2182**] with an ejection fraction of approximately 30-35%, who had been managed medically and was living an active lifestyle. She had been experiencing some chest pain and worsening shortness of breath and orthopnea. On the night prior to admission, the patient had worsening chest pain and presented to the emergency room for evaluation. Upon arrival, she complained of chest pain and the electrocardiogram showed new lateral ST depressions concerning for acute ischemia. Her cardiac enzymes were positive for a CK leak with a troponin of 43. Her chest x-ray was consistent with congestive heart failure. The patient was given sublingual nitroglycerin, morphine, beta blockers and aspirin and was started on a heparin drip. The cardiology service was consulted and the patient was taken for a cardiac catheterization. PAST MEDICAL HISTORY: The past medical history was significant for coronary artery disease with previous echocardiograms documenting an ejection fraction of 30-35%, hypertension, colon cancer status post partial colectomy, partial deafness and right eye blindness secondary to eyeball rupture. MEDICATIONS ON ADMISSION: Her medications at home included aspirin, Lipitor, Zestril, Lopressor, Fosamax, nortriptyline and Imdur. ALLERGIES: The patient had no known drug allergies. SOCIAL HISTORY: The patient lived at home with her husband, who was also very active per her primary care physician. PHYSICAL EXAMINATION: On examination, the patient was afebrile with vital signs stable. The heart rate was 84 and the blood pressure was in the 150s/70s. The oxygen saturation was 90-98% on a nonrebreather mask. The heart had a regular rate and rhythm with no murmurs, rubs or gallops. The lungs had crackles bilaterally. The abdomen was soft, nontender and nondistended. The extremities revealed no clubbing, cyanosis or edema with palpable dorsalis pedis pulses. HOSPITAL COURSE: The patient was taken to the cardiac catheterization laboratory and catheterization revealed diffuse disease of the left anterior descending artery, a 40% ostial lesion of the left main coronary artery, a 90% proximal lesion of the left circumflex coronary artery and a 100% mid lesion of the right coronary artery. An intra-aortic balloon pump was placed, the patient was transferred to the unit and the cardiac surgery service was consulted. On the following day, the intra-aortic balloon pump was removed and the patient was managed medically and stabilized. On [**2185-9-26**], the patient underwent coronary artery bypass grafting times four. She received a left internal mammary artery graft to the left anterior descending artery and saphenous vein grafts to the first obtuse marginal artery and right posterolateral vein as a sequential graft as well as another saphenous vein graft to the diagonal artery. The patient tolerated the procedure well and was transferred to the unit in stable condition. The patient was maintained on milrinone drip at 0.5 mg overnight, which was weaned on the following day. The patient was also extubated without any problems and she was transferred to the floor on postoperative day #1. On postoperative day #2, the patient was noted to be extremely stable as she remained afebrile with stable vital signs. She had mild hypertension and thus her Lopressor was increased from 25 to 50 mg p.o. b.i.d. Her Zestril was also increased from 5 to 10 mg p.o. q.d. Her chest tubes were removed and the physical therapy service was consulted. Upon the physical therapy consultant's recommendation, it was deemed that the patient would benefit best from a rehabilitation stay. On postoperative day #3, the patient remains afebrile with stable vital signs. Her blood pressure is well controlled with a heart rate of 75 and a blood pressure of 100/50. All of her chest tubes and pacing wires have been removed. The patient is currently awaiting rehabilitation placement. She will discharged to rehabilitation, as soon as a rehabilitation bed is available. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: Coronary artery disease, status post acute myocardial infarction, status post coronary artery bypass grafting times four. DISCHARGE MEDICATIONS: Lopressor 50 mg p.o. b.i.d. Zestril 10 mg p.o. q.d. Lasix 20 mg p.o. b.i.d. times five days. K-Dur 20 mEq p.o. b.i.d. times five days. Colace 100 mg p.o. b.i.d. Percocet one to two tablets p.o. every four to six hours p.r.n. Aspirin 81 mg p.o. q.d. Lipitor 10 mg p.o. q.d. Fosamax 10 mg p.o. q.d. DISCHARGE INSTRUCTIONS: The patient will follow up in rehabilitation. She should follow up with Dr. [**Last Name (STitle) 70**] in approximately three weeks. She should also follow up with her primary care physician in approximately two weeks. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Dictated By:[**Name8 (MD) 3181**] MEDQUIST36 D: [**2185-9-29**] 08:20 T: [**2185-9-29**] 09:32 JOB#: [**Job Number 100042**]

[ "733.00", "410.71", "V10.05", "424.1", "401.9", "414.01", "428.0", "998.12", "272.0" ]

icd9cm

[ [ [] ] ]

[ "88.72", "36.13", "39.61", "37.61", "37.64", "36.15", "88.56", "42.23", "37.23" ]

icd9pcs

[ [ [] ] ]

4338, 4461

4484, 4782

1413, 1573

2182, 4283

4807, 5265

1715, 2164

175, 1090

1113, 1386

1590, 1692

4308, 4317

20,240

124,434

25266

Discharge summary

report

Admission Date: [**2128-10-7**] Discharge Date: [**2128-10-20**] Date of Birth: [**2078-7-8**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8747**] Chief Complaint: Seizure and Hemorrhage Major Surgical or Invasive Procedure: Intubation Arterial line placement bilaterally. History of Present Illness: 50 year-old man with a history of HTN, chol, right parietal infarct [**8-13**], s/p R CEA (stenosis 80%) [**2128-9-30**], admitted to [**Hospital **] Hospital [**2128-10-3**] with status epilepticus and worsening left hemiparesis ([**Doctor Last Name 555**] vs new stroke), then with decreasing alertness [**10-6**] and repeat CT with parieto-occipital hemorrhage. Pt presented in [**8-13**] with left hemiparesis, had right parietal infarct, and recovered well with only mild residual hemiparesis. Workup revealed an 80% R ICA stenosis. He was discharged on ASA, lipitor and coumadin. He then underwent R CEA on [**2128-9-30**], without complications and was discharged on [**10-1**]. On [**2128-10-3**], family observed clonic movements of left arm followed by a generalized tonic-clonic seizure at home. No h/o headache or head injury. EMS arrived and en route to [**Hospital **] Hospital he had another GTC lasting 2.5 minutes, and was given valium 5mg IMx1, and he became combative and restless. He was intubated for airway protection, given morphine, ativan and 1gm fosphenytoin with good effect and resolution of seziures. Etiology of seizures was unclear. [**Name2 (NI) 430**] CT at that time showed only old right parietal stroke. Bilateral carotid ultrasound without stenosis. On exam, he had worsened left hemiparesis, unclear if due to [**Name (NI) 555**] vs new right-sided stroke. Head CT [**10-5**] unchanged, and CTA neck without carotid disease. Pt was never stable enough for MRI. On [**10-5**], motor exam was uncahnged but he was increasingly lethargic. Sedation was discontinued, and by the evening of [**10-5**] he was agitated and combative. On morning of [**10-6**] he started to become more lethargic, and this progressed over the day despite lack of sedation. He also had worsening hypertension that was refractory to labetalol, enalaprilat, and metoprolol. he was started on nipride with increased doses of enalaprilat and metoprolol with SBP 170s (goal). Due to increased lethargy, neurology consultant recommended repeat head CT which showed large right temporo-occipital bleed with extension into right ambient cistern, 5x4x1.8 cm. CT also showed diffuse edema R>L and narrowing of the ambient cistern concerning for early herniation so pt started on decadron and mannitol. Exam prior to transfer with no purposeful movement, some movement of bilateral limbs with deep sternal rub, increased tone on left, equal and reactive pupil's with +oculocephalic reflex. ROS: Unable Past Medical History: 1. Right parietal stroke [**8-13**], residual mild left hemiparesis. Per records, had multiple TIAs involving left arm and leg and then had stroke high right parietal lobe. Carotid US with >805 R ICA stenosis, echo with LVH but no siurce of embolus, no afib on tele. Rx'd acutely with heparin, then with ASA/coumadin while awaiting CEA. Workup also with normal Factor V, ATIII, Protein C and S, homocysteine [**11-22**]. 2. Hypertension 3. Hypercholesterolemia 4. R ICA stenosis (80%), s/p R CEA [**2128-9-30**] 5. COPD 6. Chronic LBP 7. Chronic eczema 8. s/p bilateral inguinal hernia repair [**2123**], vasectomy 9. Hepatitis B Social History: Lives at home with family. Works in automotive and motorcycle repair. Quit smoking a few years ago. H/o alcoholism, sober x6yrs. No other drug use. Family History: No h/o seizures, early stroke or MI Physical Exam: T 97.8 BP 194/108 HR 119 AC FiO2 1.0 650x16 PEEP 5 O2 sat 99% General: Appears stated age, intubated HEENT: NC/AT Sclera anicteric Neck: Supple. R CEA incision c/d/i, stapled Lungs: Clear to auscultation anterolaterally CV: RRR, nl S1, S2, no murmur. Abd: Soft, nontender, normoactive bowel sounds Extr: No edema, good dorsalis pedis pulses Neurologic Examination: Mental Status: Awake, agitated, bucking vent, vigorously moving right arm and leg, responding to noxious stimulus of a-line placement. Does not follow commands. No obvious neglect Cranial Nerves: Pupils equally round and reactive to light, 4 to 3 mm bilaterally, brisk. Does turn head to both sides, unable to assess VOR as pt too awake but does not look right or left to command. Corneal reflexes normal bilaterally. No upper face droop with grimace to noxious, difficult to assess lower face given intubation. Motor: Normal bulk. Decreased tone left arm and leg. No fasiculations. No tremor. Vigorously moves right arm and leg to noxious/spontaneously with full strength. Some flexion of left arm in response to arterial stick but otherwise minimal, no spontaneous movement left leg. Sensation: Withdraws right arm/leg. Minimal, near absent posturing of left leg and arm to noxious. Reflexes: DTRs brisker left vs right. Toes were up on right, mute on left. Unable to assess coordination and gait given mental status. Pertinent Results: Admission Labs: [**2128-10-7**] 02:38AM BLOOD WBC-27.2* RBC-4.43* Hgb-13.7* Hct-39.4* MCV-89 MCH-31.0 MCHC-34.9 RDW-13.3 Plt Ct-403 [**2128-10-7**] 02:38AM BLOOD PT-14.1* PTT-30.2 INR(PT)-1.3 [**2128-10-16**] 03:36PM BLOOD Ret Aut-0.5* [**2128-10-7**] 02:38AM BLOOD Glucose-150* UreaN-16 Creat-0.7 Na-138 K-3.5 Cl-100 HCO3-23 AnGap-19 [**2128-10-7**] 02:38AM BLOOD ALT-17 AST-21 AlkPhos-105 Amylase-21 TotBili-0.7 [**2128-10-16**] 03:36PM BLOOD LD(LDH)-328* [**2128-10-7**] 02:38AM BLOOD Calcium-9.8 Phos-4.4 Mg-2.3 [**2128-10-16**] 03:36PM BLOOD calTIBC-221* VitB12-427 Folate-8.3 Hapto-PND Ferritn-468* TRF-170* [**2128-10-7**] 02:38AM BLOOD Phenyto-14.9 ---- Discharge Labs: [**2128-10-20**] 06:15AM BLOOD WBC-16.8* RBC-3.47* Hgb-11.0* Hct-31.4* MCV-90 MCH-31.8 MCHC-35.2* RDW-13.7 Plt Ct-617* [**2128-10-20**] 06:15AM BLOOD PT-13.6* PTT-29.0 INR(PT)-1.2 [**2128-10-20**] 06:15AM BLOOD Glucose-101 UreaN-17 Creat-0.8 Na-140 K-4.0 Cl-103 HCO3-23 AnGap-18 [**2128-10-20**] 06:15AM BLOOD ALT-46* AST-24 CK(CPK)-32* AlkPhos-170* TotBili-0.4 [**2128-10-20**] 06:15AM BLOOD TotProt-7.5 Albumin-4.0 Globuln-3.5 Calcium-10.0 Phos-4.6* Mg-1.9 ---- Studies: Head MRI: Evolving right parietal hematoma with extension into the adjacent lateral ventricle and basal CSF cisterns, with much associated vasogenic edema. In this clinical setting, intracerebral hemorrhage secondary to hyperperfusion post carotid endarterectomy remains a distinct possibility. Hemorrhage into a pre-existing vascular malformation is possible. Other etiologies, such as hemorrhage secondary to amyloid angiopathy, overcoagulation, or pre-existing tumor, either primary or secondary, are thought to be less likely. Followup MRA or CTA will provide further information, to exclude underlying vascular malformation. ---- Head CT:Large area of parietal occipital intraparenchymal hemorrhage which extends into the ambient cistern and quadrigeminal plate cistern all the way to the foramen magnum in the subarachnoid space. No or minimal shift of midline structures to the left. Normal-sized ventricles without evidence of hydrocephalus. The pattern of white matter hypodensity is not characteristic for infarction, and a white matter process, including a tumor and a multifocal vascular process, should be considered as a cause for this hemorrhage. An MRI/MRA is recommended. This was discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 9:40am on [**2128-10-7**]. ---- CTA:Fetal type posterior communicating arteries bilaterally as described. No definite evidence of aneurysm. ---- MR [**Name13 (STitle) **]:Anterolisthesis with posterior disc bulge at L4-L5 with associated bilateral pars defect. Increased L4-L5 disc T2-signal, which may reflect spinal degeneration, although possible infection cannot be excluded. Recommend clinical correlation and followup radiographs to monitor for interval change. ---- MR [**Name13 (STitle) 2853**]:Mild-to-moderate cervical spondylosis at C5-C6 level with central shallow disc protrusion. Moderate-to-severe narrowing of the right foramen at that level probably impinging on the right exiting C6 nerve root. Minor cervical spondylosis and annular bulge at C6-C7 level. Small central disc protrusion of the upper thoracic disc at T3-T4 level. ---- Repeat Head CT:: Interval decrease in size of right parietal/occipital intraparenchymal hemorrhage with continued surrounding edema and subcortical white matter hypodensity. No new intracranial hemorrhage or mass effect demonstrated. ---- EEG:Abnormal portable EEG due to the slow and disorganized background and bursts of generalized slowing. These indicate a widespread encephalopathic condition. The record did not appear much changed from the earlier encephalopathic record except that suppressive bursts were no longer as evident. This might be related to discontinuation of Prpofol. There were still occasional focal isolated sharp waves, possibly slightly fewer than on the previous recording, but there were no electrographic seizures. ---- CXR:9/30:1. Malpositioning of feeding tube, which coils within the thoracic esophagus. 2. New patchy bibasilar opacities, which may reflect aspiration or atelectasis. Brief Hospital Course: Pt was transferred to [**Hospital1 18**] ICU with his parieto-occiptal intracranial hemorrhage on [**2128-10-7**] and was treated initially with decadron, mannitol, and hyperventilation. The decadron was stopped on [**10-8**]. He continued to do well so mannitol stopped several days later. An initial EEG showed a slow background, ~2Hz, with frequent fronto-central discharges, but no seizure activity. He was loaded with dilantin, but had difficulty maintaining adequate levels, so he was switched to Keppra and titrated up to his current dose. A repeat EEG was essentially unchanged, but showed him to be somewhat more awake. His bleed is felt to be the result of carotid hyperperfusion syndrome, but the time course is odd as he did not have hemorrhage for several days after his seizure, and 6 full days after his CEA. This still appears to be the most likely etiology. He should continue Keppra until neuro follow-up. The patient was extubated on [**10-12**] and became more awake and conversational. While in the ICU, his elevated blood pressure was difficult to control. He was thought to have developed a Right hilar pneumonia in the setting of fevers and an elevated white count and sputum culture growing coag positive staph. He therefore completed 10 days of Levofloxacin/Vancomycin and defervesced by [**10-13**]. Pt complained of worsenign of his chronic low back pain and MRI L-spine showed anterolisthesis at L4-5 with possible nerve root compression. This is believed to be old and did not seem greatly changed from a prior film. This back pain resolved during his stay. Patient was transferred to floor on [**10-17**] with stable blood pressure and heart rate. This was acheived using metoprolol, norvasc, and enalapril(initially required much more acutely in the ICU). He did well with this. He did have 1-2 episodes of bradycardia to the high 30s while sleeping that were not symptomatic. These were sinus brady. His hospital course on the floor was notable for Right arm (triceps and deltoid) and Right hand (finger extensor) weakness as well as decreased R arm reflexes that could not be explained by his intracranial hemorrhage. His wife believes that these deficits were not present prior to his seizure on [**10-3**]. Repeat head CT on [**10-19**] did not show new or worsening hemorrhage or evidnce of any left sided stroke. An MRI of the C-spine on [**10-18**] showed moderate to severe compression of C6 nerve root, which is not entirely consistent with his motor deficits. Etiology of his R arm weakness is not entirely understood and we have strongly recommended that he follow-up with a neurogist as an outpatient for further evaluation. We recommnded an LP to evaluate for possible infection such as Lyme, or evidence of malignancy/paraneoplastic syndrome. A plexopathy is also a possiblity. He refused this despite our strong insistence. At this time, we are unsure why he has developed arm weakness, but given the wasting in his muscles, it appears to be a more chronic process. This is not in agreement with his wife's thoughts. It is possible that he has more than one process contributing. This does not appear to be an acute issue though and he will need to follow up in neurology clinic for further work-up whether this resolves or not. An EMG may be a next step to assess for whether this is a peripheral problem or not. Pt was also seen by hematology on [**10-19**] for eval of leukocytosis and increased platelets. Heme believes these findings are most consistent with a reactive process, but SPEP, UPEP, LAP, ESR, CRP, hep B viral load pending at time of discharge to rule out a myelodysplastic syndrome. These will need to be followed by his PCP or [**Name9 (PRE) 702**] MDs. During their evaluation, they also noted burr cells on his smear and became concerned about liver disease, given his history of Hep B and alcoholism. A Hep B viral load was checked and is pending. An abd ultrasound showed an essentially normal iver(non-specific heterogeneity only) and a slightly small spleen. Patient's mental status has gradually improved, although he remains quite inattentive. He also continues to have unchanged right arm weakness as above in a pattern not typical for a particualr pathology, but is closer to an upper motor neuron pattern than anything else. His left arm is also weak in an upper motor neuron pattern since his stroke. Both legs remain slightly weak as well, with his left weaker than his right. He was discharged on an 81 mg ASA for secondary ischemic stroke prevention. His Plavix was not restarted. He will possibly need additional antiplatelet agents in the future, but needs to be further from his hemorrhage before starting these. Medications on Admission: Asa 81 mg PO QD Plavix Lipitor 40 mg PO QD Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Right-sided parieto-occipital hemorrhage with generalized tonic-clonic seizure thought to be secondary to carotid hyperperfusion syndrome. -- HTN h/o stroke Leukocytosis Discharge Condition: Stable. Continued right arm weakness, left arm weakness and leg weakness bilaterally. Mild confusion at times Discharge Instructions: Please tell the doctors at rehab if you have any change in your symptoms, chest pain, shortness of breath, or new weakness/numbness. Take your medications. Please follow up with a neurologist after you leave rehab. Followup Instructions: Please call [**Telephone/Fax (1) 2574**] to schedule a follow-up appointment with Dr. [**Last Name (STitle) **], Dr [**Last Name (STitle) 4638**] or Dr [**First Name (STitle) **] in the neurology clinic. Please follow up with your PCP after you leave rehab.

[ "729.89", "496", "V12.59", "285.8", "431", "780.39", "999.2", "724.2", "276.8", "289.9", "272.0", "288.8", "401.9", "486" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

14286, 14356

9462, 14193

339, 389

14570, 14682

5232, 5232

14946, 15207

3762, 3800

14377, 14549

14219, 14263

14706, 14923

5910, 7018

3815, 4162

277, 301

417, 2926

4383, 5213

8537, 9439

5248, 5894

4201, 4367

4186, 4186

2948, 3580

3596, 3746

58,319

177,391

2152

Discharge summary

report

Admission Date: [**2200-6-1**] Discharge Date: [**2200-6-3**] Date of Birth: [**2122-3-19**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 3290**] Chief Complaint: body pain Major Surgical or Invasive Procedure: None History of Present Illness: 78y/o F h/o diabetes, chronic back pain, recurrent SBO requiring multiple surgeries who presents to the ED with hypotension after reported fall. Admitted to ICU for monitoring of hypotension. Pt was seen recently in the ED [**5-30**] for left wrist pain and itching after splinted [**5-27**] from fall-related ulnar and distal radius fractures. She had been feeling alright at home but today felt fatigue, nausea, diffuse body aches and joint aches, with subjective fevers at home. She had some mild headache but no altered mental status/confusion or neck stiffness to suggest meningitis. Patient may have had another fall last night. . ED course: V/s: 97.6 109 127/74 20 95% on 2L NC. Developed fever to 102 (oral). Pt was noted to have a nonproductive cough. Interventions: Pt was given morphine at 10:30 AM for total body aches. Also given CTX, azithro, nebs for possible PNA and 2L IVF. Pt then triggered for hypotension to 85 systolic from previous pressures in 150s, moved from the periphery to the core and given an additional 2L IVF NS along with vancomycin. Pt received 125mg methylpred for wheezing. Flu swab sent. After total 4L sbp in low-mid 90s. . On arrival to the ICU, pt noted to be extremely somnolent which had not been noted before. Could barely whisper her first name and only opened her eyes for several seconds in response to sternal rub and voice commands. Pt received 0.4mg narcan and immediately became more alert, crying out that she was cold and that her back was cold. Denied pain. Would not answer any history questions other than , did not know the year. did know that she was in the hospital and that it was [**Hospital3 **]. Pt was also administered another liter of NS. . Spoke with Pts son who states that she has become increasingly depressed although fully functional still at home. In the last year bought a cemetery plot and whenever something happens to her for example her recent wrist fracture she goes and visits the plot. . Review of systems: unable to obtain fully, pt altered. Son saw her day before yesterday and denies that she complained of the following or that he noted any of the following. (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: PMHx: DM, obesity, HTN, asthma, OA, jejunal divertic, peritonitis, perforated viscus, chronic back pain, plantar fasciitis . PSHx: Ex-lap/LOA, trigger finger, SBR, jujunal diverticulotomy, TAH/BSO, tubal ligation He surgical history began with a perforated jejunal diverticulim in [**2191**]. Since that time she has required multiple Exlaps, LOA for SBOs. Social History: - Tobacco: remote - Alcohol: remote - Illicits: none Family History: Non-contributory. Physical Exam: ADMISSION EXAM: Vitals: T: 98.5 (tylenol in ED) BP:103/52 P:83 R:21 O2: 99%RA General: lethargic but arousable (for brief intervals) not responding verbally appropriately, does not follow commands or answer questions although oriented to her own name. HEENT: Sclera anicteric, MMM, oropharynx clear but dry mucous membranes Neck: supple, JVP not elevated, no LAD Lungs: diffuse rhonchorous breath sounds CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley present Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2200-6-1**] 10:25AM BLOOD WBC-12.1* RBC-3.84* Hgb-11.7* Hct-36.2 MCV-94 MCH-30.3 MCHC-32.2 RDW-12.9 Plt Ct-300 [**2200-6-1**] 10:25AM BLOOD Neuts-83.8* Lymphs-6.9* Monos-5.3 Eos-3.6 Baso-0.4 [**2200-6-1**] 11:52AM BLOOD PT-11.8 PTT-28.8 INR(PT)-1.1 [**2200-6-1**] 10:25AM BLOOD Glucose-188* UreaN-12 Creat-0.7 Na-132* K-4.3 Cl-97 HCO3-24 AnGap-15 [**2200-6-1**] 10:25AM BLOOD ALT-32 AST-43* AlkPhos-74 TotBili-0.3 [**2200-6-1**] 10:25AM BLOOD Lipase-25 [**2200-6-1**] 10:25AM BLOOD proBNP-136 [**2200-6-1**] 10:25AM BLOOD cTropnT-<0.01 [**2200-6-1**] 10:25AM BLOOD Albumin-3.9 [**2200-6-1**] 06:35PM BLOOD TSH-0.37 [**2200-6-1**] 10:25AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2200-6-1**] 05:47PM BLOOD Type-ART pO2-109* pCO2-35 pH-7.39 calTCO2-22 Base XS--2 [**2200-6-1**] 10:28AM BLOOD Lactate-1.3 [**2200-6-1**] 01:37PM BLOOD Lactate-0.9 [**2200-6-1**] 05:47PM BLOOD Lactate-0.8 Na-137 K-3.7 Cl-108 [**2200-6-1**] 05:47PM BLOOD freeCa-1.10* Brief Hospital Course: 78 y/o F h/o DM, multiple abdominal surgeries for SBOs, OA, falls, presents with hypotension and fever, admitted to the [**Hospital Unit Name 153**] for hypotension, found to have altered mental status. #AMS - on arrival to the [**Hospital Unit Name 153**] noted to be lethargic not responding well to commands, oriented only to name. Mental status improved with one dose of narcan, making medication effect likely source of AMS as patient had received morphine in ED, in addition to home morphine/oxycodone. In addition, patient had received medications during her observation stay in the Emergency Room just a day prior to this admission. She insists that her chronic pain medications were not the cause of her change in mental status and her hypotension, but rather that the additional medications she received in the ED during her observation stay were culprit. SHe insisted on being very responsible regarding her medications. As medications have worn off, patient is now awake and alert. Head CT negative for subdural in the setting of fall. Patient was febrile in the ED, but is now hemodynamically stable without other fevers and CXR negative for pneumonia, making infection unlikely source of AMS. Patient remained lucid for the remainder of the admission, and was seen to be extremely anxious to go home. #hypotension: Patient with hypotension to SBP 80s in the ED (baseline SBP 110-160). BP now stable in 120??????s since admission to the ICU. Given blood pressure normalized following clearance of opioids, likely opioid-induced. No further evidence of infection to support sepsis as etiology. Troponin x 2 negative for evidence of cardiac ischemia. Systolic blood pressures started to rise to 150 at the time of discharge so patient was instructed to continue all of her home antihypertensives. #h/o asthma - pt was reportedly wheezy in ED. s/p 125mg solumedrol. Lungs clear for the remainder of the admission. #h/o anxiety - holding home diazepam in setting of AMS, but patient was clearly anxious to be discharged from the hospital, and insisted on repeating every detail of her history. #h/o left wrist fracture - on long acting morphine and oxycodone at home. in setting of AMS and lethargy/unresponsiveness, these medications were initially held. However, these are patient's long standing medications, so she will continue to use them, as they have not caused lethargy or change in mental status in the past. Vitamin D level ordered and is pending at time of discharge. #chronic back pain- patient to resume home medications on discharge Medications on Admission: Medications: per pcp [**Name Initial (PRE) 626**] [**2200-5-16**] Medications - Prescription ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for Nebulization - 1 vial inhaled four times a day as needed for shortness of breath ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 (Two) puffs(s) inhaled q 4h for one month then qid as needed for as needed for asthma - No Substitution BETAMETHASONE DIPROPIONATE - 0.05 % Cream - apply [**Hospital1 **] twice a day as needed for itching CHLOROQUINE PHOSPHATE - 250 mg Tablet - 1 Tablet(s) by mouth twice a week CLONIDINE - 0.1 mg Tablet - 1 Tablet(s) by mouth twice a day CLOTRIMAZOLE - 1 % Cream - APPLY TO FEET ONCE A DAY ONCE A DAY as needed for FUNGAL INFECTION DISCONTINUE IF YOU EXPERIENCE ANY ADVERSE REACTIONS OR RASHES DIAZEPAM - 5 mg Tablet - 1 Tablet(s) by mouth qhs prn FLUTICASONE - 50 mcg Spray, Suspension - 1 puff(s) each nostril twice a day for allergies/running nose FLUTICASONE - 0.05 % Cream - apply to affected area twice a day as needed for pruritis FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose Disk with Device - 1 puff po twice a day for asthma FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day for swelling and blood pressure GABAPENTIN - 600 mg Tablet - 1 Tablet(s) by mouth three times a day for neuropathy GLIPIZIDE - 10 mg Tablet - 1 Tablet(s) by mouth once a day for sugar HYDROXYZINE HCL - 25 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for itching IPRATROPIUM-ALBUTEROL - 0.5 mg-2.5 mg/3 mL Solution for Nebulization - 1 vial inhaled three times a day LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day for blood pressure METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth 2 q pm for diabetes (also called GLUCOPHAGE) MORPHINE - 30 mg Tablet Extended Release - 1 Tablet(s) by mouth twice a day as needed for pain OLOPATADINE [PATANOL] - 0.1 % Drops - 1 drop eqch eye twice a day OXYCODONE - 15 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for pain POLYETHYLENE GLYCOL 3350 - 17 gram Powder in Packet - 1 packet(s) by mouth qd, as needed for hard stool PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth at bedtime for cholesterol SERTRALINE - 50 mg Tablet - 1 Tablet(s) by mouth once a day for sadness, depression also called ZOLOFT TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime as needed for sleep . Medications - OTC ACETAMINOPHEN - 500 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for pain also called TYLENOL ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day CARBAMIDE PEROXIDE - 6.5 % Drops - 3 drops(s) to right ear daily as needed to soften ear wax CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s) by mouth DAILY (Daily) DEXTRAN 70-HYPROMELLOSE - Drops - 1 drop both eyes twice a day DEXTRAN 70-HYPROMELLOSE [ARTIFICIAL TEARS] - Drops - 1 drop OU four times a day as needed for eye irritation bedtime as needed for constipation NEOMYCIN-POLYMYXIN-PRAMOXINE [ANTIBIOTIC + PAIN RELIEF] - 0.35 %-10,000 unit-[**Unit Number **] mg/gram Cream - apply to biopsy site tid-qid OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - 20 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day for acid POLYVINYL ALCOHOL - 1.4 % Drops - 1 gt ou three times a day SENNOSIDES [SENNA] - 8.6 mg Capsule - [**2-10**] Capsule(s) by mouth once a day as needed for constipation - No Substitution WHITE PETROLATUM-MINERAL OIL - Cream - pply to feet and hands bidd as needed for dry, cracking skin Discharge Medications: 1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 3. Patanol 0.1 % Drops Sig: 1 drop Ophthalmic twice a day: for both eyes. 4. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day. 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 8. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 10. trazodone 50 mg Tablet Sig: One (1) Tablet PO qhs prn as needed for insomnia. 11. Valium 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for dyspnea, wheezing. 13. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO three times a day as needed for itching. 14. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day as needed for pain. 15. oxycodone 15 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 16. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 17. polyethylene glycol 3350 Powder Sig: 1 pouch Miscellaneous once a day. 18. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation three times a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Sedation, hypotension, from medication effect 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 sedation and low blood pressure, and this appears to have been caused by medications that you received in the Emergency Room for your wrist pain. Your blood pressures are now normal and you are in stable condition. You may continue to take all of your home medications. Followup Instructions: Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER When: MONDAY [**2200-6-9**] at 10:45 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 8268**], MD [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site *Dr. [**Last Name (STitle) **] works with Dr. [**Last Name (STitle) 8499**]

[ "401.9", "300.00", "780.97", "724.5", "458.8", "E935.2", "493.90", "V15.51", "338.29" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12789, 12846

5141, 7724

313, 320

12936, 12936

4128, 4128

13421, 13835

3410, 3429

11281, 12766

12867, 12915

7750, 11258

13087, 13398

3444, 4109

2336, 2939

264, 275

348, 2316

4144, 5118

12951, 13063

2961, 3320

3336, 3394

2,948

158,914

48019

Discharge summary

report

Admission Date: [**2129-11-12**] Discharge Date: [**2129-11-17**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2186**] Chief Complaint: Fall and syncope Major Surgical or Invasive Procedure: EGD History of Present Illness: This 81 year old male with a history of orthostatic hypotension and gait disturbance presents with presyncope. He initially felt OK the day prior to admission had gone to [**Hospital1 2025**] for a CT scan for anemia work-up. He went home and was straining at a BM, stood up and felt dizzy, had his wife help him to a chair. Once he sat down he vomited coffee ground emesis. He continued to feel lousy and his wife called 911 who brought him here. No chest pain, no shortness of breath, no focal weakness or other neurological changes. An NG was placed in the ED and drained coffee grounds about 300cc continuously flowing. Rectal exam was guiaic positive. His HCT had dropped to 25.3 from a baseline of 33. Two large bore IVs were placed, IV protonix, IV fluid were given, he was transfused 1 unit. A U/S and CT were performed. Past Medical History: 1. Pituitary adenoma s/p resection 2. Anemia, virtual colonoscopy at [**Hospital1 2025**] negative 3. 4.2 cm AAA 4. Orthostatic hypotension 5. Gait problem causing recurrent falls, uses cane at home 6. Urinary incontinence 7. history of TIAs Social History: Lives with his wife, no EtOH or drugs, quit smoking 20 years ago Family History: Father had a bleeding duodenal ulcer Physical Exam: Vitals: Temp 97.5, Pulse 83, BP 110/70, 100% on RA Gen: alert, oriented, cooperative male in NAD HEENT: MMM, OP clear, NG tube in place, PERRL Lungs: clear to auscultation bilaterally, anterior exam CV: RRR, nl S1S2 no murmers Abd: soft, non-tender, non-distended, positive BS Ext: [**Male First Name (un) **] stockings Pertinent Results: [**2129-11-17**] 05:05AM BLOOD WBC-7.3 RBC-3.50* Hgb-10.4* Hct-30.6* MCV-88 MCH-29.7 MCHC-34.0 RDW-16.8* Plt Ct-141* [**2129-11-16**] 04:55AM BLOOD WBC-5.8 RBC-3.21* Hgb-10.2* Hct-28.7* MCV-90 MCH-31.7 MCHC-35.4* RDW-16.9* Plt Ct-126* [**2129-11-15**] 05:05AM BLOOD WBC-6.7 RBC-3.37* Hgb-10.5* Hct-29.8* MCV-88 MCH-31.1 MCHC-35.1* RDW-16.8* Plt Ct-126* [**2129-11-14**] 07:20PM BLOOD Hct-31.5* [**2129-11-12**] 06:40AM BLOOD WBC-5.7 RBC-2.92* Hgb-7.9* Hct-25.5* MCV-87 MCH-27.1 MCHC-31.1 RDW-17.8* Plt Ct-141* [**2129-11-12**] 12:50AM BLOOD Hct-22.9* [**2129-11-11**] 07:20PM BLOOD WBC-5.9 RBC-2.92*# Hgb-7.8*# Hct-25.3*# MCV-86 MCH-26.5*# MCHC-30.7* RDW-18.2* Plt Ct-220 [**2129-11-11**] 07:20PM BLOOD Neuts-53.6 Lymphs-34.1 Monos-5.6 Eos-6.5* Baso-0.2 [**2129-11-12**] 06:40AM BLOOD PT-13.2 PTT-24.5 INR(PT)-1.2 [**2129-11-17**] 05:05AM BLOOD Glucose-96 UreaN-27* Creat-1.0 Na-142 K-3.1* Cl-110* HCO3-22 AnGap-13 [**2129-11-12**] 06:40AM BLOOD ALT-10 AST-15 LD(LDH)-157 AlkPhos-75 TotBili-0.7 [**2129-11-11**] 07:20PM BLOOD cTropnT-<0.01 [**2129-11-14**] 04:06AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.6 [**2129-11-13**] 03:27AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.9 [**2129-11-12**] 06:40AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.4 Mg-2.0 Iron-54 [**2129-11-12**] 06:40AM BLOOD calTIBC-230* Ferritn-30 TRF-177* Brief Hospital Course: 81 year old male with history of anemia presenting with presyncope found to have GI bleed due to duodenal ulcer. . 1. GI Bleed - Mr [**Known lastname 56908**] had coffee grounds on NG tube placement in ED indicating upper GI as most likely source. NG lavage cleared intially, but there were small recurrences of coffee grounds from NGT overnight first hospital night. In AM pt acutely began to have bright red blood frmo his NGT, and emergent EGD was performed. EGD showed large duodenal ulcer, actively bleeding. It was injected with epinephrine and the EGD was stopped early due to the pt vomiting large quantities of brught red blood. H pylori was sent, and he was initally treated for suspected H pylori. However, the H Pylori returned negative, so treatment was stopped. He was also treated with a prtonix drip initially, then transitioned to 40mg IV BID. He was transfused 5 units pRBCs in his first 24 hours, then one unit on the second hospital day to keep his hematocrit above 30. His HCT remained stable without any evidence of active rebleeding. He will need to continue Protonix [**Hospital1 **] for at least 1-2 months. . 2. Orthostatic hypotension: Mr [**Known lastname 56908**] has had episodes of presyncope and orthostatic hypotension over the last 3-6 months that may relate to his GI bleeding. He was treated with IV fluids and p RBC transfusions PRN to mantain a hematocrit > 30, and was not hypotensive during his stay. He was hemodynamically stable throughout his stay except for two episodes of bradycardia to the 30's associated with episodes of bleeding that were felt to be vagal episodes and spontaneously resolved. After this resolved, patient was restarted on his usualy anti-HTN regimen of Norvasc 2.5 mg PO BID, however his BP remained high, up to 170/100. His amlodipine was increased to 5mg PO BID with improved control. His BP will need to be monitored and amlodipine may need to be adjusted. . 3. FEN: Mr [**Known lastname **] was initally NPO, the advanced to clears on his third hospital day, which he tolerated well. This was advanced as tolerated to soft solids. A speech and swallow evaluation was performed as patient was scheduled for this soon as outpatient. He reports a hx of coughing following taking in mixed consistencies food, i.e. solids and liquids at the same time, such as cereal and milk. He should avoid such foods to minimize aspiration risk. . 4. Hypokalemia - patient's K trended down during his course. He did not experience any significant diarrhea. This was repleted orally. Patient and wife report that he has been on [**Name (NI) 101285**] in the past, but no recently. Pt received K 60mg as well as Magnesium 2 gm on the day of discharge. He will be discharge on K-Dur 40 mEq daily. His K level needs to be monitored and medications may need to be adjusted as needed. . 5. PPx: Mr [**Known lastname 56908**] was on pneumoboots, protonix and a bowel regimen. . 6. Mr. [**Known lastname 56908**] was FULL code . 7. Communication was with Mr. [**Known lastname 56908**] and his wife. . 8. Dispo: discharge to short term inpatient facility. Wife states that she is switching [**Name (NI) 6435**], unclear who this will be. She is planning to call their cardiologist to see if he will monitor the patient's potassium and BP meds. Medications on Admission: 1. ASA 2. Iron 3. Norvasc 2.5mg [**Hospital1 **] 4. Proscar 5. Synthroid/levoxyl 25 mg daily 6. Tums Discharge Medications: 1. Levothyroxine Sodium 50 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO once a day. 8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Duodenal ulcer bleeding Hypertension Discharge Condition: stable Discharge Instructions: Please call your physician to schedule [**Name Initial (PRE) **] follow-up appointment in the next 1-2 weeks. You can call the [**Hospital **] clinic at ([**Telephone/Fax (1) 2306**] if you experience any recurrence of vomiting. Take your medications as prescribed. Call or report to the nearest ER if you develop any weakness, lightheadedness, or other concerning symptoms. Followup Instructions: Please call your primary care physician to schedule [**Name Initial (PRE) **] follow up as needed. Completed by:[**2129-11-17**]

[ "401.9", "441.4", "244.9", "585.9", "276.8", "285.1", "532.40" ]

icd9cm

[ [ [] ] ]

[ "44.43", "99.04" ]

icd9pcs

[ [ [] ] ]

7412, 7484

3198, 6501

238, 243

7565, 7574

1868, 3175

7999, 8130

1474, 1512

6652, 7389

7505, 7544

6527, 6629

7598, 7976

1527, 1849

182, 200

271, 1111

1133, 1376

1392, 1458

27,576

199,655

34515

Discharge summary

report

[** **] Date: [**2116-7-1**] Discharge Date: [**2116-7-9**] Date of Birth: [**2044-11-20**] Sex: M Service: MEDICINE Allergies: Celebrex Attending:[**First Name3 (LF) 1936**] Chief Complaint: Hypotension, respiratory failure Major Surgical or Invasive Procedure: Intubation History of Present Illness: 71 year old male with MMP including severe OSA, recent [**First Name3 (LF) **] [**Date range (1) 79292**] for large R MCA stroke with residual weakness, L hemineglect, bulbar dysfunction (dysphagia s/p PEG, slurred speech), bilateral PEs on coumadin, was readmitted from [**Hospital1 15454**] Hosp rehab to [**Hospital3 417**] Hospital on [**7-1**] with lethargy, depressed MS, fevers. Was febrile and hypotensive and intubated for lethargy/airway protection. subsequently transfered to [**Hospital1 18**] MICU. He was found to have septic shock [**1-4**] either central line (had old R subclavian central line since [**6-17**]) vs PNA. Got IVF reccussitation, short term pressor support. He has been on Vanc, cefepime, and flagyl, and has shown clinical improvement. Also as part of AMS w/u on [**Month/Year (2) **], he got CT head, which showed small area of hemmorhagic conversion. Given concern for expansion, his coumadin was stopped (INR reversed) and he underwent IVC filter since LE dopplers showed RLE DVT. The question now is whether the coumadin is safe to be resumed, and it is for this question that the patient transfered to medicine [**7-5**]. Neurology evaluated the patient and felt right MCA bleed does not explain decline in mental status, which is likely [**1-4**] infection/sepsis. Past Medical History: 1. severe OSA - BiPAP at 16/8 at night 2. Asthma 3. GERD 4. BPH 5. CVA, LARGE R MCA stroke [**6-9**] (MRA with distal occlusion R MCA), residual weakness L sided, L hemineglect, bulbar dysfunction (dysphagia s/p g-tube [**2116-6-15**], slurred speech) 6. Anemia, unclear etiology 7. Bilateral PEs [**6-9**], initially on coumadin, now s/p IVC filter this [**Month/Year (2) **] for RLE DVT. 8. Recent aspiration Pneumonitis, requiring intubation [**2116-6-17**], then VAP s/p zosyn X 8 days, extubated [**6-23**] s/p L knee repair and replacement s/p ventral hernia repair s/p L hand surgery after fracture s/p L elbow surgery s/p G tube and J tube? Social History: SH: Quit smoking in [**2074**] and sober for 7 years. Works as full-time maintenance person at [**Hospital1 11485**] School in [**Location (un) 2624**]. Has three children and several grandchildren. Family History: FH: Father died of CAD and mother died of stomach cancer. No FH of strokes, seizures and bleeding issues. Physical Exam: Upon [**Location (un) **] to ICU, physical exam was as follows: GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. On discharge Physical Exam: Vitals: 98.0 97.0 136-140/63-68 95%2Lnc Pain: 0/10 Access: RUE PICC placed [**7-7**] Gen: alert and oriented, communicating Eyes: anicteric ENT: o/p clear, missing teeth, mmm, nasal canula in place CV: distant, RRR, no m Resp: more clear BS, good air movement, no wheezing ABd: obese, +PEG c/d/i, nontender, +BS, foley with yellow urine Ext: no edema, +SCDs Neuro: improved MS [**First Name (Titles) 14169**] [**Last Name (Titles) **], verbally communicating. stable L hemiplegia/hemineglect/dysarthria Psych: improved affect Skin: no new rashes Pertinent Results: hgb 14 [**2116-6-6**]-->[**8-12**] [**6-26**]-->[**6-9**] this [**Month/Day (3) **]->1U prbc->9's for past 3days Creat normal this [**Month/Day (3) **] Trops negative Fe 11, TIBC 153, ferritin 526, Vit B12 wnl, folate wnl LDL 89 . . Micro: Blood CX X2 on [**7-1**] and [**7-3**] and [**7-4**] are NTD Sputum cx [**7-1**] normal flora Urine Cx [**7-1**] negative Central line tip [**7-1**]: negative . EKG [**2116-7-1**] NSR, unremarkable . . CXR [**2116-7-4**] IMPRESSION: Persistent bibasilar atelectasis. Pneumonia is not excluded. . CXR [**7-6**] In comparison with study of [**7-4**], the right hemidiaphragm is now sharply seen. However, the left hemidiaphragm is indistinct, suggesting underlying effusion, atelectasis, or even pneumonia. Streak of atelectasis is seen in the lingular region. Upper lobes are clear and the left subclavian catheter extends to the mid portion of the SVC. . . Echo: [**7-6**] poor study, grossly normal LVEF 55% . . CT HEAD [**2116-7-1**] IMPRESSION: 1. Large right middle cerebral artery territory infarct, with hemorrhagic transformation. There is no herniation or shift of normally midline structures or herniation. 2. Fluid within the right mastoid sinus and posterior nasopharynx, likely related to intubation. 3. Bony defect and irregular ossific density within the right frontal sinus. This may relate to prior surgery, or may be an osteoma. Please correlate with patient's surgical history. . CT head [**7-2**]: IMPRESSION: Evolution of the infarct in the right frontotemporal region, with increased hyperdensity in the gyriform pattern, and new small area of hemorrhage within the infract. . CT head [**7-6**] Evolving infart, stable hemmorhage . Brief Hospital Course: 71y/o male with severe OSA, recent large R MCA CVA with residual deficits, s/p PEG, prolonged hospital course [**1-4**] aspiration pneumonitis requiring intubation, VAP s/p zosyn, bilateral PEs on coumadin, discharged [**6-26**], now admitted to [**7-1**] with depressed MS, fevers, septic shock, unclear source (line sepsis or PNA). Also noted to have newly noted hemorrhagic 1.1cm focus in prior CVA territory (right temporal lobe), now off coumadin. Found to have RLE DVT, s/p IVC filter [**7-2**]. Transfered to Gen Med [**7-5**] for further management. Did very well on Gen med. Resp status improved greatly with resuming BiPaP. See below for details of Gen Med events. . . Anemia, normocytic. hgb was 14 [**6-6**], then [**8-12**] on discharge [**6-26**], this [**Month/Year (2) **] has been [**6-9**]. Got 1U prbc on [**7-4**], now hgb stable around 9. Unable to perform endoscopy given high risk procedure in this patient per anesthisiology. -plan to monitor hgb qweek while on ASA and heparin SC. IF HGB is trending down on this, then he will need reevaluation for endoscopy under general anesthesia. -cont PPI PO bid indefinately while on ASA/heparin SC - cont Fe supp. B12/folate wnl. . . Septic shock, resolved with fluids/pressors/abx: Unclear source (?line sepsis vs aspiration pneumonitis/PNA (RLL on CXR). All blood/urine cultures, including RIJ tip NTD. CXR with poss RLL infiltrate (vs Atx), which has now resolved. Regardless, has been afebrile, MS much improved, resp status much improved. -cont on Vanc, cefepime, and flagyl for broad coverage, day [**7-12**] today. Has RUE PICC, which needs to be removed after on [**7-13**]. -tylenol for fevers, CIS . . Respiratory failure: Multifactorial [**1-4**] possible aspiration pneumonitis, severe OSA, depressed MS, bilateral PEs. Intubated on [**7-1**], extubated [**7-2**]. His pulm symptoms have greatly improved, less secretions. Able to wean down to 2L nc. -cont Abx as above -cont O2 to keep sats around 93%, frequent suctioning by NS when unable to swallow/clear secretions, chest PT -also cont albuterol/mucomyst nebs for cough/thick sputum. -cont BiPAP for severe OSA -NO oral intake when depressed MS, aspiration precautions, continue speech therapy . . CVA, R large MCA territory with multiple residual deficits. Now with small area of hemmorhagic transformation noted [**7-1**], which has been stable per CT [**7-6**]. Acute MS changes [**1-4**] infection, and are resolving to new baseline. -appreciate neuro recs: okay to resume coumadin (for VTE) HOWEVER, will not do this given concern for unmasking GIB that we couldnt adequately eval. -Will resume ASA 325mg (also heparin 5000U SC tid for VTE) for stroke prevention. -have set up neuro f/u with Dr. [**Last Name (STitle) 724**] on [**8-6**] 3pm. -keep BP with goal SBP b/w 120-160 to prevent extension of hemmorhage while maintaining cerebral perfusion -cont PT/OT, SCDs, TEDs, kinair mattress, speech therapy -plan to t/f to [**Hospital1 1319**] for long term/rehab today . . Dysphagia [**1-4**] bulbar dysfunction; s/p PEG on TF, however, surprisingly doing WELL with oral intake as long as awake/alert enough to swallow properly. Passed swallow eval, though needs ongoing speech therapy and reassessment. -started on pureed diet with thin liquids, NEEDS to have HOB elevated, close aspiration precautions, 1:1 assistance, ongoing speech therapy. -if tolerating PO adequately (do calorie count), can change TF to cycle 12hours overnight. . . VTE: bilateral PEs, R peroneal DVT s/p IVC [**7-2**], now off coumadin given recent finding of ICH over prior stroke territory and poss GI source of dropping hgb. -as above, will not place on couamdin as he has IVC filter and asymptomatic for his PE/DVT given high risk for GIB that we couldnt adequately rule out. -instead will place on ASA 325mg and heparin 5000U tid. . . HTN: -well controlled on enalapril 20mg qd, metoprolol 12.5mg [**Hospital1 **] . . NSVT: unclear significance, occuring in setting of infection. started on metoprolol 12.5mg [**Hospital1 **]. note trops neg since [**Hospital1 **]. -Echo unremarkable, cont BB -keep K>4.5, Mag>2.0, keep on tele . . OSA-severe. Cont BiPAP at home settings 16/8 with 2-4L NC with careful monitoring for aspiration of secretions. . . FEN/proph: HLIV, monitor/replete lytes, close monitoring with pureed diet trial and cont Nutrien TF 75cc/hr via PEG overnight, no AC, TEDs/SCDs, PPI, bowel regimen, PT/OT . . dispo/Code: FULL Code. plan to transfer to [**Hospital 1319**] rehab today. . POA, [**Name (NI) 66255**] [**Name (NI) 34909**] (daughter) updated face to face today, cell [**Telephone/Fax (1) 79293**], home [**Telephone/Fax (1) 79294**] . . Medications on [**Telephone/Fax (1) **]: [**Telephone/Fax (1) **] Medications: Acetaminophen 650 mg PRN Q6H as needed for knee pain Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Atorvastatin 20 mg Tablet PO QHS Bisacodyl -Delayed Release, 10mg PO DAILY PRN Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. Warfarin 5 mg Tablet PO DAILY Metoclopramide 10 mg PO QID ACHS Enalapril 40 mg PO DAILY Omeprazole 20 mg Capsule Daily Aspirin 81 mg Tablet daily Discharge Medications: 1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 2. Docusate Sodium 50 mg/5 mL Liquid Sig: [**12-4**] PO BID (2 times a day). Disp:*qs qs* Refills:*2* 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:*qs qs* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*qs Tablet(s)* Refills:*0* 6. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every [**3-8**] hours as needed for pain. Disp:*qs Tablet(s)* Refills:*0* 8. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours). Disp:*120 ML(s)* Refills:*2* 9. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours) for 2 days. Disp:*4 Recon Soln(s)* Refills:*0* 10. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 2 days. Disp:*qs qs* Refills:*0* 11. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 2 days. Disp:*qs qs* Refills:*0* 12. 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* 13. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO once a day. Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 14. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 15. Reglan 5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection every eight (8) hours: Sub Q. Disp:*qs qs* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Sepsis of unclear etiology Severe sleep apnea DVT Anemia mental status changes. Discharge Condition: Good Discharge Instructions: Please note that pt CAN be on pureed diet with thin liquids ONLY when AWAKE, with HOB elevated, with full 1:1 assistance. Needs ongoing speech therapy/reassessment. if calorie count okay with oral intake, decrease nutren TF to cycle overnight only at same rate 75cc/hr. Please complete Abx for 2more days, then REMOVE PICC. Please monitor hgb every week, he is on ASA and heparin SC tid for stroke and VTE. Could not do endoscopy to r/o GIB given high risk, but if hgb drops, then needs reeval. Cont BiPAP at night. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2116-7-24**] 1:00 Provider: [**Name10 (NameIs) 640**] [**Name11 (NameIs) 747**] [**Name12 (NameIs) **], M.D. Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2116-8-6**] 3:00

[ "V12.51", "995.92", "507.0", "427.1", "038.9", "285.9", "728.89", "530.81", "518.81", "453.42", "438.89", "V58.61", "327.23", "493.90", "V44.1", "785.52", "438.20", "438.82", "600.00", "431" ]

icd9cm

[ [ [] ] ]

[ "99.04", "96.6", "96.71", "38.93", "38.7" ]

icd9pcs

[ [ [] ] ]

13078, 13148

5762, 11028

299, 311

13272, 13279

4041, 5739

13847, 14189

2561, 2670

11051, 13055

13169, 13251

13303, 13824

3470, 4021

227, 261

339, 1646

1668, 2324

2340, 2545

44,527

125,479

37747

Discharge summary

report

Admission Date: [**2132-2-17**] Discharge Date: [**2132-2-23**] Date of Birth: [**2082-1-15**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: sepsis, pericardial effusion, esophageal cancer Major Surgical or Invasive Procedure: [**2132-2-20**] pericardial window History of Present Illness: Mr. [**Known lastname 17132**] is a 50M with a history of locally invasive esophageal cancer (T3, N1) py who was scheduled for an esophagectomy [**2-22**] by Dr. [**Last Name (STitle) **], who presented to [**Hospital3 20284**] Center [**2132-2-15**] with fatigue, cough, and vomiting. He was found to be hypotensive with a leukocytosis. He was put on sepsis protocol, resuscitated and started on broad-spectrum antibiotics (Vanc/Zosyn). During his hospitalization, he developed acute renal failure, atrial fibrillation, became acidotic and hemodynamically unstable. He was intubated and started on pressors. A TTE was performed with the discovery of pericardial effusion. He was taken to the cath lab semi-urgently for a pericardiocentesis and right heart cath. Approximately 600cc of viscous green-yellow fluid was removed. Initial gram stain of this fluid revealed no organisms but cell count was >20,000 with 98% neutrophils. His hemodynamics improved s/p pericardiocentesis. He was then transferred to [**Hospital1 18**] for further management. Past Medical History: PMH: esophageal cancer s/p chemo (cisplatin/5FU), paroxysmal AFib with CHADS score of 0 treated with ASA only PSH: portacath & lap Jtube [**11-4**] Social History: The patient has a history of drinking alcohol in the past, but quit two years ago. He has smoked one pack of cigarettes per day for many years. He works as a handyman and machinist. Family History: There is no family history of carcinoma. Physical Exam: T: 96.4, HR 107, BP 134/77, RR 8, O2Sa 91% GEN - intubated/sedated, thin HEENT - b/l JVD, R>L CVS - tachycardic, irregular, muffled heart sounds PULM - coarse breath sounds b/l ABD - firm, nondistended; Jtube in place; no erythema or purulent drainage EXTREM - cool & dry; no C/C/E Pertinent Results: ABG: 7.29 / 53 / 38 / 27 / -1 Lactate: 3.6 137 / 103 / 55 AGap=12 --------------< 61 4.4 / 26 / 2.2 ∆ Ca: 7.5 Mg: 2.4 P: 6.9 8.2 30.3 >-----< 556 26.1 PT: 30.8 PTT: 43.2 INR: 3.1 . Imaging [**2132-2-19**] TTE: Overall left ventricular systolic function is normal (LVEF>55%). Compared with the prior study (images reviewed) of [**2132-2-17**], the effusion is larger. The severity of tricuspid regurgitation has increased. . [**2132-2-18**] CT chest: 1. Sufficient opacification of the esophagus. No evidence of esophageo-pericardial fistula. 2.Multifocal PNA. 3. Large bilateral pleural effusions. 4. Large ascites. 5. Small pericardial effusion. 6. Limited assessment without IV contrast to assess abscess. . [**2132-2-18**] Abd US: 1. No hydronephrosis. Diffusely echogenic kidneys bilaterally, suggestive of medical renal disease. 2. Small to moderate ascites, largest pocket in the RLQ. 3. Bilateral pleural effusions and a pericardial effusion. 4. Rounded echogenic foci in the porta [**Last Name (LF) 84553**], [**First Name3 (LF) **] reflect normal fat within the porta [**First Name3 (LF) 84553**]. However, as these appear fairly discrete and rounded, lymphadenopathy cannot be excluded. If clinically indicated, this can be evaulated by cross-sectional imaging. . [**2132-2-18**] ECHO: Small circumferential pericardial effusion without evidence for tamponade physiology. Mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%) . Micro/Imaging: [**2132-2-21**] myco BCx pending [**2132-2-20**] tissue cx GS-2+PMNs, no orgs [**2132-2-20**] pleural fluid GS-2+PMNs, no orgs [**2132-2-20**] peric fluid GS-2+PMNs, no orgs [**2132-2-19**] sputum cx GS->25 PMNs, no orgs; Cx- SPARSE Commensal Respiratory Flora [**2132-2-19**] BCx pending [**2132-2-19**] BCx pending [**2132-2-18**] BCx pending [**2132-2-18**] BCx pending [**2132-2-18**] UCx no growth OSH cxr data - (prelim) diphtheroids, 1 single colony, very rare, will not do sensitivities Brief Hospital Course: This is a 50M w/ esophageal cancer, with a purulent pericardial effusion and pericardial tamponade, sepsis, and acute renal failure, who transfered from an OSH hospital for additional management. The patient was admitted to the SICU for aggressive resuscitation with IV fluids, blood products and pressors. He was additionally treated with broad spectrum antibiotics (vanco/zosyn/micafungin). He had an arterial line and [**Last Name (un) 18821**] monitoring initiaited to monitor his hemodynamics and a CVL placed to provide additional access reuscitation. Repeat TTE after admission showed small circumferential pericardial effusion without evidence for tamponade. ID was consulted to provide antibiotic recommedations. Blood and urine cultures were sent. Thoracics was consulted to help evaluate whether there was a communication between the esophagus and pericardium and to perform either pigtail placement or a pericardial window for drainage of the pericardium--a pericardial window was ultimatedly placed. Imaging studies failed to reveal any abnormal connection between the esophagus and the pericardium, so the source of the pericardial infection remained unclear (possibly hematogenous spread from a pneumonia). Despite aggressive resuscitation as described above and successful weaning of IV pressor support, the patient's renal failure failed to improve and urine output dropped of preciptitously. Renal was consulted to initiate hemodialysis; however, the patient's family and HCP ultimately decided that this was not in-keeping with the patient's wishes; he was made CMO and placed on minimal vent settings and a fentanyl drip. The final cause of death was from respiratory failure at 1715pm on [**2132-2-23**]. The family did request a complete autopsy to shed additional light on his death. Medications on Admission: [**Last Name (un) 1724**]: ASA 325', diltiazem 240', magic mouth wash, nystatin swish & swallow, percocet . MEDS @OSH: atrovent INH, levalbuterol, admiodarone 900', diltiazem, hydromorphone, imipenem 250q8hrs, lorazepam, morphine, sodium bicarb, zofran, pantoprazole 40', zosyn 3.375q8hrs, vancomycin 1', neosynephrine, ASA 325', benadryl, lidocaine viscous, percocet, miralax, nitroglycerin 0.4q5min prn, colace Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1. respiratory failure; 2. sepsis; 3. esophageal carcinoma; 4. pericardial effusion; 5. acute renal failure Discharge Condition: Expired. Discharge Instructions: Not applicable. Followup Instructions: Not applicable.

[ "785.52", "423.3", "427.31", "276.2", "038.9", "584.5", "518.81", "995.92", "V66.7", "486", "286.7", "570", "420.99", "151.0" ]

icd9cm

[ [ [] ] ]

[ "37.12", "96.6", "38.93", "38.91", "34.09", "96.72" ]

icd9pcs

[ [ [] ] ]

6592, 6601

4288, 6099

362, 398

6752, 6762

2229, 4265

6826, 6844

1868, 1911

6563, 6569

6622, 6731

6125, 6540

6786, 6803

1926, 2210

275, 324

426, 1478

1500, 1651

1667, 1852

49,514

101,619

37582

Discharge summary

report

Admission Date: [**2126-10-3**] Discharge Date: [**2126-10-10**] Date of Birth: [**2054-8-10**] Sex: F Service: NEUROSURGERY Allergies: Morphine / Codeine Attending:[**First Name3 (LF) 3227**] Chief Complaint: Headache and Nausea Major Surgical or Invasive Procedure: None History of Present Illness: 72F with MS [**First Name (Titles) **] [**Last Name (Titles) **] for h/o DVT and PE has had progressive headche today with associated nausea and vomiting. Presented to OSH with CT showing left cerebellar hemorrhage. Pt received Vit K for INR 5.5 and was transferred to [**Hospital1 18**] ED. Past Medical History: MS,HTN, incontinence,inc chol,neuropathy,non-healing L ankle wound, fx R ankle Social History: Hx:lives with husband, [**Name (NI) 269**], nonsmoker, no EToH Family History: Noncontributory Physical Exam: O: T: 97.5 BP: 186/50 HR:83 R18 O2Sats92 Gen: WD/WN, comfortable, NAD, drowsy but easily arousable HEENT: Pupils:L 5, R 4.5 both briskly reactive EOMs full Neck: Supple. Extrem: Warm and well-perfused. birthmark left arm Neuro: Mental status: Awake though slightly drowsy, trying to be cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils round and reactive to light, 5mm on left and 4.5 on right. 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. antigravity all 4 extremities, cast on right LE Sensation: Intact to light touch bilaterally. Coordination:unable to assess ** Upon Discharge ** AOx3, PERRL, EOM intact, face symm, tongue midline. MAE [**3-26**] except RLE in cast- + antigravity Pertinent Results: [**2126-10-4**] 02:11AM BLOOD WBC-10.2 RBC-3.22* Hgb-9.9* Hct-30.1* MCV-94 MCH-30.9 MCHC-32.9 RDW-14.8 Plt Ct-324 [**2126-10-4**] 02:11AM BLOOD Plt Ct-324 [**2126-10-2**] 11:00PM BLOOD Neuts-90.1* Lymphs-7.6* Monos-1.7* Eos-0.5 Baso-0.1 [**2126-10-4**] 02:11AM BLOOD Glucose-84 UreaN-44* Creat-2.0* Na-144 K-4.9 Cl-113* HCO3-23 AnGap-13 [**2126-10-4**] 02:11AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1 [**2126-10-3**] 02:27AM BLOOD Triglyc-78 HDL-46 CHOL/HD-3.6 LDLcalc-104 HEAD CT [**2126-10-2**]: IMPRESSION: Interval mild enlargement of the left superior cerebellar hyperdense area with mildly increased mass effect. Clinical correlation is recommended. While this is most likely to represent hemorrhage, DDX includes dense neoplasms like meningioma; underlying vascular or neoplastic causes cannot be excluded. HEAD CT [**2126-10-3**]: IMPRESSION: Little change since the prior study of the left cerebellar hemorrhage with mass effect on 4th ventricle and cerebral aqueduct. Stable 2- mm rightward shift of midline structures. Underlying vascular or neoplastic lesions, if any, can be better assessed by MR/CTA after resolution or as indicated clinically. EKG [**2126-10-6**] Normal sinus rhythm, rate 59. Non-specific anterolateral repolarization changes. Possible inferior myocardial infarction of indeterminate age. Compared to the previous tracing of [**2126-10-2**] no significant change. Intervals Axes Rate PR QRS QT/QTc P QRS T 59 146 92 422/420 41 -4 75 NECK/Soft tissue Ultrasound [**2126-10-6**]: No abnormal fluid collection or mass in the right neck. Carotid US [**2126-10-7**]: Less than 40% stenosis of the bilateral extracranial internal carotid arteries. Brief Hospital Course: Ms [**Known lastname 4223**] was admitted to the NeuroICU after a CT showed cerebellar hemorrhage. Her neurological status was monitored very closely and remained unchanged throughout her hospital course. Her INR was reversed to a goal of less than 1.5 A CTA was desired for rule out vascular cause of bleed. Due to her renal insufficiency a MRA was recommended. Given her exterme claustrophobia, an open MRI was scheduled after discharge. On [**10-6**] it was noted that there was some swelling to her right neck- a soft tissue ultrasound was done which was negative. She subsequenty had one 15 minute episode of Left chest discomfort. Cardiac work up was unimpressive and cardiology consult felt that there were no acute cardiac episodes. She was evaluated by PT and ultimately discharged home. Medications on Admission: [**Month/Year (2) **] 6.5', lipitor 20',altase5',metoprolol 25',valium 2qhs,neurontin 400'',ramipril 5', lasix 80', aspirin 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. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Ramipril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:*9 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Care Tenders Discharge Diagnosis: Cerebellar Hemorrhage Carotid stenosis UTI Discharge Condition: Neurologically stable Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy 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. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????We are making your appointments for MRI, CT and Dr [**Location (un) 84339**] will be sending you a letter with the exact appointment times. The follow up appointment is in the next 4 weeks. ??????You will need a MRA +gad in open MRI prior to your appointment. This can be scheduled when you call to make your office visit appointment or you may have the scan done at an outside facility. You must bring a CD with the images to your appointment. During your hospital stay you had an ultrasound of the neck. This showed carotid stenosis. You should follow up with you PCP [**Name Initial (PRE) 176**] 2 weeks to discuss this diagnosis. Completed by:[**2126-10-10**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

5556, 5599

3776, 4577

304, 311

5686, 5710

2075, 3753

6687, 7396

833, 850

4754, 5533

5620, 5665

4603, 4731

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865, 1093

245, 266

339, 633

1317, 2056

1108, 1301

655, 736

752, 817

22,783

124,678

20561+57185

Discharge summary

report+addendum

Admission Date: [**2167-2-13**] Discharge Date: [**2167-2-22**] Date of Birth: [**2134-6-23**] Sex: F Service: ICU This report covers the date from [**2167-2-13**] until [**2167-2-22**]. REASON FOR ADMISSION: The patient is a 32 year old female transferred from an outside hospital for adult respiratory distress syndrome, poly- and pancreatitis following multiple ingestions in an attempted suicide. HISTORY OF PRESENT ILLNESS: The patient is a 32 year old female with a past medical history of bipolar disorder and multiple prior suicide attempts who was found unresponsive by her husband on the [**7-9**]. Multiple empty pill bottles were noted in her vicinity that included Seroquel, Motrin, Prozac, and Lamictal. The patient was taken to the [**Hospital3 417**] Hospital although aspirated in the ambulance on the way over. The patient's toxicology screen on admission to the [**Hospital3 417**] Hospital was positive for cocaine as well as ethanol with ethanol level of 128.7. The patient had a further episodes of aspiration in the Emergency Department and was thought to have aspirated charcoal and gastric contents at which point she experienced acute respiratory failure and was intubated for hypoxic respiratory distress. Her [**Hospital3 417**] hospital course was further complicated by inability to wean her from the ventilator with worsening progressive bilateral infiltrates consistent with adult respiratory distress syndrome, as well as elevation of pancreatic enzymes in the setting of hypertriglyceridemia at 995 while on TPN and Propofol. The patient also experienced persistent fevers despite initiation of broad spectrum antibiotics that included Vancomycin, Ceftriaxone, Clindamycin, as well as replacement of her central venous line. The patient further experienced and developed ATN that developed by the [**7-12**] which was treated with Mannitol and intravenous fluid, diuresis with good recovery with creatinine on transfer of 0.8. The patient's temperature maximum at the hospital was 102.3 F., with blood pressures that ranged in the 90 to 100s over 60s to 80s. Pulse is 100 to 110, saturations 95 to 97% on FIO2 of 0.6, CVP of 810 and Swan-Ganz catheter data obtained on the [**7-11**] showed a pulmonary capillary wedge pressure (PCWP) of 23 to 25 with a PAP of 60/30. An echocardiogram demonstrated an ejection fraction of 55% with mild left ventricular hypertrophy and apical dyssynergy. PAST MEDICAL HISTORY: 1. Bipolar disorder. 2. Multiple prior suicide attempts, approximately seven. 3. Obesity. ALLERGIES: The patient has no known drug allergies. MEDICATIONS AT HOME: 1. Prozac. 2. Lamictal. 3. Seroquel. MEDICATIONS ON TRANSFER: 1. Clindamycin. 2. Vancomycin. 3. Ativan drip. 4. Heparin subcutaneously. 5. Dexamethasone 4 three times a day. SOCIAL HISTORY: The patient smokes one pack per day. She does use alcohol and cocaine. She lives with her husband. She was recently dismissed from a job at a Mobil Gas Station and has no children. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: On admission, temperature 99.5 F.; pulse 94; blood pressure 100/57; respiratory rate of 23; O2 saturation of 97% on assist control with tidal volume of 650, respiratory rate of 24 and FIO2 of 60%. In general, the patient was found to be intubated, sedated, appearing her stated age. The patient's pupils equally round and reactive to light. She is anicteric. Conjunctivae are not injected. Mucous membranes were moist. No thrush or lesions are evidence in the oropharynx. No cervical lymphadenopathy. Lungs are clear anteriorly and laterally. Heart rate is tachycardic although regular without any murmurs, rubs or gallops. Abdomen is soft, nontender. The patient grimaces however with deep palpation. There are bowel sounds present times four. Extremities show no edema. LABORATORY: Data from the day of transfer sputum culture obtained at the outside hospital is white blood cell count of 7.4, hematocrit of 39, platelets 201. Sodium 137, potassium 3.7, chloride of 103, bicarbonate of 21, BUN of 25, creatinine of 0.8, amylase of 420, lipase of [**2180**], total bilirubin 0.5, alkaline phosphatase 51, AST 26, ALT 49. Arterial blood gas of 7.4/32/65.1 on AC-650/24/80/60% FIO2. Microbiology data from the outside hospital include from the [**7-15**] that shows Gram negative rods as well as scant Gram positive cocci in clusters with rare polymorphic nuclear cells. Urine culture on the 20, 23 and 24 were negative. Blood cultures on the 19th, 23, and 24 were negative. Chest films demonstrated significantly worsening bilateral infiltrates. CT scan of the abdomen at the outside hospital did not demonstrate any abscess, masses, fluid collection or pancreatic necrosis, and as mentioned, the echocardiogram at the outside hospital showed an ejection fraction of 55% with concentric left ventricular hypertrophy, no effusion, normal right ventricular function with trace tricuspid regurgitation. EKG shows sinus tachycardia, pulse of 101, normal axis and intervals. No ST or T segment changes. HOSPITAL COURSE: 1. ADULT RESPIRATORY DISTRESS SYNDROME: The patient was noted to have progressively worsening pulmonary function. Given her apparent adult respiratory distress syndrome on chest film, the patient was attempted to be ventilated according to the adult respiratory distress syndrome protocol. CT scan on the [**6-29**] showed extensive ground glass opacification / consolidation consistent with adult respiratory distress syndrome. The patient did not tolerate the rapid respiratory rate and small target volumes of the ARDS protocol and required further sedation with fentanyl and midazolam as well as eventually paralysis with cisatracurium. The patient was ventilated according to permissive hypercapnia with a pH between 7.2 and 7.35, however, the patient was noted to have worsening pulmonary compliance measured both by recordings taken through the ventilator as well as by several esophageal balloon studies. Despite ARDS ventilation with paralysis adequate sedation, the patient continued to have worsening infiltrates fibrosis on chest film with worsening pulmonary compliance and worsening hypoxia and the patient was given a trial of prone positioning on the [**6-23**] with little improvement and returned to the supine position. As the patient continued to have ongoing fevers (see below) and as her sputum repeatedly grew out Gram negative rods. The patient was maintained on empiric antibiotic coverage for possible ventilator associated pneumonia. The speciation of this Gram negative rod is not available at the time of this dictation although it is a non-lactose fermenting organism and is not thought to be Pseudomonas. The patient was covered with Levofloxacin which the isolate is known to be sensitive to and Zosyn was added on the [**6-24**] for double coverage as the patient continued to have fever and worsening respiratory status. Repeat CT scan was obtained on the [**6-24**] and the results of that scan are pending at the time of this dictation. 2. FEVER: The patient was noted to have ongoing fevers at the [**Hospital3 417**] Hospital for most of her hospitalization there. The patient continued to experience fevers on transfer to the [**Hospital1 69**] and further work-up for the etiology of these fevers has been negative other than for the presence of the Gram negative rods in her sputum mentioned above as well as one plus Gram positive cocci in the sputum whose speciation and sensitivities are pending at the time of this dictation. Serial blood cultures have been negative. Urinalysis revealed only 10,000 to 100,000 yeast and the patient's Foley catheter was changed; however, she did have zero white cells, zero red cells on urinary sediment. As mentioned above, the patient was transferred on broad spectrum antibiotics that included Vancomycin, Clindamycin and Ceftriaxone. The patient was begun on imipenem while in transfer given the concern for possible necrosis in the setting of pancreatitis (see below). The ceftriaxone, Clindamycin and Vancomycin were initially discontinued, however, as it became clear that the patient did not have pancreatic necrosis, the patient's imipenem was discontinued and as the fevers continued despite improvement of her pancreatitis (see below), the patient was started on empiric antibiotic coverage with Vancomycin as well as Levofloxacin for possible ventilator associated pneumonia. Vancomycin was discontinued on the [**6-24**] and as the patient continued to have ongoing fevers and as her fever work-up was only notable for the above mentioned Gram negative rods that had been abundant in her sputum since initial assay at the outside hospital, Zosyn was added for double coverage on the [**6-24**] along with Levofloxacin (this has been shown to be sensitive to both Levofloxacin as well as to Zosyn). 3. PANCREATITIS: This patient was transferred with pancreatitis from the outside hospital. As mentioned above, the source of the pancreatitis may have been from her initial ingestion versus from hypertriglyceridemia associated with Propofol or her tube feeds. On transfer, the patient's lipase was initially found here to be 394, although was 949 on subsequent assay on the [**7-18**] and from there declined serially to 53 on the [**6-24**]. CT scan of the abdomen on the [**7-18**] demonstrated no evidence of pancreatic necrosis but rather showed stranding adjacent to the tail of the pancreas consistent with the patient's known pancreatitis. There was no peripancreatic fluid collection, hematoma or abnormal pancreatic perfusion. As mentioned above, the patient's pancreatitis was initially covered with imipenem, although as it became clear that there was no evidence of pancreatic necrosis, the imipenem was discontinued as described above. The patient was initially maintained on aggressive fluid intravenous supplementation and was given also appropriate analgesia and a post pyloric feeding tube was placed for early initiation of tube feeds. The patient was given tube feeds for the first several days following admission to [**Hospital1 1444**]. She was later noted to have aspiration and the tube feeds were discontinued. Tube feeds were then restarted at a low rate and were at a rate up to 20 at the time of this dictation. 4. HYPERGLYCEMIA: The patient was noted to have significant hyperglycemia on transfer and it was thought that this was perhaps secondary to the TPN as well as to the steroids that she was on at transfer. The patient was found to have no adrenal insufficiency on a cosyntropin stimulation test and the empiric dexamethasone which was started at the outside hospital was discontinued. The patient was maintained on an insulin drip for tight control of her hyperglycemia. 5. ANEMIA: The patient was noted to have a blood count of 38 on admission, however, her count declined serially to a level of 22.9 on the third of [**Month (only) 547**] at which time she received one unit of packed red blood cells with appropriate change in her hematocrit to 24.6 on the [**6-24**]. 6. FLUIDS, ELECTROLYTES AND NUTRITION: As mentioned above, the patient was started on tube feeds through a post pyloric feeding tube. While these feeds were not yet up to goal, the patient was maintained on TPN and when the tube feeds were discontinued for aspiration, TPN was again started. No lipids were present in the TPN given the concern over pancreatitis in the setting of hypertriglyceridemia at the outside hospital. 7. HYPOTENSION: The patient, on several episodes, had transient hypotension that required treatment with pressors. The patient was intermittently on pressors including Neo-Synephrine. She was also given normal saline boluses to maintain adequate perfusion and her sedatives were titrated accordingly. 8. PROPHYLAXIS: The patient was maintained on famotidine as well as subcutaneous heparin and Pneumoboots. She was given Triadyne support services. Her access was left subclavian line that was placed on the [**7-15**] as well as a right sided arterial line that was placed here on the [**7-16**]. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. Dictated By:[**Last Name (NamePattern1) 11363**] MEDQUIST36 D: [**2167-2-22**] 14:25 T: [**2167-2-22**] 15:29 JOB#: [**Job Number 54989**] Name: [**Known lastname 5132**], [**Known firstname 1873**] Unit No: [**Numeric Identifier 10325**] Admission Date: Discharge Date: [**2167-2-27**] Date of Birth: Sex: F Service: ADDENDUM: The patient continued to spike fevers despite broad spectrum antibiotics. She was diagnosed with a ventilator associated pneumonia growing out meningosepticum. She also was bacteremic with Enterococcus fecalis and had a urinary tract infection growing yeast. Additionally, she developed a transaminitis and frequently became tachycardic up to the 160s and hypertensive with a systolic blood pressure up to 180. Pulmonary embolism was ruled out with a CTA. Tamponade was ruled out with a transthoracic echocardiogram. Her heart rate and blood pressure did not respond to fluid boluses or increasing sedation. Around 7:00 p.m. on [**2167-2-27**], another family meeting was held and the decision was made to make her comfort measures only. Her paralytics were discontinued at approximately 8:00 p.m. Approximately one and one half hours later, the ventilator settings were changed to pressure support and then discontinued. She was given Fentanyl and Marcaine and Propofol. The family was with her and she eventually became apneic and had cardiac arrest. Her time of death was 10:15 p.m. on [**2167-2-27**]. The family denied postmortem examination. [**Location (un) **] Organ Bank was denied any organ donation given her infectious concerns. Dr. [**Last Name (STitle) **] was involved throughout the entire process. [**First Name11 (Name Pattern1) 126**] [**Last Name (NamePattern4) 2098**], M.D. [**MD Number(1) 2099**] Dictated By:[**Last Name (NamePattern1) 1023**] MEDQUIST36 D: [**2167-2-28**] 12:25 T: [**2167-2-28**] 12:38 JOB#: [**Job Number 10326**]

[ "482.83", "577.0", "867.0", "790.7", "584.5", "518.81", "560.1", "507.0", "599.7" ]

icd9cm

[ [ [] ] ]

[ "93.96", "88.72", "42.92", "99.15", "96.72", "96.6", "38.91", "99.04", "00.14" ]

icd9pcs

[ [ [] ] ]

3051, 3069

5129, 14296

2649, 2690

3092, 5112

453, 2457

2715, 2833

2479, 2628

2850, 3034

1,278

111,843

28234

Discharge summary

report

Admission Date: [**2139-9-29**] Discharge Date: [**2139-10-5**] Date of Birth: [**2071-6-29**] Sex: F Service: CARDIOTHORACIC Allergies: Naproxen / Iodine; Iodine Containing / Rofecoxib / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1505**] Chief Complaint: increased DOE Major Surgical or Invasive Procedure: s/p OPCABx1(LIMA->LAD) [**2139-9-30**] History of Present Illness: 68 yo F with exertional chest pressure and DOE, diagnosed with CAD one year prior. ETT + for ischemia, referred for surgical revascularization. Past Medical History: CAD HTN hypercholesterolemia PVD COPD TIA Aorto-Bifem BPG right CEA laminectomy bilat iliac stents appy pilonidal cyst right cataract Social History: retired quit tobacco [**2120**], 20 pack year history [**12-8**] glasses wine/day Family History: sister with CABG in mid [**2082**]'s Physical Exam: WDWN F in NAD, mildly overweight Skin well healed abdominal and groin incisions. HEENT unremarkable Neck supple bilat carotid bruits L>R Lungs CTAB Heart RRR Abd + bruit L side extrem warm, no edema superficial varicosities r thigh Neuro alert and oriented, 5/5 strength t/o, MAE, normal gait Pertinent Results: [**2139-10-5**] 06:51AM BLOOD WBC-9.0 RBC-3.39* Hgb-10.8* Hct-30.2* MCV-89 MCH-31.8 MCHC-35.6* RDW-15.9* Plt Ct-265# [**2139-10-5**] 06:51AM BLOOD Plt Ct-265# [**2139-10-5**] 06:51AM BLOOD Glucose-102 UreaN-12 Creat-0.6 Na-133 K-4.1 Cl-98 HCO3-25 AnGap-14 Brief Hospital Course: Ms. [**Known lastname **] was scheduled for surgery on [**9-29**], carotid u/s on [**9-28**] showed 100% [**Doctor First Name 3098**] stenosis & occluded L vertebral. Her surgery was cancelled and she was admitted to F2 for further work up. She was seen by vascular surgery who cleared her for surgery. MRIshowed occluded [**Doctor First Name 3098**], patent L vert and moderate to severe [**Country **] stenosis. On 10.25 she underwent an off-pump CABG x 1. She awoke neurologically intake and was extubated that same day. She was weaned from her vasoactive drips and transferred to the floor on POD #1. She developed a small left apical pneumothorax following chest tube removal whoch resolved spontaneously. She was ready for discharge to home on POD #5. Medications on Admission: [**Doctor First Name 130**] crestor diovan advair spiriva low dose aspirin calcium CoQ Flaxseed Fish oil MVI albuterol fiber caps 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 every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*1 Cap(s)* Refills:*0* 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:*60 Tablet, Chewable(s)* Refills:*0* 6. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day) for 7 days. Disp:*40 Capsule, Sustained Release(s)* Refills:*0* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*qs * Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Greater [**Location (un) 5871**]/[**Location (un) 6159**] Discharge Diagnosis: CAD Bilat. severe carotid stenoses 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. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office for temp>101.5, sternal drainage. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 68568**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 6254**] for 3-4 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Completed by:[**2139-10-6**]

[ "443.9", "401.9", "272.0", "433.30", "414.01", "512.1", "496", "413.9" ]

icd9cm

[ [ [] ] ]

[ "36.15" ]

icd9pcs

[ [ [] ] ]

4119, 4214

1484, 2243

352, 393

4293, 4301

1204, 1461

4629, 4877

838, 876

2424, 4096

4235, 4272

2269, 2401

4325, 4606

891, 1185

299, 314

421, 566

588, 723

739, 822

51,327

185,781

41520

Discharge summary

report

Admission Date: [**2158-10-3**] Discharge Date: [**2158-10-5**] Date of Birth: [**2103-4-6**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1145**] Chief Complaint: pericardial effusiosn with likely tamponade physiology Major Surgical or Invasive Procedure: Pericardiocentesis History of Present Illness: Mrs. [**Known lastname **] is a 55 year old woman with history of limited small cell lung cancer s/p chemoradiation theraphy in [**2157**], and history of paraoxysmal atrial fibriallation who was found to have worsening pericardial effusion on recent outpatient TTE on [**2158-9-30**] with likely tamponade physiology and went to the cath lab today for pericardiocentesis. . Patient's small cell lung cancer was diagnosed in [**2157-2-12**] after which patient was started on chemotheraphy with Cisplatin/Etoposide and radiation to the chest with course compelted in [**2157-5-13**]. She has been stable from her oncologic standpoint with serial CT showing no new recurrences. . Patient had an echocardiogram on [**2157-10-4**] for work-up of atrial fibrillation by Dr. [**Last Name (STitle) **] which showed normal cardiac and valvular function along with small pericardial effusion. On Chest CT in [**6-24**] and [**9-24**] the pericardial effusion appeared to be getting larger. She had TTE on [**2158-9-30**] which showed moderate pericardial effusions with sustained right atrial collapse, consistent with low filling pressures or early tamponade. She was seen by Dr.[**Name (NI) 17483**] at cardiology clinic who recommended that patient get pericardiocentesis today. . Her pericariocentesis was complicated by micropuncture needle entering the RV cavity twice after which patient became lightheaded, apneic, and pulseless. CPR was initaited and patient regained consciousness within 2 minutes. RA pressure was noted to 25 up from 7 with pulsus of 30. Pericaridla fluid was then accessed and rained with 220cc of bloody fluid with resoolution of RA pressure to 5 and pulsus dropping to <10. A pericardial drain was left. . Patient was transfered to CCU in stable consition and denies any chest pain, shortness of breath, lightheadedd, nausea, vomiting or diaphreosis. She has swan in place thorugh femoral vein and arterial line through femoral artery. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Paroxysymal atrial fibrillation. - S/p C section [**2139**] . ONCOLOGIC HISTORY: - Presented with cough, dyspnea on exertion, wheezing and a hoarse voice in [**2-/2157**] - Imaging demonstrated a left upper lobe mass with mass effect on the pulmonary artery and left upper lobe bronchus. CT-guided biopsy of the mass and pathology revealed small cell lung cancer. PET/CT scan prior to therapy demonstrated the large FDG-avid left upper lobe mass with a hypodense nodular lesion in the right thyroid. - Began therapy for limited stage small cell lung cancer with Cisplatin/Etoposide on [**2157-3-17**] and began radiation therapy on [**2157-4-7**]. Therapy was completed [**2157-5-25**]. She underwent prophylactic cranial irradiation, completed on [**2157-9-28**]. Social History: Smoked 1 ppd for 25-30 years, quit [**1-22**]. Denies any alcohol of IV drug abuse. Works as an elementary school librarian. Family History: Mother: deceased, long history of dementia Father: died of asbestos-related lung cancer, possibly mesothelioma Sister: died of breast cancer at age 52 Brother with atrial fibrillations. Physical Exam: GENERAL: Alert and awake. Oriented x3.NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM. NECK: Supple with JVP of 7. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No murmurs. No pericardial friction rubs. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi on anterior chest. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 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: Admission Labs: [**2158-10-3**] 04:00PM BLOOD WBC-7.8 RBC-4.53 Hgb-12.6 Hct-39.3 MCV-87 MCH-27.7 MCHC-31.9 RDW-13.8 Plt Ct-317 [**2158-10-3**] 04:00PM BLOOD PT-10.9 PTT-32.9 INR(PT)-1.0 [**2158-10-3**] 04:00PM BLOOD Glucose-76 UreaN-11 Creat-0.8 Na-142 K-3.6 Cl-102 HCO3-29 AnGap-15 [**2158-10-3**] 08:00PM BLOOD Calcium-8.3* Phos-2.7 Mg-1.8 . Discharged Labs: [**2158-10-5**] 06:54AM BLOOD WBC-11.0 RBC-3.65* Hgb-10.2* Hct-31.6* MCV-87 MCH-27.9 MCHC-32.2 RDW-13.6 Plt Ct-260 [**2158-10-5**] 06:54AM BLOOD Glucose-96 UreaN-10 Creat-0.6 Na-138 K-4.2 Cl-106 HCO3-24 AnGap-12 [**2158-10-5**] 06:54AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.7 . TTE: [**2158-10-3**] The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is mild pulmonary artery systolic hypertension. There is a small to moderate sized circumferential pericardial effusion most prominent (1.5cm) anterior to the right atrium and <1.0cm anterior to the right ventricle, apex, and inferolateral left ventricle. There is intermittent mild right ventricular diastolic invagination, but no significant respiratory eccentuation in transmitral Doppler E wave velocity. . Compared with the prior study (images reviewed) of [**2158-9-30**], the effusion is similar. . TTE: [**2158-10-3**] Overall left ventricular systolic function is normal (LVEF>55%). There is a small to moderate sized pericardial effusion located predominantly along the right atrium, free wall of the right ventricle and apex. After insertion of the needle in the pericardial space and injection of normal saline, no saline is seen in the pericardial space (although image quality is suboptimal). Following clips demonstrate progressive increase of size of the pericardial effusion which appears circumferential and large with evidence of early diastolic collapse of the right ventricle and formation of clot in the pericardial space anterior to the right ventricle. After removal of 200 cc of pericardial fluid, a small residual circumferential effusion is appreciated predominantly along the righta atrium and anterior RV without evidence of tamponade physiology. . TTE: [**2158-10-5**] 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. There is abnormal septal motion/position. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. . IMPRESSION: Small circumferential pericardial effusion with echodense components. No evidence of tamponade. There is a septal bounce present which is suggestive of effusive-constrictive physiology - which is often present for a few weeks post pericardiocentesis. Normal biventricular sizes and systolic function. . Compared with the prior study (images reviewed) of [**2158-10-4**], the amount of pericardial fluid has increased slightly. Tricuspid and mitral inflows do not suggest impaired filling on the current study. There is a septal bounce present on the current study. Other findings are similar. . Pericardial Effusion Cytology: [**2158-10-3**] Pericardial fluid: NEGATIVE FOR MALIGNANT CELLS. Blood and rare inflammatory cells only. Brief Hospital Course: 55 year old woman with history of limited small cell lung cancer s/p chemoradiation therapy in [**2157**], and history of paroxysmal atrial fibrillation who was found to have worsening pericardial effusion on recent outpatient TTE on [**2158-9-30**] with likely tamponade physiology and went to the cath lab for pericardiocentesis. . # Pericardial Effusions: Patient's pericardial effusion was first incidentally noted on [**9-/2157**] TTE. However on recent CT chest imaging performed for surveillance of her small cell lung cancer, her pericardial effusions appeared to be getting larger. Therefore she had TTE on [**2158-9-30**] which showed pericardial effusion with likely early tamponade physiology. She was then electively admitted for pericardiocentesis on [**2158-10-3**]. Her pericardiocentesis was complicated by micropuncture needle entering the RV cavity twice after which patient became lightheaded, apneic, and pulseless. CPR was initiated and patient regained consciousness within 2 minutes. RA pressure was noted to 25 up from 7 with pulsus paradoxes of 30. Pericardial fluid was then accessed and rained with 220cc of bloody fluid with resolution of RA pressure to 5 and pulsus dropping to <10. A pericardial drain was left and removed the following day after very little drainage overnight. In the CCU patient remained hemodynamically stable without any further chest pain or shortness of breath. Her pericardial fluid cytology came back as negative for malignancy cells. Her pericardial effusions were thought to have resulted from her prior radiation to the chest near the pericardium. On the day of discharge patient had another TTE which showed a small interval increase in the size of pericardial effusion with no signs of tamponade physiology. Therefore she is scheduled for another TTE on Monday [**2158-10-9**]. The results of TTE will be communicated to patient by Dr.[**Name (NI) 3733**] who will also meet with patient for a follow up appointment in [**Month (only) 462**]. . # Paroxysmal Atrial Fibrillation: Patient with CHADS2 score of 0. During her hospitalization she continued to have afib with RVR. Despite starting her on her home dose of verapamil and metoprolol her rates were not well controlled. She went in and out of afib continuously in the matter of minutes. On discharge her metoprolol was stopped and she was discharged on higher dose of verapamil 480mg daily. She was also continued on aspirin. . # Acute Anemia: Patient had drop in HCT from 39 to 31 after pericardiocentesis most likely in the setting of RV puncture with resulting blood loss. Her HCT continued to remain stable. . # Limited small lung cancer: Cisplatin/Etoposide on [**2157-3-17**] and began radiation therapy on [**2157-4-7**]. Therapy was completed [**2157-5-25**]. Serial CT chest has not shown any recurrence of cancer. The cytology from her pericardial fluid was negative for malignant cells. She will follow up with her [**Month/Day/Year 5564**] for further surveillance. . Transitions of care: - Patient scheduled for TTE on Monday [**2158-10-9**] which will be followed by Dr[**Doctor Last Name **]. - Patient scheduled to follow with PCP, [**Name10 (NameIs) **] and cardiologist for further management of her various medical problems. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Aspirin 81 mg PO DAILY 2. Metoprolol Tartrate 12.5 mg PO BID 3. Verapamil 120 mg PO Q8H 4. Senna 1 TAB PO BID:PRN Constipation Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Senna 1 TAB PO BID:PRN Constipation 3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain Please avoid handling any machinery or dirving while taking this medication. RX *oxycodone 5 mg 1 tablet(s) by mouth Every 6 hours as need for pain Disp #*20 Tablet Refills:*0 4. Verapamil SR 480 mg PO Q24H RX *verapamil 240 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: 1. Pericardial effusion complicated by worsening tamponade during pericardiocentesis with 2 minutes of cardiac arrest Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname **], It was a pleasure taking care of you during your hospitalization at [**Hospital1 18**]. You were admitted because you had fluid surrounding your heart. You had a procedure to remove that fluid which was complicated by needle going though your heart and causing rapid accumulation of blood around your heart which then lead you to become unresponsive temporarly. This fluid was removed and your blood pressure normalized. You were monitored in the cardiac intensive unit where you had improvement in your shortness of breath. Repeat imaging of your heart showed minimal reaccumulation of fluid. Microscopic review of the fluid from your heart did not show any cancer cells. You should follow up with your cardiologist, Dr.[**Name (NI) 3733**] (see below) for further mangement. You should also follow up with your [**Name (NI) 5564**], Dr. [**Last Name (STitle) 3274**] (see below) for further surveilance of your prior lung cancer. You were also in and out of atrial fibrillation during your hospitalization. Because of this, we are changing your medications: # Please stop verapamil 120 mg three times a day. Instead, start verapamil extended release 480 mg in the morning. # Stop your metoprolol. Followup Instructions: Echocardiogram: Monday [**2158-10-9**] [**Hospital Ward Name 2104**] Building 1pm [**Location (un) 861**] Name: [**Last Name (LF) 5302**],[**First Name3 (LF) **] B. Location: [**Hospital1 **] Family Medicine of [**Location (un) 620**] Heights Address: [**Apartment Address(1) 31234**], [**Location (un) **],[**Numeric Identifier 14512**] Phone: [**Telephone/Fax (1) 31235**] Appt: Thursday, [**10-12**] at 9am Department: CARDIAC SERVICES When: FRIDAY [**2158-10-27**] at 11:00 AM 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 Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2158-11-7**] at 2:00 PM With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2158-10-6**]

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Discharge summary

report

Admission Date: [**2145-5-4**] Discharge Date: [**2145-5-18**] Date of Birth: [**2081-10-8**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: Weak/Lethargic Major Surgical or Invasive Procedure: Intubation/Extubation History of Present Illness: The patient is a 63 yoF w/ a h/o ESRD secondary to HTN and DM, failed renal tx (primary graft non function), and recent admission for staph epi bactermia thought to be related to an HD catheter infection presented initally to the ER at [**Hospital 6451**] with R sided weakness and blurred vision, the patient was then transferred to the [**Hospital1 18**] ER after a Head CT without bleed. . Per the family her bilateral blurred vision started the day prior to her admission, she said this improved with glasses. Then the day of admission she began to feel as though her vision was "enclosed in glass" and she began to have abnormal speech and tongue swelling, she had some R sided weakness and was at that time her home health aide called 911. EMS reported the patient had slurred speech. The patient had recently started an albuterol inhaler this a.m. . In the ED, initial VS: T 97.9 HR 60 BP 85/40 RR 12 O2 sat: 90's. In the ER she was noted to be hypotensive, anasarca with facial / tongue / arm swelling. She was noted to be intermittently hypoxic without a good pleth. Neuro was consulted and thought a stroke versus septic emboli was possible. Neuro recommended an LP and then anticoagulation for her possible intracardiac thrombus. A femoral line was placed in the ER. She was started on a bicarb drip for metabolic acidosis She rec'd benadryl 50mg IV, famotidine 20mg, solumedrol 125mg x 1 IV, epi pen, Calcium gluconate, vancomycin 1g, zosyn. The patient was intubated. She rec'd 1 L NS. . She was intubated mainly for airway protection. (and unable to get good pleth). HR 51, BP 92/66, 93% FiO2 400x20, PEEP 10. On levophed 0.1 and propofol. Past Medical History: Past Medical History: - Stage V CKD secondary to hypertension/diabetes and was HD dependent (R sided indwelling line) s/p cadaveric renal transplant [**2144-8-15**] c/b delayed graft function and wound infection - Diabetes type II - Depression - multiple DVT - Atrial fibrillation in setting of parathyroidectomy. - Coag negative staph bacteremia during [**3-/2145**] admission in which HD line was removed and replaced, which then needed to be replace and found to be Pseudomonas positive cath tip. Tx'd with one month Vancomycin and Ceftazadime. Seen to have clot at junction of RA and SVC, Cardiac surgery recommended completing antibiotics course. . Past Surgical History: - neck exploration and subtotal parathyroidectomy [**4-20**] - left upper extremity AV fistula - hysterectomy - s/p cadaveric renal transplant as above Social History: She lives with her daughter. She has never smoked and is an occasional drinker. No illicit drugs. She is on disability and is very sedentary. Family History: Notable for two sisters with diabetes mellitus. Physical Exam: Vitals - T: 95.6 HR 54 BP 111/29 AC 20x400 PEEP 5, FiO2 100% O2 sat 100%. GENERAL: NAD, intubated, sedated HEENT: Pupils constricted with minimal reaction to light, facial edema with tongue enlargement, conjunctival edema CARDIAC: RRR, [**3-20**] HSM at the LLSB LUNG: minimal expiratory wheezes bilaterally ABDOMEN: anasarca, obese, absent bowel sounds, moderate distension without any tenderness EXT: UE significant symmetric edema, bilateral lower extremity edema NEURO: withdraws all 4 ext to painful stimuli, PERRL but constricted Pertinent Results: Admission labs: [**2145-5-4**] WBC-5.4 RBC-4.72 Hgb-14.1# Hct-47.5# MCV-101*# RDW-23.6* Plt Ct-102* Neuts-69.9 Lymphs-17.5* Monos-9.3 Eos-3.1 Baso-0.3 PT-13.9* PTT-33.0 INR(PT)-1.2* Glucose-87 UreaN-55* Creat-8.2*# Na-131* K-7.5* Cl-98 HCO3-18* AnGap-23* ALT-20 AST-70* CK(CPK)-77 AlkPhos-76 TotBili-0.3 Glucose-83 Lactate-1.1 Na-135 K-6.9* Cl-99* calHCO3-19* . Discharge Labs: [**2145-5-18**] WBC-6.4 RBC-4.18* Hgb-12.3 Hct-41.6 MCV-100* RDW-22.5* Plt Ct-112* PT-22.1* PTT-35.8* INR(PT)-2.1* Glucose-83 UreaN-67* Creat-5.1* Na-133 K-4.7 Cl-93* HCO3-26 AnGap-19 Calcium-8.1* Phos-5.5* Mg-2.0 . MICRO: [**2145-5-4**] Blood cx x2: negative, final [**2145-5-7**] Blood cx x2: negative, final [**2145-5-4**] Urine cx: yeast [**2145-5-9**] Urine cx: yeast . [**2145-5-4**] CT head: 1. No acute intracranial hemorrhage or process. 2. Interval partial opacification of the ethmoid air cells and mild mucosal thickening of the maxillary sinuses. Stable partial opacification of the mastoid air cells bilaterally. . [**2145-5-4**] CT TORSO: 1. No definite evidence of thrombus within the SVC. Lower SVC is still probably slightly narrowed as seen on the recent angiography study of [**2145-4-1**]. Evaluation is somewhat limited due to cardiac motion and presence of central venous line through the SVC. The azygos vein remains mildly dilated as seen on the previous study. 2. Small bilateral pleural effusions, right greater than left. The right-sided pleural effusion has increased in size since previous study and the left-sided pleural effusion has decreased in size. There is bibasilar atelectasis. 3. Small amount of free fluid within the abdomen and pelvis. Three large calcified gallstones noted within the gallbladder with pericholecystic fluid. Findings are likely due to third spacing, but in the appropriate clinical setting, cholecystitis is not excluded. Further evaluation with ultrasound can be performed for further evaluation. 4. Normally enhancing renal transplant within the pelvis. 5. Severe wedge compression fracture of L1, stable since [**45**]/[**2144**]. . [**2145-5-4**] Unilateral LE U/S:Extremely limited exam due to diffuse edema and body habitus. Distal left superficial femoral vein not imaged in addition to the calf veins. However, no evidence of DVT within the visualized veins. . [**2145-5-5**] EEG: This is an abnormal portable EEG due to slowing and disorganization of the background rhythm. No areas of focal slowing, epileptiform discharges or electrographic seizures were seen during this recording. . [**2145-5-6**] MRI brain: 1. There is no evidence of large acute infarction, mass effect, or hemorrhage. A tiny focus of increased DWI signal in the right medial temporal lobe which may represent an artifact or less likely a very tiny acute infarct. Attention on follow up can be considered. 2. The right posterior inferior cerebellar artery is not visualized. This might be secondary to its small caliber less likely disease process. CTA can be considered if there is clinical concern. 3. Unchanged opacification of the mastoid air cells bilaterally. This is nonspecific but can be seen in mastoiditis. Please correlate clinically. . [**2145-5-5**] ECHO: There is moderate regional left ventricular systolic dysfunction with inferior akinesis and inferolateral akinesis/hypokinesis. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mitral regurgitation is probably moderate but was not fully assessed. The tricuspid valve leaflets are mildly thickened. Tricuspid regurgitation is present but was not fully assessed. There is mild pulmonary artery systolic hypertension. A catheter is seen in the right atrium. There is a small mobile echodense structure (~0.4x1.0 cm) near the junction of the SVC and right atrium (see cell 28) that may be adherent to catheter. This structure is in the same vicinity as echodense structures seen in the prior study of [**2145-4-2**] but fewer views were obtained so comparison is limited. . [**2145-5-5**] RUQ U/S: Cannot assess for acute cholecystitis given limitations and inability to asses for son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. Cholelithiasis and similar appearance of gallbladder as seen on recent CT. Small right pleural effusion. Brief Hospital Course: 63 yoF w/ ESRD on HD presenting from OSH with right sided upper extremitiy weakness, blurred vision, and lethargy. . # Blurred vision / R sided weakness: Symptoms resolved on admission to the ICU. Echo with bubble did show evidence of pulmonary shunting. MRI of the brain, however, was without evidence of stroke or bleed. EEG did not reveal any eliptiform activity to suggest seizures. Serum and urine toxicology screens were negative. Patient's symptoms resolved prior to discharge. . # Facial Swelling: Per medical records the patient commonly has increased upper extremity and facial edema related to her SVC stenosis. She underwent CT Torso which showed no evidence of new clot. Clinical presentation was not consistent with allergic reaction or angioedema so antihistamine treatments were discontinued. Patient swelling improved slightly during hospitalization with CVVH ultrafiltration and later HD. . # Hypotension: Patient was initially felt to be hypotensive and started on vanc/zosyn. However, on review patient routinely has SBP 90s-100s. No evidence of infection based on culture data. Patient's midodrine was increased from 5 to 10 [**Hospital1 **] so she could tolerated HD. . # ESRD: Patient was initially on CVVH and then transitioned to HD. She will continue her outpatient HD schedule of T,Th,Sat. . # Respiratory failure: Patient was intubated on arrival to the ED for depressed mental status. She was extubated on [**2145-5-6**] and was stable on RA prior to discharge. . # RA/SVC thrombus vs. vegetation: Patient with known mass that was evaluated on prior admission by CT surgery. Mass is unchanged and consistent with cast of prior HD line. CT surgery team from prior admission was e-mailed and stated that in the setting of no known embolization (stroke/PE) they would not recommend surgical intervention at this time. . # Failed renal transplant: Patient had tenderness on flank over transplant site so started on steroids. See medications for steroid taper . # Atrial filbrillation and h/o DVT: Patient temporarily taken off coumadin in case procedures were necessary. Patient was put on heparin bridge and coumadin restarted. Remained on heparin drip until INR therapeutic. Patient should have her INR checked at next dialysis session and rehab should follow up on INR. . # Goals of care: Patient has expressed both the desire to get stronger and go home and the concern that her health is failing. She is considering stopping dialysis. However, the patient and her family have not reached a final decision. Given her psychiatric history, psychiatry was consulted and they did not feel that she was depressed or psychotic. They felt that she had a flat affect and recommended decreasing her Zyprexa from 5mg to 2.5mg at night. Palliative care was also consulted and provided the patient with information. The patient and her family needed more time to make the decision and they agreed to continue with rehab and dialysis until more discussions could take place. Social work has been consulted and her rehab facility to help continue the goals of care discussion. Her outpatient nephrologist has also been notified. . # Access: HD catheter and PICC line . # CONTACT: Daughter: Ms. [**First Name8 (NamePattern2) 58382**] [**Known lastname 732**]: [**Telephone/Fax (1) 58437**] Son: Mr. [**First Name8 (NamePattern2) 3441**] [**Known lastname 732**]: [**Telephone/Fax (1) 58438**] Medications on Admission: Citalopram 20 mg po daily Famotidine 20 mg po daily Gabapentin 300 mg po daily Metoprolol Tartrate 12.5mg po bid Mirtazapine 15 mg po qhs Zyprexa 5 mg po qhs Sulfamethoxazole-Trimethoprim 400-80 mg po daily Midodrine 5 mg po bid Albuterol q6hrs prn Vancomycin- course finished [**2145-4-20**] Warfarin 2.5 mg po daily Nephrocaps 1 mg po daily Digoxin 125 mcg po on Wed and Sunday Lasix 120 mg on MWF and Sun Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. 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. 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR). 11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO 2X/WEEK ([**Doctor First Name **],WE). 12. Prednisone 10 mg Tablet Sig: asdir Tablet PO DAILY (Daily): 20mg until [**5-25**], then 10mg until stopped by outpt nephrologist. 13. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Disp:*90 Tablet(s)* Refills:*2* 14. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [**Last Name (un) **] Center - [**Location (un) 701**] Discharge Diagnosis: Primary Diagnosis: End Stage Renal Disease on Dialysis S/P Failed Renal Transplant SVC stenosis . Secondary Diagnosis: DVT Atrial Fibrillation on Coumadin Discharge Condition: stable, alert, needs assistance for ambulation Discharge Instructions: You were admitted to the hospital with weakness and blurry vision. Imaging of your brain showed no acute bleed and your symptoms resolved. We were concerned about your the oxygen saturation in your blood so you were temporarily intubated. You continued on your hemodialysis schedule while hospitalized. We were concerned that your body might be rejecting your kidney so we started you on steroid medications. In terms of your arm and face swelling this was most likely due to your known SVC stenosis. It should improve with dialysis. We temporarily stopped your coumadin and your blood was thinned with heparin until your coumadin level was therapeutic again. . We have made the following changes to your medications: 1. Prednisone 20mg by mouth every day until [**5-25**], then 10mg by mouth each day until you see your nephrologist at the appointment listed below. 2. Bactrim 400-80 mg Tablet by mouth DAILY 3. Warfarin 7.5mg by mouth once a day 4. Decrease Olanzapine to 2.5mg by mouth at night Followup Instructions: Department: TRANSPLANT CENTER When: WEDNESDAY [**2145-6-9**] at 11:30 AM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2145-5-19**]

[ "278.8", "996.81", "276.4", "427.31", "459.2", "E878.0", "585.6", "486", "311", "276.7", "V58.61", "780.97", "458.8", "V12.51", "250.40", "V45.11", "518.81", "327.23", "V58.67", "276.6", "403.91" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

13190, 13271

8040, 11453

328, 352

13470, 13519

3707, 3707

14565, 15033

3079, 3128

11912, 13167

13292, 13292

11479, 11889

13543, 14232

4085, 4475

2751, 2904

3143, 3688

14261, 14542

274, 290

380, 2051

4484, 8017

13411, 13449

3723, 4069

13311, 13390

2095, 2728

2920, 3063

9,505

144,498

53461

Discharge summary

report

Admission Date: [**2188-2-17**] Discharge Date: [**2188-2-25**] Service: MEDICINE Allergies: Zosyn Attending:[**First Name3 (LF) 3507**] Chief Complaint: Urosepsis Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **]F from nursing home ([**Hospital1 **]) recently dc'd from [**Hospital1 18**] after being admitted for weakness, abd pain, taken to [**Hospital1 **] ed for periods of unresponsiveness and delta ms. Somnolent and arousable to pain in the ED. Bp was 90/50 at NH, down to 83/43; satting 92% ra. Upon arrival from to the ED, HR was 55; BP was 78/55 and RR 20, 100% on 2L. Got 1L NS, BP increased from 80s to 110s. Pt received vanc/levo/flagyl in the ED along with ASA and Narcan (for pinpoint pupils). Pt has chronic abd pain and tonight was also c/o tenderness over the bladder. . On arrival to the floor, patient was initially agitated and speaking loudly/groaning. Pt denied any pain. Became progressively less arousable with HR down to 40s, BP down to 70s/80s systolic when patient sleeping. Given atropine 0.5 mg X 1 with HR to 60s/70s. Normal saline bolus completed; oxygen sats decreased to high 80s/low 90s on nasal cannula so patient placed on nonrebreather with sats up to 100%. Repeat CXR and portable abdomen performed. ABG sent. . MICU COURSE: [**2-17**]: Levo/Flagyl changed to Zosyn. Vanc dosed q48h. Fluid boluses to keep SBP up Past Medical History: PAST MEDICAL HISTORY: 1. Diverticulosis [**2180**]. 2. Irritable bowel syndrome. 3. Spinal stenosis. 4. Memory loss - CT c/w old small vascular disease #. Lacunar infarct left caudate lobe and right thalamus 5. Hearing loss. 6. Vitamin B12 deficiency. 7. Retinal detachment [**2170**]. 8. Chronic abdominal pain PAST SURGICAL HISTORY: Status post tonsillectomy Social History: She was an English professor for many years. She now lives with her husband, [**Name (NI) **], who is her primary caregiver. She has two sons, one in [**Name (NI) 531**] and the other one in [**Location (un) 86**]. Family History: nc Physical Exam: temp 97.4, hr 76/min, rr 18/min, sats 97% on RA, bp 146/76 neck supple, no jvd, no bruit rrr, nl s1+s2, PSM in apex to axilla chest with reduced air entry bilaterally, but no wheeze or crackles [**Last Name (un) 103**] soft, non tender, nl bs no o/c/c Pertinent Results: pCXR: Left basilar atelectasis. No evidence of pneumonia or CHF. . TTE: Symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Aortic valve stenosis. Pulmonary artery systolic hypertension. . [**2188-2-16**] 11:00PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2188-2-17**] 07:00AM BLOOD CK-MB-5 cTropnT-0.03* [**2188-2-16**] 11:00PM BLOOD ALT-24 AST-22 CK(CPK)-17* AlkPhos-49 Amylase-32 TotBili-0.5 [**2188-2-17**] 07:00AM BLOOD CK(CPK)-22* [**2188-2-16**] 11:00PM BLOOD Glucose-132* UreaN-30* Creat-1.7* Na-136 K-3.8 Cl-102 HCO3-25 AnGap-13 [**2188-2-25**] 05:19AM BLOOD Glucose-103 UreaN-11 Creat-1.1 Na-138 K-4.3 Cl-104 HCO3-27 AnGap-11 [**2188-2-16**] 11:00PM BLOOD WBC-12.4*# RBC-4.34 Hgb-12.1 Hct-37.1 MCV-86 MCH-27.8 MCHC-32.5 RDW-14.8 Plt Ct-240 [**2188-2-25**] 05:19AM BLOOD WBC-6.1 RBC-3.68* Hgb-10.1* Hct-32.5* MCV-88 MCH-27.6 MCHC-31.2 RDW-16.0* Plt Ct-297 . Urine Cx: Pan-S E coli Brief Hospital Course: # Urosepsis: foley placed during last admission and was supposed to be dc'd after 2 days in rehab ([**2-16**]) after the patient passed a voiding trial. Pt was started on vanco and zosyn, eventually transitioned to PO Cipro as Ucx grew Pan-S E Coli. Will complete a total of a 14 day course. Pt with urinary retention that improved with scheduled voidings and holding of Detrol. Detrol to be held on d/c. . # MS changes: likely [**1-18**] UTI. and ARF. Resolved during hospitalization. Per Geriatric consultants, Celexa, Aricept, and Zyprexa held upon d/c. . # Bradycardia: Likely combination of taking usual atenolol plus acute renal failure. BB held on d/c (see below). . # HTN: meds (BB/ACE) were stopped in the setting of urosepsis. BP remained well controlled off these agents, and they were held on d/c. To f/u with PCP for BP check within 1-2 weeks. . # ARF: baseline Cr 1.2-1.5; 1.7 on admission but improved to 1.1 after fluid. Medications on Admission: tylenol prn mom dulcolax [**Name2 (NI) 109927**] 10 qhs asa 81 qd celexa 10 qd lipitor 10 qd psyllium vit b12 100mcg qd vit d zyprexa 2.5 po qhs prilosec 20 qd atenolol 12.5 qd lisinopril 5mg qd detrol 2mg qhs Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain/fever. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 9. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Tablet, Delayed Release (E.C.)(s) 10. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 11. Vitamin B-12 100 mcg Tablet Sig: One (1) Tablet PO once a day. 12. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Sepsis due to Urinary Tract Infection Delirium, resolving Urinary Retention, resolving Discharge Condition: stable Discharge Instructions: Please continue your medications as listed (see medication sheet for changes). Call your doctor if you experience fever, abdominal pain, difficulty urinating, or any other concerning symptoms. Please make sure you follow up with Dr. [**Last Name (STitle) **] in the next 1-2 weeks. Do not take Celexa, Aricept, Zyprexa, Atenolol, Lisinopril or Detrol until you see Dr. [**Last Name (STitle) **]. Followup Instructions: 1. Please make sure you follow up with Dr. [**Last Name (STitle) **] in the next 1-2 weeks.

[ "995.92", "599.0", "584.9", "276.51", "788.20", "780.09", "038.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

5741, 5827

3307, 4252

223, 229

5958, 5967

2342, 3284

6412, 6507

2050, 2054

4513, 5718

5848, 5937

4278, 4490

5991, 6389

1774, 1802

2069, 2323

174, 185

257, 1417

1461, 1751

1818, 2034

31,942

180,806

54112

Discharge summary

report

Admission Date: [**2126-11-10**] Discharge Date: [**2126-11-13**] Date of Birth: [**2073-1-25**] Sex: M Service: MEDICINE Allergies: Codeine / Compazine / Penicillins / Metformin / Heparin Agents Attending:[**First Name3 (LF) 17865**] Chief Complaint: broken external fixation Major Surgical or Invasive Procedure: None History of Present Illness: 53 yo m with hx of severe COPD, s/p trach, and recent prolonged hospitalization ([**Date range (1) 110912**]) after a mechanical fall resulting in R radius and ulnar fracture s/p external fixation complicated by PEA arrest after trach change, COPD exacerbation, VAP, C. diff colitis, clinical seizures though negative EEG, and altered mental status who presents with broken external fixation. . Per rehab notes, he has had recurrent episodes of vomiting 2-3x per day and continues to have diarrhea. His tube feeds have been placed on hold and his G-tube is currently on gravity. WBC from [**11-8**] is 12. He had a KUB that either showed an ileus or is unremarkable. UCx is growing ESBL E. coli but no sensitivities are included. Reportedly, he is on po vanc for c. diff and empiric gent for recent pseudomonas pneumonia though these are not on his medication list. . In the ED, initial vs were: 100.8, 130, 122/42, 18, 100% on FiO2 50%. Tmax was rectal of 102.3. On exam his ex-fix was noted to be broken and taped together. There are areas of purulent drainage. CXR shows possible L sided pneumonia v. aspiration. Pt recevied vanc/levo/flagyl and tylenol. He also received 1mg of ativan for agitation. Ortho plans to take him to the OR tomorrow to replace the pin. Current vital signs are: 124 101/68, 96% on vent settings. Access: midline on L. Past Medical History: COPD with trach on O2 and chronic prednisone, tracheomalacia, h/o tracheal stenosis -Type II DM -diastolic CHF -mild pulmonary HTN -osteoporosis s/p mid-thoracic vertebral body fracture, hip fx, and R wrist fracture -chronic LBP - pt reports compression fractures from osteoporosis -h/o C. diff colitis -Hepatitis B -Iron def. anemia -h/o gastric and duodenal ulcers -h/o nephrolithiasis -h/o MRSA nasal swab, MRSA sputum Cx Social History: Mr. [**Name13 (STitle) 14302**] was at [**Hospital1 100**] rewhab. He quit drinking more than seven years ago. He quit smoking approximately 2+ yrs ago, and has a 60 pack year history. He quit using heroin about eight years ago, after a 20 yr hx. Family History: Non-contributory. Physical Exam: Vitals: T:99 BP: 113/91 P: 120 R: 21 O2: 98% General: , complaining of severe pain in wrist when awake HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, no LAD Lungs: rhonchi bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild distention, non-tender, bowel sounds present Ext: warm, well perfused, 2+ pulses, erythema on lower extremities, 1+ edema to knees, venous statsis changes Pertinent Results: [**2126-11-10**] 01:50PM BLOOD WBC-26.2*# RBC-4.27*# Hgb-10.9*# Hct-34.6*# MCV-81* MCH-25.6* MCHC-31.6 RDW-15.5 Plt Ct-406 [**2126-11-13**] 05:45AM BLOOD WBC-12.2* RBC-3.50* Hgb-8.8* Hct-27.7* MCV-79* MCH-25.1* MCHC-31.7 RDW-16.1* Plt Ct-431 [**2126-11-10**] 01:50PM BLOOD PT-14.3* PTT-26.7 INR(PT)-1.2* [**2126-11-13**] 05:45AM BLOOD Plt Ct-431 [**2126-11-10**] 01:50PM BLOOD Glucose-115* UreaN-8 Creat-0.6 Na-141 K-3.2* Cl-98 HCO3-32 AnGap-14 [**2126-11-13**] 05:45AM BLOOD Glucose-98 UreaN-5* Creat-0.4* Na-143 K-3.0* Cl-102 HCO3-31 AnGap-13 [**2126-11-10**] 07:17PM BLOOD ALT-11 AST-14 AlkPhos-96 TotBili-0.3 [**2126-11-13**] 05:45AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.6 [**2126-11-10**] 07:17PM BLOOD calTIBC-238* Ferritn-158 TRF-183* [**2126-11-10**] 11:17PM BLOOD Type-ART pO2-112* pCO2-52* pH-7.41 calTCO2-34* Base XS-7 [**2126-11-10**] 02:58PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-15 Bilirub-SM Urobiln-0.2 pH-5.5 Leuks-NEG [**11-12**] C diff negative [**11-10**] Sputum cx GRAM STAIN (Final [**2126-11-10**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. [**11-10**] Blood cultures x2 [**11-10**] Urine culture negative [**11-10**] Blood culture negative [**11-10**] CXR Low lung volumes with persistent retrocardiac and left lower lobe airspace opacity and bilateral pleural effusions. While the retrocardiac opacity may in part be secondary to compressive atelectasis, infection cannot be excluded. [**11-10**] arm x-ray Stable position of external fixator without evidence of hardware complication. [**11-10**] abdominal x-ray There is no evidence of small-bowel obstruction or ileus. [**11-11**] R arm x-ray FINDINGS: In comparison with the study of [**11-10**], the external fixation has been removed. There is still a large joint effusion seen as displacement of the anterior and posterior fat pads. There is some displacement of the olecranon from the fossa, consistent with dislocation. Small areas of bony opacification are consistent with heterotopic ossification or previous small avulsions. [**11-12**] R arm x-ray FINDINGS: Single view of the elbow shows overall normal alignment of the bony structures. Probably avulsion is seen from the outer aspect of the proximal ulna. The views of the wrist show metallic fixation device in place about the comminuted fracture of the distal radius. Severely comminuted fracture of the distal ulna is seen with some callus formation. FINDINGS: Single view of the elbow shows overall normal alignment of the bony structures. Probably avulsion is seen from the outer aspect of the proximal ulna. The views of the wrist show metallic fixation device in place about the comminuted fracture of the distal radius. Severely comminuted fracture of the distal ulna is seen with some callus formation. Brief Hospital Course: 53 yo m with hx of severe COPD, s/p trach, and recent prolonged hospitalizzation after a mechanical fall resulting in R radius and ulnar fracture s/p external fixation complicated by PEA arrest after trach change, COPD exacerbation, VAP, C. diff colitis, clinical seizures though negative EEG, and altered mental status who presents with worsening wrist pain. . 1. Leukocytosis/fever: Patient was empirically treated for presumed C diff with po Vancomycin and flagyl. However once C diff toxin came back negative, these antibiotics were stopped. UA, Urine culture were negative. Blood cultures were negative. CXR was negative. His external fixation has broken though there was no inflammation at the site. Midline site appears clean. He was treated with Meropenem for ESBL Ecoli from Urine culture at rehab. Meropenem was started on [**11-9**], and will need to be continued for a 14 day course (last day [**11-22**]). On discharge, patient was afebrile, with resolving leukocytosis. . 2. Respiratory failure: Patient is trach-dependent from COPD. He was weaned to pressure support, and did not tolerate trach collar. Vent settings on discharge were Pressure support [**10-14**], with FiO2 of 40%. Patient tolerated this well. Please continue to attempt to wean to trach collar. . 3 Nausea, vomiting, diarrhea: [**Hospital 110913**] rehab notes regarding possible ileus on KUB. Abdominal x-ray here was negative. C diff negative. Nausea, vomiting, and diarrhea resolved. . 4. R ulna/humerus fracture, s/p external fixation on [**10-7**]: Pins of external fixation were adjusted - cont. calcium and vitamin D - DVT ppx with Fondaparinux . # Chronic Obstructive Lung Disease: He is on steroids chronically. - cont. current dose of prednisone 7 mg, switch to IV formulation, . # Seizure: Neurology felt that the patient had clinical seizures although his EEG did not show any epileptiform activity. - cont. Keppra . # Fungal rash on back: - cont. antifungal cream . # Diabetes: - cont. home ISS. . # Anxiety/Agitation: On klonopin and haldol at rehab. This was held during hospitalization. . # FEN: Tube Feeds by PEG # PPx: Fondaparinux, PPI # Access: midline # FULL CODE Medications on Admission: Acetaminophen 650 mg q6 hrs Calcium carbonate 650 mg TID Vitamin D 1000 units daily Klonopin 0.5 mg [**Hospital1 **] Iron 325 mg daily Haloperidol 5 mg [**Hospital1 **] Insulin SS Keppra 750 mg [**Hospital1 **] Pantoprazole 40 mg IV BID Prednisone 7 mg daily Bactrim DS MWF albuterol Zofran prn Cadexomer iodine topical q 2 days Hydrocortisone 1% cream [**Hospital1 **] Terbinafine [**Hospital1 **] Discharge Medications: 1. Fondaparinux 2.5 mg/0.5 mL Syringe [**Hospital1 **]: One (1) syringe Subcutaneous DAILY (Daily). 2. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: Two (2) solutions PO Q8H (every 8 hours) as needed for pain. 3. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: 2.5 Tablets PO DAILY (Daily). 5. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Hospital1 **]: One (1) tab PO DAILY (Daily). 6. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: see below units Injection ASDIR (AS DIRECTED): Please resume prior sliding scale qachs. 7. Levetiracetam 750 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Prednisone 1 mg Tablet [**Last Name (STitle) **]: Seven (7) Tablet PO DAILY (Daily). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]: 6-8 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 11. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6) Puff Inhalation Q4H (every 4 hours). 12. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: One (1) injection Injection Q8H (every 8 hours) as needed for nausea. 13. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Last Name (STitle) **]: One (1) Appl Ophthalmic DAILY (Daily) as needed for dry eyes. 14. Terbinafine 1 % Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 15. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Five (5) ML PO BID (2 times a day). 16. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 17. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 18. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day) as needed for oral care. 19. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID (3 times a day) for 1 weeks. 20. Bacitracin Zinc 500 unit/g Ointment [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) for 1 weeks. 21. Meropenem 500 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 10 days. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary diagnosis: 1. Urinary tract infection with ESBL Ecoli 2. Loose pins of external elbow fixator Secondary diagnosis: Chronic obstructive pulmonary disease with trach dependence Type 2 Diabetes Discharge Condition: Stable. Afebrile. Discharge Instructions: You were admitted with fevers. Your urine from rehab grew Ecoli. We continued treatment with Meropenem. We made sure you did not have any other sources of infection, and you no longer had fevers. The external fixator in your right arm had some loose pins, which were adjusted by orthopedic surgery. Please continue Meropenem until [**2126-11-22**]. If you develop recurrent fevers, shortness of breath, cough, burning when you urinate, diarrhea, or any other symptoms that concern you please see your primary doctor or go to the emergency department. Followup Instructions: Please follow up with your doctors [**First Name (Titles) **] [**Last Name (Titles) **] rehab. Please follow up with orthopedics 1 week after discharge from MACU with Dr. [**Last Name (STitle) 1005**]. His clinic number is [**Telephone/Fax (1) 1228**]. Please follow up with your pulmonologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4507**] 2 weeks after your discharge from MACU. His clinic number is ([**Telephone/Fax (1) 514**]. Please also follow up with Neurology regarding your seizure activity. The clinic number is ([**Telephone/Fax (1) 58666**]. Completed by:[**2126-11-13**]

[ "280.9", "428.0", "E878.8", "E849.8", "733.00", "416.8", "428.30", "996.49", "719.43", "V44.0", "996.78", "V46.11", "599.0", "787.91", "518.81", "496", "070.30" ]

icd9cm

[ [ [] ] ]

[ "97.88", "96.72" ]

icd9pcs

[ [ [] ] ]

11070, 11136

5966, 8156

351, 357

11379, 11399

2985, 5943

12003, 12624

2482, 2501

8606, 11047

11157, 11157

8182, 8583

11423, 11980

2516, 2966

287, 313

385, 1752

11280, 11358

11176, 11259

1774, 2200

2216, 2466

67,446

176,498

9040

Discharge summary

report

Admission Date: [**2193-1-22**] Discharge Date: [**2193-1-28**] Date of Birth: [**2108-6-1**] Sex: F Service: MEDICINE Allergies: Bacitracin Attending:[**First Name3 (LF) 759**] Chief Complaint: cough Major Surgical or Invasive Procedure: none History of Present Illness: 84yo F HTN, HL, depression, pulm HTN, pulmonary fibrosis, h/o GIB, recent pulmonary emboli presents to the MICU with fever and cough productive of green sputum for 3 days. Her daughters have noticed that she has been feeling ill and developing a cough over three days at her NH. They therefore demanded that she be transferred to the hospital for care. Her daughter has had a cold. She declines gastrointestinal symptoms. She has some upper nasal congestions. Denies headaches or muscle aches. . In the ED, initial VS were: 98.7, 102/52, HR 124, rr 24, o2 sat 97% on 6L nc. She was treated with vancomycin 1g iv once and levofloxacin had been given prior at rehab. Upon transfer to the ICU, 116/49, hr 150, rr 29, 95% 5L, no fevers. . On arrival to the MICU, pt was not able to speak in full sentences and became febrile to 101. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - severe pulmonary fibrosis with exertional dyspnea and resting and exertional hypoxemia, FVC 1.08 33% and FEV1 0.96 49% - pulmonary hypertension with biventricular dilatation. - DMII - HTN - HL - severe lower back pain - depression - hiatal hernia - small left upper lobe nodule - thyroid nodule - h/o pontine stroke ([**2186**]) - residual mild left hemiparesis Social History: She lives in [**Hospital1 392**] with her daughter [**Name (NI) **]. She has been a widow since [**2159**]. She has two daughters, one who lives in [**State 350**], and another who lives in [**State 5887**]. She has a son who lives in [**Name (NI) 12000**]. She smoked only for 10 years and quit 40 years ago. She reports [**2-15**] glasses of wine per week Family History: No family history of blood clots or strokes. She reports a cousin has [**Name2 (NI) 500**] cancer but denies other cancer in the family. She also notes several family members have heart disease. Physical Exam: ADMISSION EXAM General??????speaking in broken sentences, alert HEENT??????central cyanosis, OP clear Cardio--- irregular s1 and s2, no jvd Pulmonary??????coarse crackles throughout, no wheezing; she has anterior crackles as well Abdomen??????S, NT, ND, normoactive BS, no organomegaly Ext??????trace edema bilaterally Neuro: alert, oriented times three, CN II to XII grossly in tact, left sided weakness, readily sits up in bed. . DISCHARGE EXAM VS - 97.3 120/66 (120/66-140/66) 64 (64-70) 20 99% ON 5L NC. GENERAL - elderly female in NAD, comfortable, appropriate HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear NECK - supple LUNGS - Diffuse dry crackles. no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - no peripheral edema LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: ADMISSION EXAM [**2193-1-22**] 10:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2193-1-22**] 10:55PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2193-1-22**] 10:55PM URINE RBC-4* WBC-4 BACTERIA-FEW YEAST-MOD EPI-<1 TRANS EPI-<1 [**2193-1-22**] 10:55PM URINE HYALINE-3* [**2193-1-22**] 10:55PM URINE MUCOUS-RARE [**2193-1-22**] 05:17PM LACTATE-3.3* [**2193-1-22**] 04:45PM GLUCOSE-224* UREA N-22* CREAT-0.9 SODIUM-138 POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-30 ANION GAP-16 [**2193-1-22**] 04:45PM estGFR-Using this [**2193-1-22**] 04:45PM WBC-7.3 RBC-3.20* HGB-10.4* HCT-31.1* MCV-97 MCH-32.6* MCHC-33.5 RDW-14.6 [**2193-1-22**] 04:45PM NEUTS-86.8* LYMPHS-10.0* MONOS-2.2 EOS-0.4 BASOS-0.6 [**2193-1-22**] 04:45PM PLT COUNT-197 [**2193-1-22**] 04:45PM PT-20.6* PTT-32.8 [**Year/Month/Day 263**](PT)-2.0* . DISCHARGE LABS [**2193-1-28**] 06:46AM BLOOD WBC-6.5 RBC-2.76* Hgb-9.0* Hct-26.5* MCV-96 MCH-32.6* MCHC-34.0 RDW-15.0 Plt Ct-200 [**2193-1-28**] 06:46AM BLOOD PT-33.6* PTT-34.0 [**Month/Day/Year 263**](PT)-3.3* [**2193-1-28**] 06:46AM BLOOD Glucose-85 UreaN-13 Creat-0.9 Na-144 K-3.5 Cl-104 HCO3-34* AnGap-10 [**2193-1-28**] 06:46AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.7 [**2193-1-23**] 08:34AM BLOOD Lactate-1.8 . URINE [**2193-1-22**] 10:55PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 [**2193-1-22**] 10:55PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2193-1-22**] 10:55PM URINE RBC-4* WBC-4 Bacteri-FEW Yeast-MOD Epi-<1 TransE-<1 [**2193-1-22**] 10:55PM URINE CastHy-3* . MICROBIOLOGY Blood culture [**2193-1-22**]- negative x 2 Urine culture- yeast Urine legionella negative S. Pneumoniae antigen- negative Respiratory Viral Culture (Final [**2193-1-25**]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [**Telephone/Fax (1) 6182**] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [**2193-1-23**]): Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. . [**2192-1-23**] ECG- Artifact is present. Sinus rhythm. Atrial ectopy. Left axis deviation. There is a late transition with tiny R waves in the anterior leads consistent with possible infarction. Left ventricular hypertrophy with associated ST-T wave changes, although ischemia or infarction cannot be excluded. Compared to the previous tracing of [**2193-1-12**] the rate is slightly slower. . CHEST XRAY IMPRESSION: Stable diffuse radiopacities consistent with known interstitial lung disease as well as increased pulmonary edema from the prior examination. Brief Hospital Course: PRIMARY REASON FOR ADMISSION 84F with pulmonary fibrosis, recent GIB, recent submassive PE anticoagulated p/w fever and cough productive of green sputum for 3 days. . #Cough and fever: Patient was treated with vancomycin, zosyn and levofloxacin for healthcare associated pneumonia. On hospital day two she felt better and was oxygenating more avidly. She was transferred to the medical floor. As a precaution she had been started on oseltamivir, which was discontinued after her viral throat swab reulted negative. Legionella urinary antigen was negative. Streptococcus pneumoniae antigen was negative. Blood cultures were negative. Beta glucan was pending at the time of discharge. The patient continued to improve and was transitioned to levofloxacin alone of which she completed a 7 day course. At the time of discharge her oxygen requirement was at baseline and the patient reported symptom improvement. . #Elevated lactate: Resolved with fluids. Metformin was initially held but was restarted at the time of discharge. . # Pulmonary Embolus: [**Date Range 263**] 2.8 at rehab on [**2192-1-23**]. Initially she was continued on lovenox. Her warfarin was then restarted. Her [**Date Range 263**] was 3.3 at the time of discharge. coumadin dosing was as follows DATE [**Date Range 263**] DOSE [**2193-1-25**] 3.4 0 [**2193-1-26**] 3.2 0 [**2193-1-27**] 2.9 1 [**2193-1-28**] 3.3 0 She was discharge on a regimen of 1 mg of coumadin every other day. She will follow-up with her PCP for [**Month/Day/Year 263**] monitoring and dose adjustments. . # Idiopathic Pulmonary Fibrosis: Her home prednisone and bactrim ppx were continued. . # New T12/L1 compression fracture: Pain was well controlled with a lidoderm patch, ca/vitD continued. . #Rash: Ongoing Rx for zoster. Finished last day of valacyclovir. Rash was noted to be markedly improved. . # DMII: Metformin was initially held and insulin sliding scale initiated. The patient was restarted on her home dose of metformin 1000 mg [**Hospital1 **] at the time of discharge. . # HX CVA: She was continued on her home asa 81mg daily. . # Depression: She was continued on escitalopram and mirtazipime . # Multifocal atrial Tachycardia: She was continued on metoprolol . # GERD: She was continued on her home pantoprazole. . # HL: Patient was continued on her home simvastatin . TRANSITIONAL ISSUES - Patient was DNR/DNI throughout this admission - Beta glucan was pending at the time of discharge - [**Hospital1 263**] monitoring and coumadin dosing will be managed by her PCP Medications on Admission: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 2. escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain. 4. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 2 days. Disp:*4 syringes* Refills:*0* 5. metformin 1,000 mg Tablet Sig: 2 in the morning 1 at night Tablets PO twice a day. 6. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit Tablet Sig: Two (2) Tablet PO once a day. 11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension Sig: Ten (10) ML PO DAILY (Daily). 14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-14**] Sprays Nasal [**Hospital1 **] (2 times a day) as needed for nasal dryness. 16. warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day: Please speak with your doctor regarding your coumadin dose . Disp:*60 Tablet(s)* Refills:*0* 17. valacyclovir 1 g Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 7 days. Discharge Medications: 1. escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 3. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit Tablet Sig: Two (2) Tablet PO once a day. 11. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 12. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension Sig: Ten (10) ML PO DAILY (Daily). 13. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 14. warfarin 1 mg Tablet Sig: One (1) Tablet PO every other day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: PRIMARY [**Hospital **] Health Care associated pneumonia Pulmonary Embolism . SECONDARY DIAGNOSIS pulmonary fibrosis history of stroke Diabetes High cholesterol High blood pressure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms [**Known lastname 10113**], It was a pleasure participating in your care while you were admitted to [**Hospital1 69**]. As you know you were admitted because you were having increased shortness of breath and a cough. This was most likely due to a pneumonia. You were given antibiotics for this infection. We did not make any changes to your medications.You should continue to take all other medications as instructed. You will need to follow up with Dr. [**First Name (STitle) **] regarding changes in your coumadin dose. Followup Instructions: Department: PULMONARY FUNCTION LAB When: FRIDAY [**2193-2-1**] at 11:10 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: FRIDAY [**2193-2-1**] at 11:30 AM With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please call Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 8324**] tomorrow to make an appointment to be seen in [**1-14**] weeks

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Discharge summary

report

Admission Date: [**2133-10-23**] Discharge Date: [**2133-10-25**] Date of Birth: [**2056-5-21**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Latex Attending:[**First Name3 (LF) 3531**] Chief Complaint: BPBPR Major Surgical or Invasive Procedure: none History of Present Illness: 77 y/o with h/o colon adenomas, esophageal rings / dysmotility, CAD s/p CABG, and DM presents with BRBPR and diarrhea x1 day. Pt had EGD and colonoscopy [**2133-10-15**] with removal of 2 polyps in the ascending colon. Last evening after dinner she had approximately 10 episode of diarrhea with blood "filling the toilet bowl". The patient denies Abd pain. Reports chonic intermittant dark stools attributed to constipation (not temporally related to Fe). No blood in her stool prior to last evening. Had nausea this am without vomitting. Reports lightheadness without syncope. No F/C/NS. . Review of systems: no F/C/S. 10 lb wt loss over 3 months. Fatigue for 4 months. Chronic excersional leftsided CP with walking across a parking lot. None in last week. No SOB, Cough. No dysuria. Chronic back and leg pain. . In the emergency department initial VS 96.5, HR 54, BP 117/49, 18, 100% RA. She was starting 1L IVF and 1 U pRBC had had been ordered but not given. 2 PIV in place. EKG with sinus bradycardia but no ischemic changes. CXR without free air. GI requesting ICU admission for likely colonoscopy tomorrow. VS prior to transfer 96.5 53, 120/42, 100RA. Past Medical History: - DM2 - HTN - CAD - s/p CABG [**2127**] LIMA-->LAD, SVG--> D1, SVG--> PDA - hypercholesterolemia - s/p laminectomy [**2115**] - spondylosis - Lumbar Spinal Stenosis S/P L1-L3 Laminectomy and Fusion of L2-L3 in [**2129**] - s/p bilateral carpal tunnel release [**2105**] - cataracts - GERD - dysphagia: esophageal manometry ([**10/2130**]) shows evidence of ineffective esophageal peristalsis in just under 50% of wet swallows with a borderline low [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 23216**] pressure - 6mm lung nodule in RML two year stability in [**2133**] - adenomatous polyps on colonoscopy [**2131**]. 2 Polypectomys in ascending colon on [**2133-10-15**] - [**2130**] gastritis and doudenitis on EGD (NSIAD induced?) - esophogeal ring [**2130**] egd Social History: Widow x 13 years. Lives alone in [**Location 1268**]. Has six children and six granchildren. Independent in daily activities. Walks without aid of a cane or a walker. Catholic, goes to church every morning. Denies tobacco, IVDU. Occasional EtOH with dinner. Family History: mother: [**Name (NI) 11398**], deceased from MI age 62 father: lung cancer, deceased Brother renal cancer Physical Exam: VITAL SIGNS: T=96 BP=130-53 HR=59 RR=14 O2= 100 RA. . . PHYSICAL EXAM GENERAL: Pleasant, pale appearing elderly female in NAD HEENT: Normocephalic, atraumatic. Conjunctival pallor. No scleral icterus. PERRLA/EOMI. Dry MM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 3/6 SEM at LUSB, [**1-13**] holosystolic murmur at apex. JVP= 1cm above clavicle LUNGS: CTAB, good air movement biaterally. ABDOMEN: NL BS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2133-10-23**] 08:45AM BLOOD WBC-4.4 RBC-3.17*# Hgb-7.4* Hct-23.9* MCV-75* MCH-23.5* MCHC-31.2 RDW-19.8* Plt Ct-196 [**2133-10-23**] 07:38PM BLOOD Hct-27.0* [**2133-10-24**] 04:29AM BLOOD WBC-4.8 RBC-3.99*# Hgb-10.3*# Hct-31.5* MCV-79* MCH-25.8* MCHC-32.7 RDW-17.8* Plt Ct-162 [**2133-10-24**] 10:24AM BLOOD Hct-32.1* [**2133-10-24**] 04:25PM BLOOD Hct-29.9* [**2133-10-25**] 12:20AM BLOOD WBC-5.1 RBC-3.97* Hgb-10.4* Hct-31.4* MCV-79* MCH-26.1* MCHC-33.0 RDW-18.0* Plt Ct-160 [**2133-10-25**] 06:10AM BLOOD WBC-5.0 RBC-4.12* Hgb-10.6* Hct-32.3* MCV-78* MCH-25.7* MCHC-32.8 RDW-18.6* Plt Ct-161 [**2133-10-23**] 08:45AM BLOOD Neuts-71.5* Lymphs-23.6 Monos-2.6 Eos-1.3 Baso-1.0 [**2133-10-24**] 04:29AM BLOOD Neuts-67.7 Bands-0 Lymphs-25.2 Monos-5.3 Eos-1.5 Baso-0.3 [**2133-10-24**] 04:29AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Spheroc-1+ Ovalocy-1+ Schisto-OCCASIONAL [**2133-10-23**] 08:45AM BLOOD PT-12.0 PTT-18.3* INR(PT)-1.0 [**2133-10-23**] 08:45AM BLOOD Plt Ct-196 [**2133-10-24**] 04:29AM BLOOD PT-11.8 PTT-20.4* INR(PT)-1.0 [**2133-10-24**] 04:29AM BLOOD Plt Smr-NORMAL Plt Ct-162 [**2133-10-25**] 12:20AM BLOOD Plt Ct-160 [**2133-10-25**] 06:10AM BLOOD Plt Ct-161 [**2133-10-23**] 08:45AM BLOOD Glucose-176* UreaN-37* Creat-1.3* Na-138 K-5.7* Cl-104 HCO3-23 AnGap-17 [**2133-10-23**] 02:44PM BLOOD Glucose-71 UreaN-28* Creat-0.9 Na-140 K-4.6 Cl-109* HCO3-24 AnGap-12 [**2133-10-24**] 04:29AM BLOOD Glucose-82 UreaN-19 Creat-0.9 Na-140 K-4.1 Cl-108 HCO3-24 AnGap-12 [**2133-10-25**] 06:10AM BLOOD Glucose-84 UreaN-13 Creat-1.0 Na-140 K-3.9 Cl-105 HCO3-23 AnGap-16 [**2133-10-23**] 08:45AM BLOOD ALT-12 AST-17 AlkPhos-46 TotBili-0.2 [**2133-10-23**] 02:44PM BLOOD Calcium-8.8 Phos-3.2 Mg-1.8 [**2133-10-25**] 06:10AM BLOOD Calcium-9.3 Phos-4.4 Mg-1.8 [**2133-10-23**] 08:56AM BLOOD Lactate-3.8* [**2133-10-23**] 04:32PM BLOOD Lactate-1.9 STUDIES: [**2133-10-23**] CXR: IMPRESSION: No evidence of intra-abdominal free air. No acute cardiopulmonary process. Brief Hospital Course: ASSESSMENT AND PLAN: 77 y/o with CAD, DM, h/o gastritis, and recent ascending colon polyopectomy presenting with 1 day of BRBPR. . #. BRBPR: The temporal correlation with recent polyopectomy on [**2133-10-15**] and onset of painless BRBPR makes post-polypectomy bleeding most likely. The presence of BRBPR from a site in the ascending colon suggest a brisk rate of bleeding. The onset with diarrhea makes infection possible, however less likely without abd pain, leukocytosis, or fever. UGI bleed is possible given h/o gastritis but unlikely given recent normal EGD. Pt has h/o grade 1 hemmirhoids on past colonoscopy, but not noted on most recent Colonoscopy. In addition no diverticulosis noted on colonoscopy. . GI was consulted and felt by the time she was in the ICU, she did not appear to be bleeding and was hemodynamically stable. Emergent colonscopy was deferred. She was closely monitored in the ICU for > 24 hours. Patient received 3 units PRBC's to maintain Hct > 30 per GI recs. She was also started on high dose pantoprazole IV BID. She was given IVF's for hydration and her Hct remained stable near 30 for over 12 hours. Her diet was advanced to clear liquids prior to transfer to the floor. Orthostatics were done and were negative prior to transfer. . Upon arrival to the medical floor, her HCT remained stable x36hrs without transfusion. Her diet was advanced without difficulty. She was discharged home with instructions to follow-up with her PCP [**Last Name (NamePattern4) **] 4 days, and to arrange for f/u with her gastroenterologist for further workup of her anemia. She was instructed to resume aspirin 1 day after discharge, but to avoid NSAIDs until she had followed-up with her GI physician. . # Hyperkalemia: Normalized during ICU course. Likely [**2-9**] dehydration as it improved with IVFs. Cr near baseline. No EKG changes. . # Renal: Cr mildly elevated to 1.3 from baseline of 1.0 to 1.1. Likely prerenal given diarrhea and blood loss. Improved with hydration and prbc's. 0.9 upon transfer to the floor. . #. CAD: s/p stents in [**2125**], CABG [**2127**]. [**9-15**] normal p MIBI. No CP or ischemic changes on EKG in setting of HCT drop. ASA was held given no recent stents and active bleeding initially. BP meds were also held in this setting. . Upon arrival to the medical floor her BP regimen was resumed (metoprolol, [**Last Name (un) **], HCTZ). After discussion with the GI service, she was instructed to resume aspirin 81mg po qdaily on 1d after discharge ([**10-26**]). . #. DMII: oral hypoglycemics were held while in ICU, and she was maintained on glargine and sliding scale coverage. upon discharge home, her oral regimen was resumed. . #. GERD: pt was treated with IV PPI [**Hospital1 **] in ICU, then switched back to oral PPI [**Hospital1 **] upon discharge. . # Fe deficiency anemia: etiology remains unclear, and pt will continue to have outpatient workup. . # Depression: continued SSRI. Medications on Admission: Amlodipine 10mg daily citalopram 10mg daily HCTZ 25mg dailiy ibuprofen 600mg TID-QID prn pain Glargine 22 units daily in pm losartan 50mg daily metformin 1000mg [**Hospital1 **] Metoprolol succinate 50mg daily in pm prilosec 40mg [**Hospital1 **] Repaglinide 1mg daily acetaminophen 650mg SR [**Hospital1 **] Ascorbic acid 500mg daily Aspirin 81mg daily Calcium carbonate - Vit D3 600mg-400U daily Ferrous sulfate 142mg SR dailiy Garlic 400mg daily multivitamin daily Vitamin E 400 U daily Discharge Medications: 1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 4. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day. 5. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 8. Prandin 1 mg Tablet Sig: One (1) Tablet PO once a day. 9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 11. Lantus 100 unit/mL Solution Sig: 22 UNITS Subcutaneous once a day. 12. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for pain. 13. Vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day. 14. Calcium Carbonate-Vitamin D3 600-400 mg-unit Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: primary: lower gi bleeding from polypectomy site Discharge Condition: tolerating regular diet, stable HCT, no abdominal pain. Discharge Instructions: you were admitted to the hospital with bleeding from your rectum, after a recent colonoscopy with polypectomy. you were evaluated by the GI service, who felt your bleeding was due to the polypectomy site. your blood count stabilized after receiving 3 units of blood, and the decision was made not to repeat your colonoscopy. . the following changes were made to your medication regimen: 1. your aspirin is being held, you may resume this on [**10-26**] as per the GI service. 2. you should avoid taking motrin for your back pain until you see Dr. [**Last Name (STitle) 2161**], once the polyp site heals. . if you have recurrent episodes of rectal bleeding, light headedness, dizziness, abdominal pain, or other worrisome symptoms please contact your primary care physician or the emergency department. Followup Instructions: Please follow-up with your PCP, [**Name10 (NameIs) **] appointment already exists for you: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2133-10-29**] 9:20 . upon arriving home, please contact Dr. [**Last Name (STitle) 2161**], and arrange for follow-up with him as you had discussed previously. . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2133-12-11**] 10:20 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2134-1-18**] 9:25

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10118, 10124

5530, 8477

289, 295

10217, 10275

3492, 5507

11128, 11834

2575, 2683

9018, 10095

10145, 10196

8503, 8995

10299, 11105

2698, 3473

933, 1484

244, 251

323, 914

1506, 2283

2299, 2559

49,929

153,555

36799

Discharge summary

report

Admission Date: [**2189-9-2**] Discharge Date: [**2189-10-13**] Date of Birth: [**2166-4-30**] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 2534**] Chief Complaint: s/p Motor bike crash Major Surgical or Invasive Procedure: [**2189-9-2**] [**Last Name (un) **] bolt placement [**2189-9-7**] Tracheostomy & PEG placement History of Present Illness: 23M s/p MCC vs bus; helmeted. Reportedly he ran into the back of a bus. GCS of 3 at the scene. Difficult intubation; he was Medflighted to [**Hospital1 18**] for further care. Past Medical History: None known Family History: Noncontributory Physical Exam: Upon admission: T: 100.2 BP:140/69 HR:94 R 16 O2Sats 99% Neuro:Does not open eyes; not following commands Pupils 2mm and non reactive + corneals, + gag, + cough Appears to have deceberate posturing in all 4 extremities to deep pain Toes up going bilaterally Pertinent Results: [**2189-9-2**] 09:48PM GLUCOSE-154* UREA N-22* CREAT-1.0 SODIUM-141 POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-23 ANION GAP-12 [**2189-9-2**] 08:24PM GLUCOSE-215* LACTATE-2.0 NA+-141 K+-4.3 CL--105 TCO2-25 [**2189-9-2**] 08:20PM UREA N-23* CREAT-1.3* [**2189-9-2**] 08:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2189-9-2**] 08:20PM WBC-12.0* RBC-4.15* HGB-12.5* HCT-37.3* MCV-90 MCH-30.0 MCHC-33.4 RDW-12.2 [**2189-9-2**] 08:20PM PLT COUNT-285 [**2189-9-2**] 08:20PM PT-12.5 PTT-21.9* INR(PT)-1.1 CT Head [**10-4**] IMPRESSION: 1. No significant change in foci of hemorrhage in the bilateral frontal lobes which may represent contusion or diffuse axonal injury. If clinically indicated, MRI would be helpful in further characterization. 2. Small amount of hemorrhage in the bilateral posterior horns without evidence of hydrocephalus. MRI: [**9-6**] IMPRESSION: 1. Findings most consistent with diffuse axonal injury as detailed above involving the [**Doctor Last Name 352**] white matter junction in the bifrontal and right temporal as well as basal ganglia and corpus callosum. No MRI evidence for diffuse axonal injury within the brainstem. 2. Left inferior frontal hemorrhagic contusion. CT-Head [**9-10**] IMPRESSION: 1. Evolution of left inferior frontal lobe contusion. No new foci of intraparenchymal hemorrhage identified. 2. Stable mucosal thickening of the bilateral sphenoid sinuses. Small amount of fluid within the bilateral mastoid air cells. EEG: [**9-5**] SLEEP: No normal sleep architecture was seen during this study. CARDIAC MONITOR: Showed normal sinus rhythm in a single EKG channel. IMPRESSION: This is an abnormal video EEG study because of an initial background consisting primarily of diffuse [**1-16**] Hz delta activity with intermixed alpha activity. During the course of the study, the delta activity was gradually replaced by theta and some intermittent alpha background. There were no areas of prominent focal slowing and there were no epileptiform features noted. _______________________________________________________________ Micro/Imaging: [**2189-9-30**] sputum cx MRSA, Acinetobacter [**Last Name (un) 36**] gent/tobra [**2189-9-21**] BCx (2) negative [**2189-9-21**] sputum cx Staph Aureus coag + MRSA [**2189-9-21**] C. diff negative [**2189-9-11**] PEG site MRSA Brief Hospital Course: He was admitted to the Trauma Service and transferred to the Trauma ICU. Neurosurgery was consulted, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] bolt was placed at bedside due to low GCS; he was loaded with Dilantin and serial head CT scans were followed. Neurology was consulted for the prognostic implications of involuntary tongue movements. An EEG was recommended which showed abnormal video EEG study because of an initial background consisting primarily of diffuse [**1-16**] Hz delta activity with intermixed alpha activity. During the course of the study, the delta activity was gradually replaced by theta and some intermittent alpha background. There were no areas of prominent focal slowing and there were no epileptiform features noted. Orthopedics was consulted for his radius, ulnar and malleolus fractures, these were managed non operatively. He was fitted with a splint for his radius/ulnar fracture. Because he was difficult to wean from ventilator a tracheostomy was placed and he was able to be weaned. A PEG was placed for tube feedings for which he is tolerating. He was eventually transferred from the trauma ICU to the regular nursing unit where he has remained for the past several weeks. He has been treated for a MRSA pneumonia x2 courses; the first course failed as he was noted with fever spikes once antibiotics were stopped. His Vanco levels were checked and the dosage was adjusted; the Vanco was continued for another 10 days. he up to his point has had no further fever spikes since his antibiotics course was completed several days ago. He was noted with a left heel deep tissue injury while in the ICU; a wound care nursing consult was placed and several skin care recommendations were made. His left heel site has small opening approximately 1 cm slit at the proximal( superior edge ) There is mild erythema along the wound edge - approx 1 cm - slightly pink. The remaining intact tissue is very dry. As for his mental status initially he was not responsive to any verbal or physical stimuli but over the past 2 weeks he has been noted to track with his eyes and turn his head toward the person calling his name. He has also been noted with increased movement in all 4 extremities. He was evaluated by Physical and Occupational therapy and is being recommended for traumatic brain injury rehab. Medications on Admission: None Discharge Medications: 1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic every 4-6 hours as needed for dry eyes. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID (2 times a day): via feeding tube. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 Units Injection TID (3 times a day) as needed for DVT prophylaxis. 4. Ibuprofen 100 mg/5 mL Suspension Sig: Twenty (20) ML's PO Q8H (every 8 hours) as needed for fever or pain. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day) as needed for mouth care. 7. Acetaminophen 500 mg/5 mL Liquid Sig: Five (5) ML's PO Q6H (every 6 hours) as needed for fever or pain. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 11. Zyprexa 2.5 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: s/p Motorbike crash Traumatic brain injury with subarachnoid & multiple intraparenchymal hemorrhages Right ulna/radius fracture Left lateral malleolus fracture Right 1st metatarsal & proximal phalanx fractures Respiratory failure MRSA pneumonia Deep tissue injury left heel Discharge Condition: Hemodynamically stable, tolerating tube feedings, pain adequately controlled. Followup Instructions: Follow up in 4 weeks with Dr. [**First Name (STitle) **], Neuorsurgery for repeat head CT scan. Call [**Telephone/Fax (1) 6429**] for an appointment. Follow up in 4 weeks with Dr. [**Last Name (STitle) 1005**], Orthopedics for your arm and ankle fractures. Call [**Telephone/Fax (1) 1228**] for an appointment. Follow up in 4 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery for evaluation of possible tracheosotmy removal. Call [**Telephone/Fax (1) 2359**] for an appointment. Completed by:[**2189-12-24**]

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icd9cm

[ [ [] ] ]

[ "96.72", "01.10", "79.02", "31.1", "79.06", "33.24", "43.11" ]

icd9pcs

[ [ [] ] ]

6991, 7063

3371, 5731

312, 410

7380, 7459

981, 3348

7482, 8001

665, 682

5786, 6968

7084, 7359

5757, 5763

697, 699

252, 274

438, 615

713, 962

637, 649

29,381

117,202

26875

Discharge summary

report

Admission Date: [**2166-8-8**] Discharge Date: [**2166-8-22**] Date of Birth: [**2097-11-8**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2836**] Chief Complaint: Acute necrotizing pancreatitis and pancreatic abscess. Major Surgical or Invasive Procedure: 1. Pancreatic necrosectomy and debridement with wide drainage. 2. Open cholecystectomy. 3. Gastrostomy tube placement. 4. J-tube placement. 5. IVC filter History of Present Illness: This 68-year-old man presented about 2 weeks ago with a case of pancreatitis of unknown etiology. This was moderate in severity and the patient was eventually discharged to home; but he came back for follow-up with my associate, Dr. [**First Name (STitle) **], in her clinic. She recognized Mr. [**Known lastname 66136**] to be ill-appearing and he had failure to thrive. he clearly was failing to thrive and, in fact, looked rather toxic Accordingly, a CT scan was obtained and this revealed frank gas within a pancreas which was largely replaced by necrosis. Currently, he reports increased abdominal pain localized to epigastrium and right mid-abdomen, +N/V (bilious, non-bloody), no diarrhea. Passing flatus, last BM yesterday. Low-grade subjective temperature (100F). +Hiccups. Denies CP and SOB. Past Medical History: PMH: prostate CA s/p cyberknife [**2-6**], colon CA s/p resection, HTN, MI '[**61**], hypercholesterolemia, PE [**4-5**] yrs ago w/Coumadin PSH: sigmoid colectomy '[**45**], R nephrectomy for polycystic kidney '[**35**], appy '[**07**] Social History: Lives with wife in [**Name (NI) 1268**], retired mechanic, 20-pack-year history, quit; h/o alcohol, previously [**12-16**] drinks per week, now occasional. No drug use. Physical Exam: T=100.3 HR=91 BP=103/68 RR=12 O2sat=96% RA Gen: NAD, well-nourished gentleman HEENT: NC/AT, PERRL, oropharynx clear, moist mucous membranes CV: RRR, nL S1 and S2 Pulm: clear, bilaterally. No wheezes, crackles Abdomen: soft, tender to palpation epigastrium and right mid-abdomen, no guarding or rebound tenderness, +BS Ext: wwp, no edema Neuro: no focal deficits Pertinent Results: [**2166-8-8**] 05:58PM BLOOD WBC-8.4 RBC-3.85* Hgb-11.0* Hct-32.5* MCV-85 MCH-28.6 MCHC-33.9 RDW-12.9 Plt Ct-295 [**2166-8-17**] 08:39AM BLOOD WBC-20.0*# RBC-3.86* Hgb-10.7* Hct-33.1* MCV-86 MCH-27.7 MCHC-32.3 RDW-14.8 Plt Ct-241 [**2166-8-19**] 05:40AM BLOOD WBC-11.6* RBC-3.51* Hgb-10.2* Hct-30.7* MCV-88 MCH-29.1 MCHC-33.2 RDW-15.0 Plt Ct-190 [**2166-8-8**] 05:58PM BLOOD Glucose-149* UreaN-15 Creat-0.9 Na-133 K-4.9 Cl-98 HCO3-26 AnGap-14 [**2166-8-19**] 05:40AM BLOOD Glucose-169* UreaN-15 Creat-0.9 Na-136 K-4.3 Cl-101 HCO3-28 AnGap-11 [**2166-8-8**] 05:58PM BLOOD ALT-62* AST-38 AlkPhos-186* Amylase-48 TotBili-0.7 [**2166-8-18**] 04:54AM BLOOD ALT-44* AST-24 CK(CPK)-20* AlkPhos-153* Amylase-48 TotBili-0.5 [**2166-8-18**] 04:54AM BLOOD Lipase-58 [**2166-8-19**] 05:40AM BLOOD Calcium-7.9* Phos-3.2 Mg-1.8 . Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2166-8-17**] 2:18 PM Impression: Bilateral central pulmonary emboli with extension into the lobar and segmental arteries and evidence of elevated right heart pressures. Stranding in the pancreatic bed and porta hepatis. Findings discussed with Dr. [**First Name (STitle) 2819**] by telephone at 3:00 pm on [**2166-8-17**]. CT of the abdomen. Indication: necrotizing pancreatitis with elevated white cell count Technique: axial pre and post contrast images were obtained with oral contrast. Findings: There are bilateral central pulmonary emboli, fully described in the CT chest report. There is straightening of the interventricular septum representing elevated right heart pressures. The liver, spleen, and adrenal glands are within normal limits. The gallbladder is absent or contracted. There is a percutaneous tube in the stomach. There are four drains in the pancreatic bed. There is a large amount of stranding in the pancreatic bed and porta hepatis. There is a fluid and air collection in the region of the pancreatic head measuring 4 cm x 2.5 cm x 5 cm and contains a drain. There is an additional right retroperitoneal collection measuring 9.1 x 3.5 cm x 8 cm and contains a drain. There is a midline collection of fluid and air measuring 5.3 x 2.9 cm, which appears to communicate with the more anterior collection containing a drain. The splening vein and artery enhance normally. The left kidney is normal. The right kidney is absent. Impression: Peripancreatic collections as described. . Radiology Report BILAT LOWER EXT VEINS Study Date of [**2166-8-17**] 5:39 PM IMPRESSION: Acute non-occlusive DVT involving the right common femoral vein and distal superficial femoral vein. No left DVT identified. Brief Hospital Course: This is a 68 year old male with Acute necrotizing pancreatitis with pancreatic abscess. He went to the OR on [**2166-8-8**] for: 1. Pancreatic necrosectomy and debridement with wide drainage. 2. Open cholecystectomy. 3. Gastrostomy tube placement. 4. J-tube placement. He remained in the ICU, intubated and sedated overnight. He was weaned and extubated on POD 1. He was transferred out to the floor on POD 5. He was on Imipenem and fluconazole. The Fluc was then D/C'd on POD 4 and Vancomycin was started. Swabs from the OR grew VIRIDANS STREPTOCOCCI. The Vanc/Imipenem were d/c'd on POD 7 and he was started on Levofloxacin. After the PE on POD 9, he was started on Vanc/Cipro/Flagyl. All ABX were stopped at time of discharge. Pain: He had a PCA for pain control. Once tolerating a diet he was switched to PO pain meds. Abd: He was NPO with NGT He had 5 JP drains to bulb suction with dark maroon murky drainage. The NGT was removed on POD 3. His abdomen remained soft, and nondistended. His stables were removed and drains were in place. Renal: He received Lasix 10 mg IV on POD 6 with good effect for diuresis. FEN: He was NPO and started on trophic tubefeeds on POD 2. He was slowly started on a PO diet. He was tolerating a diet and his tubefeeds were cycled and weaned as he was able to tolerate more PO's. Post-op Hypovolemia: He received several fluid boluses for low urine output and responded appropriately. Post-op Hyperglycemia: [**Last Name (un) **] was consulted and helped manage his blood sugars. He was discharged with Lantus and a sliding scale. Post-op PE: On POD 9. He became hypotensive, hypoxic, and tachycardic. He was transferred to the ICU and CTA revealed Bilateral central pulmonary emboli with extension into the lobar and segmental arteries. Evidence of elevated right heart pressures. He was started on Heparin and was bridged to Coumadin amd discharged with Lovenox and Coumadin. Vascular was consulted and he went for IVC filter placement. Medications on Admission: Toprol XL 25mg', Glucosamine 500mg', Nasacort AG, Xalantan 0.005% drops, Vytorin 10/20mg', Calcium/Vitamin D, Pumpkinseed oil Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 3 days. Disp:*6 * Refills:*0* 7. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16) units Subcutaneous once a day. Disp:*500 units* Refills:*2* 8. Insulin Lispro 100 unit/mL Solution Sig: Sliding scale Subcutaneous four times a day. Disp:*qs * Refills:*2* 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks: Follow INR closely and adjust dose accordingly. Call your PCP and [**Hospital 197**] Clinic for dose. Disp:*14 Tablet(s)* Refills:*0* 10. Insulin Syringe [**1-1**] mL 29 x [**1-1**] Syringe Sig: One (1) Miscellaneous four times a day. Disp:*150 * Refills:*2* 11. Lancets Misc Sig: One (1) Miscellaneous four times a day. Disp:*150 * Refills:*2* 12. One Touch Ultra 2 Kit Sig: One (1) Miscellaneous once a day: One Kit, including meter. Disp:*1 * Refills:*2* 13. One Touch Test Strip Sig: One (1) In [**Last Name (un) 5153**] four times a day: Blood Glucose testing strip. Disp:*150 * Refills:*2* 14. Outpatient Lab Work VNA to check INR every other day until stable. Fax PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8430**] at [**Telephone/Fax (1) 66137**] with results. Call the [**Hospital 197**] Clinic with results [**Telephone/Fax (1) 10413**]. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Acute Necrotizing Pancreatits with pancreatic abscess Hyperglycemia DVT Post-op Hypoxia Post-op Hypotension Pulmonary Embolism Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your 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. . * Take all 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. * Continue to increase activity daily * No heavy lifting (>[**10-15**] lbs) for 6 weeks. * You may shower and wash. No tub baths or swimming. Followup Instructions: You will need a CT scan at this time. Call ([**Telephone/Fax (1) 6347**] to schedule an appointment. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 2998**] Date/Time:[**2166-9-12**] 9:30 Please follow-up with your PCP and the [**Hospital 197**] Clinic for continued INR monitoring and for adjusting your Coumadin dose. [**Hospital 197**] Clinic is [**Telephone/Fax (1) 10413**]. Please follow-up with [**Last Name (un) **] on [**2166-8-27**] at 1:30pm. Call with questions or concerns ([**Telephone/Fax (1) 4847**]. Completed by:[**2166-8-22**]

[ "453.41", "799.02", "575.11", "276.52", "272.0", "V10.46", "997.2", "V10.05", "415.11", "577.0", "458.29", "401.9" ]

icd9cm

[ [ [] ] ]

[ "52.22", "51.22", "88.51", "43.19", "46.39", "96.6", "38.7" ]

icd9pcs

[ [ [] ] ]

8877, 8948

4843, 6829

369, 524

9118, 9124

2209, 4820

10586, 11200

7005, 8854

8969, 9097

6855, 6982

9148, 10563

1819, 2190

274, 331

552, 1357

1379, 1617

1633, 1804

76,282

104,632

39290

Discharge summary

report

Admission Date: [**2158-10-24**] Discharge Date: [**2158-11-10**] Date of Birth: [**2092-6-29**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3918**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Placement of PICC Aspiration of fluid from right Shoulder History of Present Illness: Mr. [**Known lastname 86903**] is a 66 yo man with AML M1-2 s/p induction currently C1D16 on HIDAC consolidation who presents with R shoulder pain and fatigue. Seen at 7Feldberg outpatient clinic for count check yesterday; he complained of feeling very poorly and requested to come in early, gait was unstable & he used a wheelchair. He states that since sleeping on his R shoulder on Sunday night, he has had [**8-4**] pain in the shoulder and difficulty moving it secondary to pain. States that he was unable to sleep at all the past two nights secondary to the pain. His vital signs at clinic the day prior to admission were BP 129/86, HR 116 T 98.2 RR 18 O2 Sat%: 98%. His labs were wbc 0.1 hgb.7.8/hct.21.8 and platelets 5; he was transfused with 2u prbc and 1 bag of platelets. . Today the patient reports that he was feeling extremely fatigued and so called an ambulance. He was taken to an outside hospital where he received vancomycin and zosyn. He was then transferred to [**Hospital1 18**] for further management and found to have T 103.3, tachycardia to 120s, and SBP 94. Blood cultures were sent and he was started on vanc/cefepime. Past Medical History: Oncologic History: His induction chemotherapy was complicated by acute kidney injury and neutropenic fever. Induction with 3+7 was unsuccessful, so he was re-induced with MEC, which resulted in prolonged cytopenias and a brief ICU stay for respiratory difficulty. His only sibling is not a match and a search for a matched unrelated donor has not been fruitful. He has therefore enrolled in a dendritic fusion vaccine trial (protocol 09-014) with PT1 and is now starting consolidation. . ROS: He reports extreme fatigue, R shoulder pain, blood tinged mucus from right nostril. Denies wght loss, headache, dizziness, visual changes, chest pain, dyspnea, cough, abd pain, back pain, constipation, diarrhea, hematochezia, hematuria, other urinary symptoms, or rash. . Past Medical History: - AML M1-2, normal cytogenetics, NPM-1 negative, FLT3 negative, s/p 3+7 induction, MEC re-induction, complicated by acute kidney injury and neutropenic fever. - Osteoarthritis, s/p L TKA, R THA. - h/o negative colonoscopy-last [**2154**]. - Hypertension. - Seasonal Allergies. - GERD. Social History: Never married, no children. Lives alone. Retired fireman. U.S.M.C. veteran during [**Country 3992**], stationed in Okinawa. He is a never smoker, denies alcohol and illicit drug use. He frequently travels to the southwest (e.g. [**State 15946**]). Family History: Thinks he had an uncle w/ liver cancer. Father died of AAA, mother of ?CHF. Multiple family members w/ CVA as cause of death. No known h/o hematologic malignancies. Physical Exam: VS: 100.8 105 102/65 76 96%3L nc. Gen: NAD HEENT: MM dry, OP clear without lesions, exudate, or erythema. CV: Tachy S1+S2. Pulm: Bibasilar crackles (R>L) Abd: S/NT/ND _bs Ext: Trace edema bilaterally. MSK: Right shoulder pain to active and passive motion. Neuro: AOx3, CN II-XII intact. Pertinent Results: Admission Labs: [**2158-10-23**] 11:10AM BLOOD WBC-0.1*# RBC-2.45* Hgb-7.8* Hct-21.8* MCV-89 MCH-31.8 MCHC-35.6* RDW-15.7* Plt Ct-5*# [**2158-10-24**] 12:45PM BLOOD Neuts-0* Bands-0 Lymphs-87* Monos-13* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2158-10-23**] 11:10AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2158-10-23**] 11:10AM BLOOD Plt Smr-RARE Plt Ct-5*# [**2158-10-24**] 12:45PM BLOOD PT-13.4 PTT-25.3 INR(PT)-1.1 [**2158-10-24**] 12:45PM BLOOD Fibrino-787*# [**2158-10-24**] 05:55PM BLOOD Gran Ct-0* [**2158-10-23**] 11:10AM BLOOD UreaN-24* Creat-1.1 Na-137 K-4.0 Cl-102 HCO3-26 AnGap-13 [**2158-10-23**] 11:10AM BLOOD ALT-65* AST-31 LD(LDH)-157 AlkPhos-186* TotBili-1.1 [**2158-10-25**] 12:00AM BLOOD proBNP-4078* [**2158-10-24**] 12:45PM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.9 Mg-1.6 Micro: Blood cultures- [**10-24**], [**Date range (1) 86904**], [**10-30**], [**10-31**]- No growth. C. diff- [**10-27**], [**10-28**]- Negative . [**2158-10-26**] 10:00 am JOINT FLUID Source: Right Shoulder. GRAM STAIN (Final [**2158-10-26**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2158-10-29**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2158-10-27**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. Jt fluid- 2500 WBC; 0% polys . [**2158-10-31**] 1:25 pm JOINT FLUID Source: R shoulder. GRAM STAIN (Final [**2158-10-31**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2158-11-3**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2158-11-1**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. Jt Fluid- 4500 WBC; 83% polys . [**2158-11-3**] 4:00 pm FLUID,OTHER RIGHT SHOULDER. **FINAL REPORT [**2158-11-9**]** GRAM STAIN (Final [**2158-11-3**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2158-11-6**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2158-11-9**]): NO GROWTH. Studies: [**10-25**] TTEcho: The left atrium and right atrium are normal in cavity size. 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 50-55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta and aortic arch are mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2158-8-1**], the left ventricular systolc function is now less vigorous (low normal) but without regional dysfunction. Valvular morphology is similar. [**10-25**] EKG: Sinus tachycardia. Otherwise, normal tracing. Compared to the previous tracing ST-T wave changes are less prominent and the Q-T interval is shorter. [**10-26**] RUQ U/S: The liver demonstrates no definite focal or textural abnormality. There is no biliary dilatation. The CBD is normal in caliber, measuring 4 mm. The portal vein demonstrates normal hepatopetal flow. The gallbladder appears mildly distended without evidence of internal stone or sludge. Previously seen tiny anterior wall gallbladder polyp is not demonstrated on current exam. There is no gallbladder wall thickening or pericholecystic fluid. A 3.6 cm simple upper pole right renal cyst is unchanged. There is no perihepatic fluid. Partially visualized pancreas appears within normal limits. No elicited [**Doctor Last Name **] sign. IMPRESSION: 1. No focal liver abnormality. 2. Mildly distended gallbladder without wall thickening or pericholecystic fluid. 3. Stable simple right renal cyst. [**10-27**] CT Chest/Abdomen/Pelvis- 1. Multifocal bilateral ground-glass opacities represent either infectious or inflammatory foci. 2. Small amount of new, intermediate density peritoneal and pelvic fluid, but no evidence of organized chest, abdominal or pelvic fluid collections to suggest abscess. 3. Unchanged, enlarged pulmonary artery measuring 4 cm consistent with pulmonary hypertension. [**10-27**] CT Head- There is no evidence for acute intracranial hemorrhage, large mass, mass effect, edema, or hydrocephalus. There is bifrontal cortical atrophy. Sinus mucosal disease is again seen with increased opacification of the anterior ethmoid air cells, increased mucosal thickening and a mucus retention cyst in the left sphenoid sinus, and mild mucosal thickening in the maxillary sinuses. Visualized bony structures are grossly unremarkable. [**10-30**] MRI R Shoulder- 1. Small glenohumeral joint effusion. Extensive subacromial/subdeltoid bursitis. In the setting of neutropenia and fever, infection is a primary consideration. In presence of full-thickness rotator cuff tear, bursal fluid is in direct communication with joint space. The bursal fluid is amenable to ultrasound guided aspiration. 2. Extensive myositis; the differential diagnosis is broad and includes infection among other causes for myositis. 3. Full-thickness tear of supraspinatus tendon with retraction. 4. Tendinopathy of the infraspinatus tendon. 5. Long head of the biceps tendon tear. 6. Abnormal signal in superior and inferior labrum. 7. Moderate AC joint arthropathy. 8. Abnormal signal in the posterior right lung, suboptimally evaluated on this nondedicated study. Should further investigation be required, this would be better evaluated with CT. [**10-30**] R Shoulder U/S: Two focal fluid collections about the right shoulder, the larger measuring 3.0 x 1.9 x 0.5 cm and located along the anterolateral aspect of the joint. [**11-4**]: RUE Venous U/S: No evidence of right upper extremity DVT. [**11-8**] Chest CT: Many new predominantly peripheral nodules, a couple with cavitation, as well as increasing mixed consolidative and ground-glass opacity in the lingula. Although differential considerations include the possibility of septic emboli, the appearance is not entirely typical, and atypical etiologies of infection including the possibility of aspergillosis should be considered in the appropriate clinical setting. [**11-10**] TTEcho: Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No echocardiographic evidence of endocarditis. Preserved regional and global biventricular ventricular systolic function. Compared with the prior study (images reviewed) of [**2158-10-25**], heart rate is slower. Estimated pulmonary artery pressures are lower. Left ventricular function is slightly more vigorous. . Discharge Labs: Na 139 Cl 103 BUN 14 gluc 87 AGap=14 K 3.9 HCO3 26 Cr 0.9 Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes Ca: 9.3 Mg: 2.0 P: 5.0 ALT: 17 AP: 257 Tbili: 0.8 Alb: 3.3 AST: 16 LDH: 178 Dbili: TProt: [**Doctor First Name **]: Lip: Source: Line-PICC WBC 2.6 HGB 8.9 24.8 plts 76 N:52 Band:0 L:20 M:26 E:0 Bas:0 Atyps: 1 Myelos: 1 Hypochr: NORMAL Anisocy: 1+ Poiklo: 1+ Macrocy: 1+ Microcy: 1+ Polychr: 1+ Spheroc: 1+ Ovalocy: 1+ Schisto: OCCASIONAL Comments: MANUALLY COUNTED Plt-Est: Very Low Other Hematology Gran-Ct: 1378 Source: [**Name (NI) 71017**] PT: 13.7 PTT: 26.9 INR: 1.2 Brief Hospital Course: 66 year old male with history of AML s/p 7+3 therapy and D17 s/p cycle 1 HIDAC on presentation, admitted with right shoulder pain and fatigue. # MSSA sepsis: Patient was initially admitted to BMT floor service and treated with vanco and cefepime with intermittent hypotensive which improved after 4L IVF and 1 unit PRBC. Morning after admission, patient developed a new O2 requirement and was felt to be volume overloaded, and so received 30 mg IV lasix. OSH blood cultures were then found to be positive for S.aureus (within 12 hours) ([**2-26**]) and he received a dose of linezolid in addition to vancomycin. He then was febrile to 102 and was found to be hypotensive to SBP 70s that was unresponsive to 1L IVF. He was started on peripheral levophed and transferred to the [**Hospital Unit Name 153**] for further management. He was started on Vancomycin, cefepime, and linezolid for empiric therapy for febirle neutropenia. He required a brief period of pressor support with norepinepherine as his MAP was <60 on ICU admission. During this time, he was also experiencing right shoulder pain. Joint space aspiration revealed 2500 leukocytes concerning for a septic joint. His blood cultures from OSH grew out [**2-26**] MSSA. TTE was negative for valvular vegetations. His abx therapy was down graded to nafcillin and ciprofloxacin by ICU day #3. However, due to recurrent low grade fevers, he was placed on fluconazole. A thoracic CT scan as well as head CT were performed to look for an indolent infection/abscess/phlegmon. CT's failed to reveal a distinct collection, though did show multifocal bilateral ground-glass opacities. He continued to have low grade fevers which were attributed to a possibly septic joint/shoulder infection. He was transferred back to the floor after a 4 day ICU stay and his antibiotics were reduced to primarily nafcillin, with fluconazole and acyclovir for PPX. He remained febrile until after undergoing two further drainages of the fluid from his shoulder (see below). After the second drainage, patient was afebrile for the rest of his hospitalization and continued on nafcillin without event. He underwent repeat chest CT when an CXR showed possible progression of the earlier opacities/nodules and this showed new predominantly peripheral nodules, a couple with cavitation, as well as increasing mixed consolidative and ground-glass opacity in the lingula concerning for septic emboli. Pulmonology was consulted and recommended TTE (Please see note for further details). Patient underwent a repeat TTE to assess for valvular disease which was negative. TEE was deferred secondary to the patient's low platelets. To Follow Up- - Patient will need repeat chest CT in [**12-28**] months to assess progression of nodules and ground glass opacities - urine histoplasma and galactomannan pending on discharge . # Febrile neutropenia: Presented s/p 7+3 therapy and C1D17 from HIDAC. Fevers were thought to be due to MSSA septicemia in conjunction with septic joint. Neutropenic [**12-27**] chemotherapy. Started on filgastrim and continued until counts recovered. . # R septic shoulder: On presentation patient had extreme right shoulder pain. Orthopedics was consulted and felt that his symptoms were secondary to a rotator cuff tear though septic joint was in the differential. They tapped the shoulder- joint fluid showed 2500 leukocytes- elevated in the setting of leucopenia concerning for septic arthritis. As the patient's neutropenia resolved his shoulder swelled up signficantly and pain worsened. He underwent MRI of the shoulder which showed joint effusion, extensive subacromial/subdeltoid bursitis, extensive myositis of the shoulder girdle and a full thickness rotator cuff tear. The patient underwent two subsequent taps, one by ortho (appx 2 ccs) [4500 WBC, 83% polys, no orgs on GS or culture] and the final by IR (appx 10cc), which showed 2+ polys and no organisms on gram stain or culture. The patient became and remained afebrile after the third tap. He was continued on nafcillin with a planned antibiotic course of 6 weeks. . #. Narrow-complex Tachycardia: Patient had sporadic bouts of SVT while in the ICU, reaching rates of about 200 bpms. Usually broke SVT on own, but on ICU day #3 had an early morning bout of SVT to 180's. Given 5 mg IV metoprolol and carotid massage, bringing HR down to 100. Thought to be due to fevers. BMT concerned of possible intracrdiac/valvular infection which may be affecting conduction system. No signs of infectious collection seen on imaging. Started on low dose beta blocker 12.5 mg metoprolol [**Hospital1 **] for baseline rate control on ICU day #4. The patient's heart rate was better controlled for the remainder of his hospitalization and he was discharged on this medication. . #. Right calf nodule- Patient with small erythematous macule on lateral right calf which progressed to a non tender erythematous nodule. Derm was consulted and did not feel that this was a manifestation of septic emboli; they felt it was more likely a resolving inflammatory process. Given location of nodule and patient already on optimal therapy, biopsy was not performed. . #. Hypertension: Patient with history of hypertension on amlodipine at home. This medication was discontinued on admission secondary to his low blood pressures in the setting of sepsis. Following his ICU stay, he was normotensive off of amlodipine and on metoprolol. He was discharged on metoprolol and amlodipine was discontinued. . # Hyperbilirbuinemia: Bilirubin slowly trending up from <1.0 to 2.7 on ICU day #4. [**Month (only) 116**] be due to recent transfusions he previously received on ICU admission. RUQ US did not show any cholangitic or hepatic process/obstruction. This trended down during the rest of his hospitalization. Medications on Admission: 1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H 2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**11-26**] Tablet, Rapid Dissolves PO three times a day as needed for nausea. Discharge Medications: 1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours). 4. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: Acute myelogenous leukemia Methicillin sensitive staphylococcus aureus bacteremia Right shoulder infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with fatigue and right shoulder pain. You were found to have bacteria growing in your blood and required a stay in the intensive care unit. Your infection was treated with antibiotics and your condition improved. The source of your infection was believed to be your shoulder- an MRI showed inflammation and tear of the muscles as well as fluid in the joints. Some of this fluid was drained and your fevers resolved. Please continue to take the antibiotics for six weeks. We made the following changes to your medications: - START taking nafcillin for your infection - START taking metoprolol for your heart rate and blood pressure - START taking fluconazole to prevent fungal infection - CHANGE your dose of acyclovir to 400 mg every eight hours - STOP taking amlodipine for your blood pressure Followup Instructions: Please follow up at the appointments below: Department: INFECTIOUS DISEASE When: MONDAY [**2158-11-27**] at 9:50 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2158-11-27**] at 2:00 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2158-11-27**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12633**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**] Completed by:[**2158-11-10**]

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