ChanBeDu/relevant_section_length · Datasets at Hugging Face

25,965

146,286

43486

Discharge summary

report

Admission Date: [**2110-7-19**] Discharge Date: [**2110-7-26**] Date of Birth: [**2047-3-20**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Pt is a 63 yo man s/p OLT [**2095**] who presented with chills and fever due to cholangitis. Major Surgical or Invasive Procedure: [**2110-7-22**] S/P PTC placement [**2110-7-23**] cholangiogram [**2110-7-25**] Lithotripsy History of Present Illness: Pt presented with chills and fever to 102. Pt was s/p lithotripsy one month prior of several large biliary stones in the CBD as well as the R HD where a stricture was seen in the R HD as well as remaining stones. Two biliary drains were left in place at that time. When pt presented, his right drain was actively draining while the left drain was not. Past Medical History: s/p OLT [**2095**] secondary alcoholic cirrhosis HTN R knee arthritis Social History: Pt is a Spanish speaking man who does not currently drink or smoke. Family History: Noncontributory. Physical Exam: Gen: well appearing, NAD CV: RRR, no m/r/g Lung: CTA bilaterally Abd: soft, NT/ND, PTC drains x 2 c/d/i Ext: warm well perfused, no edema, 2+ pulses Neuro: aao x 3, appropriate Pertinent Results: [**2110-7-19**] 04:29PM LACTATE-3.1* [**2110-7-19**] 04:05PM GLUCOSE-113* UREA N-25* CREAT-1.6* SODIUM-137 POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-20* ANION GAP-18 [**2110-7-19**] 04:05PM ALT(SGPT)-25 AST(SGOT)-33 LD(LDH)-147 ALK PHOS-154* AMYLASE-112* TOT BILI-1.9* Brief Hospital Course: Pt was admitted and underwent a cholangiogram which revealed adequate right drainage with no large filling defects. Pt remained stable and was scheduled to undergo further cholangiogram for evaluation of possible stricture. This was performed on HD#3 where both the L and R biliary trees were dilated with a 10mm balloon and new drainage catheters were placed on both sides. There was a questionable large irregular filling defect seen in the L ant biliary tree at this time. On HD#4 pt underwent a lithotripsy where one attempt was made to remove stones in his left duct. All stones were not removed at this time, and at least one large stone remained. At that time, access via pt's Roux limb was recommended to remove the remaining stones. This was attempted on HD#6 but could not be completed due to equipment malfunctioning during the procedure. Throughout his stay, pt remained stable and afebrile. He had mild abdominal tenderness which was stable. Due to the equipment malfunction and pt's stable status, he was discharged to home in good condition with plans for outpt studies and/or lithotripsy. Medications on Admission: ursodiol 300 qd, lasix 40 qd, neoral 100 [**Hospital1 **], nifedical XL 30 qd Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever > 101.5. 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*36 Tablet(s)* Refills:*0* 4. Cyclosporine Modified 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 63M alcoholic cirrhosis, s/p OLT 15 years ago, recently admitted from [**Date range (1) 93600**] with hypotension and early sepsis, likely cholangitits and hepatic failure Discharge Condition: good Discharge Instructions: call Transplant Surgery immediately at [**Telephone/Fax (1) 28344**] if any fevers, chills, nausea, vomiting, inability to take medications, inability to urinate, decreased urine Labs once a week for cbc, chem10,AST,ALT, alk phosph, albumin, t. bili, calcium, phosphorus Fax results to [**Hospital1 18**] [**Telephone/Fax (1) 697**] Followup Instructions: Patient should follow up with Dr. [**Last Name (STitle) **] next week. Please call [**Telephone/Fax (1) 28344**] for an appointment [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]

[ "401.9", "574.50", "576.1", "996.82", "E878.0" ]

icd9cm

[ [ [] ] ]

[ "51.88", "51.98", "87.54" ]

icd9pcs

[ [ [] ] ]

3539, 3545

1600, 2706

406, 500

3761, 3768

1306, 1577

4150, 4413

1076, 1094

2834, 3516

3566, 3740

2732, 2811

3792, 4127

1109, 1287

274, 368

528, 881

903, 975

991, 1060

17,708

105,798

15831

Discharge summary

report

Admission Date: [**2199-9-15**] Discharge Date: [**2199-9-19**] Date of Birth: [**2124-8-6**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: This is a 75 year-old male with cardiac risk factors of hypercholesterolemia, tobacco smoking, his age, who is known to have coronary artery disease in the past status post question of a myocardial infarction in [**2183**] at which time he underwent cardiac catheterization, but was managed medically and reportedly had episodes of pericarditis in [**2192**]. He also has a history of a abdominal aortic aneurysm repair in [**2180**], who has been relatively asymptomatic with the exception of the occasional arm weakness during golfing. This all changed the day prior to admission when he was helping his son with [**Name2 (NI) **] work when he suddenly developed left arm/elbow pain that radiated across his shoulders and was associated with mild shortness of breath (this is his anginal equivalent of left elbow pain). He had no chest pain, no nausea or vomiting. He presented to an outside hospital at approximately 3:00 p.m. (the onset of his elbow pain was at 2:30 p.m.) where an electrocardiogram revealed anterior [**Street Address(2) 4793**] elevations with inferior reciprocal depressions. Initially these were unrecognized and the patient was admitted for rule out myocardial infarction without additional treatment. At midnight his CKs were positive for myocardial infarction. The electrocardiogram still had residual ST elevations so he was transferred to [**Hospital1 69**] for further management. The patient had continued to have 6 out of 10 arm pain throughout midnight, which decreased to 2 out of 10 after the institution of aspirin, nitroglycerin, morphine, and heparin drip. He arrives at [**Hospital1 69**] complaining of 1 to 2 out of 10 arm pain, his anginal equivalent. He had no shortness of breath, no palpitations, no nausea, vomiting or chest pain. He denies recent illness. He has no recent fevers or chills. His review of systems was otherwise negative. He was taken immediately to the Cardiac Catheterization Laboratory where hemodynamically he had mild elevation of his left ventricular and diastolic pressure as well as his pulmonary capillary wedge pressure with a mean wedge of 19. He also notably had a normal cardiac index at 2.74. A left ventriculogram was performed that demonstrated trace mitral regurgitation and left ventricular ejection fraction of 40% with severe hypokinesis of the anterior wall, and akinesis of the apex. He had a hyperdynamic high anterior wall with preserved motion of the inferior wall. His coronary angiograph demonstrated a right dominant system. His left main coronary artery had mild irregularities. His left anterior descending artery showed a total occlusion at the second septal junction after a high small diagonal. TIMI 0 flow was noted. This vessel was stented with 0% residual. TIMI 3 flow was demonstrated. He also notably had a left circumflex artery of 80% proximal lesion, into a single huge marginal. The right coronary artery was 100% mid right coronary artery with [**Doctor First Name **] right to right and left to right collaterals. A large posterior descending coronary artery and post left ventricular branches were seen. Otherwise his catheterization was notable for a previously repaired abdominal aortic aneurysm. In summary his catheterization was notable for multivessel disease including a chronic occlusion of the right coronary artery and moderate to severe lesion of the proximal left circumflex. The left anterior descending coronary artery was occluded and managed with primary percutaneous transluminal coronary angioplasty from TIMI 0 to TIMI 3 flow post stent. PAST MEDICAL HISTORY: As above. FAMILY HISTORY: He has a brother who died of heart disease at 69. He has a father who died of a cerebrovascular accident at age 55. SOCIAL HISTORY: He has 80 pack year smoking of tobacco. He quit in [**2181-4-17**]. He denies any intravenous drug use. He is married, retired. He drinks one glass of alcohol/wine per night. ALLERGIES: The patient has no known drug allergies, however, on this admission appears to be allergic to betadine ointment, which causes a maculopapular rash. MEDICATIONS: His cardiac medications on admission were Lipitor, Imdur and aspirin. PHYSICAL EXAMINATION ON ADMISSION: Heart rate 67, blood pressure 117/65. Respiratory rate 12. He was sating 98% on room air. In general, he was pleasant and in no acute distress. His mucous membranes are moist. His oropharynx was clear. He had anicteric sclera. He had no JVD, no carotid bruits. His heart examination was regular rate and rhythm with distant S1 and S2 sounds. No murmurs or rubs or gallops were appreciated. His lungs were clear to auscultation. His abdomen was soft, nontender, nondistended. He had a small reducible soft hernia and a clean and dry abdominal aortic aneurysm scar. His extremities were without edema. His pedals were palpable. He had no femoral bruits bilaterally. He was guaiac negative. LABORATORY FINDINGS ON ADMISSION: White blood cell count was 11.5, hematocrit 44.2, platelets 154, sodium 139, potassium 4.1, BUN 22, creatinine 1.1, INR was 1.2. An electrocardiogram on admission, he was in normal sinus rhythm at a rate of 74. His PR interval was 304 milliseconds, left axis deviation was noted. He had ST elevations in leads V1 through V3 with T wave inversions in leads 3 and AVF. This electrocardiogram was his presenting electrocardiogram from the outside hospital. HOSPITAL COURSE: 1. Cardiac: Ischemia; the patient had an anterior ST elevation myocardial infarction with a cardiac catheterization notable for three vessel disease. He is status post a proximal left anterior descending coronary artery stent. The patient did well post catheterization. He was maintained on aspirin and Plavix to complete a thirty day course of Plavix. His CKs peaked at 1432, his peak index was 14.2. He had no further dynamic electrocardiogram changes. His lipid panel revealed a total cholesterol of 153, LDL of 88, HDL 43, triglycerides of 108. He was maintained on Lipitor for his dyslipidemia. Regarding his ischemia, the plan was to medically manage him presently and bring him back for an elective coronary artery bypass graft in four to six weeks following completion of a thirty day course of Plavix. Pump; on [**2199-9-16**] a transthoracic echocardiogram was obtained. It demonstrated a left ventricular ejection fraction of 30% with left ventricular systolic function moderately to severely depressed secondary to severe hypokinesis of the anterior septum and anterior free wall. Apical akinesis was also noted (no thrombus was seen). Also there was mid ventricular plus apical segments and inferior plus posterior wall hypokinesis. There was 1+ mitral regurgitation. The patient was maintained on beta blockers and ace inhibitors as his blood pressure and heart rate tolerated. He was continued on heparin following his catheterization for his apical akinesis. He was slowly transitioned to Coumadin for discharge. Coumadin will resume until a week prior to surgery. Rhythm; the patient had a few runs of nonsustained ventricular tachycardia following his anterior ST elevation myocardial infarction. the longest of these runs were approximately seven beats in the immediate post catheterization. He had no further episodes noted on telemetry for the rest of his hospitalization. The patient also had a signal average electrocardiogram performed by Dr. [**Last Name (STitle) 45512**]. He will follow up with a T wave alternans study following his coronary artery bypass graft. The decision was made not to stress him with T wave alternans study preoperatively given his three vessel disease. From a rhythm standpoint, there will be consideration of ICD placement post coronary artery bypass graft given his EF of 30%. Again this consideration will be post coronary artery bypass graft. The patient was evaluated by physical therapy during this admission and deemed to have return to his baseline level of function and safe to go home. MEDICATIONS ON DISCHARGE: 1. Lopresor 75 mg po b.i.d. 2. Captopril 25 mg po t.i.d. 3. Aspirin 325 mg po q.d. 4. Lipitor 10 mg po q day. 5. Protonix 40 mg po q.d. 6. Coumadin 5 mg po q.h.s. 7. Plavix 75 mg po q.d. to complete a thirty day course. FOLLOW UP: The patient will have his cardiology follow up per Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]. He was formally followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 45513**] at [**Hospital3 45514**] Center. The patient, however, expressed his wishes to be followed primarily at [**Hospital1 346**]. He will follow up with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 45515**] Dr.[**Name (NI) 9388**] nurse practitioner [**First Name (Titles) **] [**2199-10-4**] at 11:30 a.m. The patient will be discharged on Coumadin and his INR will be drawn by nurse [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 41978**] and the results will be forwarded to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 45516**] office who will titrate his Coumadin appropriately to a therapeutic level. The patient will also be seen in the [**Hospital **] Clinic on [**2199-10-7**] at 1:00 p.m. on the [**Hospital1 **] [**Location (un) **] [**Apartment Address(1) 45517**]. He will also follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] of cardiac surgery on [**10-8**] at 1:30 p.m. at [**Last Name (NamePattern1) 439**]. The patient will complete a thirty day course of Plavix prior to coronary artery bypass graft. The plan will be to undergo coronary artery bypass graft per Dr. [**Last Name (STitle) 70**]. The patient's Coumadin will likely be discontinued a week prior to surgery. The patient will follow up a T wave alternans study and consideration of ICD placement following his surgery. Arrangements for said follow up will be per Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]. ALLERGIES ON DISCHARGE: The patient has an allergy to betadine ointment, which gave him a rash. CONDITION ON DISCHARGE: Stable. PRINCIPAL DIAGNOSES: 1. Anterior ST elevation myocardial infarction, status post a proximal left anterior descending coronary artery stent. 2. Three vessel disease, plan for elective coronary artery bypass graft in four to six weeks following discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Name (STitle) 45071**] MEDQUIST36 D: [**2199-10-8**] 16:26 T: [**2199-10-11**] 07:36 JOB#: [**Job Number **]

[ "747.0", "401.9", "V10.05", "V58.61", "414.01", "410.01", "412" ]

icd9cm

[ [ [] ] ]

[ "99.20", "36.01", "88.56", "36.06", "37.23", "88.53" ]

icd9pcs

[ [ [] ] ]

3802, 3920

8219, 8450

5615, 8192

8462, 10210

10225, 10298

160, 3751

5138, 5597

3774, 3785

3937, 4384

10323, 10855

8,540

177,101

12389+56362

Discharge summary

report+addendum

Admission Date: [**2160-3-12**] Discharge Date: [**2160-3-28**] Service: HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old white female who was transferred from an outside hospital where she presented initially with epigastric pain, subsequently became septic at the outside hospital, had an eventual diagnosis of gallstone pancreatitis and ascending cholangitis based on their work-up. She became acutely ill during her hospitalization there, required to be intubated and was transferred to the [**Hospital1 188**] for further care. This was at the end of [**Month (only) 956**] of this year. The patient underwent on arrival here, assessment showed that the patient was septic with features of ARDS, gallstone pancreatitis and ascending cholangitis were confirmed based on her laboratory work-up and she underwent an ERCP with sphincterotomy on the [**12-11**] of this year. Subsequently her amylase, lipase and LFTs progressively declined, however, the patient was intubated for a prolonged period and was a slow and difficult wean. During the course of her hospitalization here at the [**Hospital1 1444**] she went into atrial fibrillation and atrial flutter a few times. She was cardioverted successfully on two occasions on [**3-18**] and [**3-20**]. Cardiology and EP service saw her and their initial plan was to perform flutter ablation when the patient was hemodynamically more stable. The patient recovered from her sepsis and the issue then became of ventilator dependence. She also demonstrated mental status changes with poor return of mental function after her hemodynamic instability had been overcome. She therefore underwent a CT scan of her head on [**3-22**] and that was negative for any acute process. The patient eventually got a tracheostomy. This was done on [**3-25**]. She grew Enterobacter cloacae and proteus mirabilis from her sputum sample which was taken following some deterioration in her increased requirement of vent support and for that she was placed on Levofloxacin around [**3-25**]. The patient has been tolerating enteral feeds via a feeding tube. She is planned to have a percutaneous endoscopic gastrostomy tube placement today. CONDITION ON DISCHARGE: Neurologically the patient has shown some slight improvement in neuro function. She does respond to voice by opening her eyes and seems to track movement. She responds more to her family members, however, does not really follow commands. Cardiorespiratory system, the patient has been on Amiodarone since [**3-18**] following her cardioversion. Since then she has been in normal sinus rhythm. The EP services saw her and at this stage did not feel that she stands dependent from flutter ablation. She is to continue on her Amiodarone at 400 mg q d for another two months and barring any further episodes of flutter or fibrillation, that should be weaned down to 200 mg q d. Respiratory, the patient has a tracheostomy tube and is undergoing a slow vent wean. GI, the patient is going to get a PEG tube placement today and resume her enteral feedings which she has been tolerating at goal. GU, the patient has been making good urine. She was being diuresed during her initial part of her hospital course, diuresis has been held for the last few days since she has been making good urine with normal renal function on chemistry. ID, the patient is currently on day #4 of Levofloxacin which was started for a positive sputum culture, however, the patient was not febrile and did not have a white count but did seem to have increased respiratory secretions and because of difficulty we weighed the benefits and risks and decided to give her the Levofloxacin trial. This is to continue for a 10 day period. Heme, the patient is on Epogen. She has myelodysplastic syndrome, chronic standing. DISCHARGE STATUS: The patient is stable for discharge to rehab. She has tracheostomy. She needs vent wean and she needs to be fed via a PEG tube. DISCHARGE DIAGNOSIS: 1. Gallstone pancreatitis. 2. Ascending cholangitis. 3. Status post ERCP and sphincterotomy on [**3-13**]. 4. Atrial fibrillation status post cardioversion on [**3-18**] and [**2160-3-20**]. 5. Prolonged intubation, status post tracheostomy. 6. History of dysmyelopoietic syndrome characterized by pancytopenia, anemia and thrombocytopenia. 7. History of coronary artery disease, reflux disease, osteoarthritis, hypercholesterolemia, hypertension and paroxysmal atrial fibrillation. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**] Dictated By:[**Name8 (MD) 27609**] MEDQUIST36 D: [**2160-3-28**] 09:08 T: [**2160-3-28**] 09:30 JOB#: [**Job Number 38564**] Name: [**Known lastname 3777**], [**Known firstname **] Unit No: [**Numeric Identifier 6982**] Admission Date: [**2160-3-12**] Discharge Date: [**2160-3-31**] Date of Birth: Sex: F Service: General Surgery Addendum to the previous discharge summary mistakingly marked as discharge date of [**2160-3-28**]. The previous dictated discharge summary was complete. Please see that note for details, and please correct discharge date to [**2160-3-31**]. [**First Name8 (NamePattern2) 116**] [**Name8 (MD) **], M.D. [**MD Number(1) 4989**] Dictated By:[**Last Name (STitle) 6781**] MEDQUIST36 D: [**2160-12-18**] 09:36 T: [**2160-12-18**] 09:44 JOB#: [**Job Number 6983**]

[ "577.0", "038.9", "518.5", "427.31", "518.81", "238.7", "574.91", "427.32", "576.1" ]

icd9cm

[ [ [] ] ]

[ "89.64", "51.85", "96.72", "51.88", "96.6", "96.04", "43.11", "99.62", "31.1" ]

icd9pcs

[ [ [] ] ]

3996, 5497

113, 2206

2230, 3975

8,333

193,890

50521

Discharge summary

report

Admission Date: [**2167-1-3**] Discharge Date: [**2167-1-9**] Service: MEDICINE Allergies: Penicillins / E-Mycin / Ampicillin / Amoxicillin / Keflex Attending:[**First Name3 (LF) 5827**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Intubation Central Line Placement History of Present Illness: [**Age over 90 **]M with h/o CAD, HTN, hypercholesterolemia brought to the ED s/p witnessed fall after getting out the chair after lunch. For the last couple weeks has felt "unwell", short of breath and red swollen hands. Also has been becoming more somnolent. Dr. [**Last Name (STitle) 5351**] saw patient and determined that he had pneumonia. Blood and urine tests were negative for gout. Also, had no fever, and other vitals stable. Patient got levaquin for 5days and lasix. Arrived to the ED minimally responsive w/ no evidence of trauma. . In [**Name (NI) **], pt found to have temp of 100.0 rectally with tachypnea to 40's. He was intubated. Initial blood gas 7.28/60/298 on AC 500/14/5/ ? FIO2 repeat at 7p 7.32/54/283 on AC 500/16/5/100% . Lactate was 1.6. Rec'd vanc/ceftriaxone, 4L IVF. Blood cultures, urine cultures were drawn. . CTA: neg pe, bilateral small effusions, also bilateral consolidations vs. atelectasis. pulm htn Past Medical History: 1. Coronary Artery Disease (s/p MI and angioplasty '[**54**], catheterization in '[**60**]--1 vessel LCA disease with mild diastolic dysfunction, MIBI in '[**61**] with severe fixed inferior and mildly reversible lateral wall defects, EF at 30%, diffuse hypokinesis, akinesis of inferior wall, ECHO [**9-25**] EF 40-45%) 2. CHF 3. Hypertension 4. GERD 5. Irritable Bowel Syndrome 6. Hypercholesterolemia 7. Periperal Vascular Disease w. claudication 8. Cervical kyphosis 9. Hiatal Hernia Social History: The patient lives with his wife of many years in [**Location (un) 55**]. He previously practiced law, and continued to lead an active life with much exercise and frequent golfing until limited by dyspnea recently. He does have a history of smoking cigarettes and pipes many years ago, quit 30 years ago. No significant history of EtOH, no other drugs. Family History: There is a strong family history of heart disease in both parents and three sisters. Physical Exam: Vitals: T 96 BP 139/97 P 74 CVP 20 98% on 500/18/5 50% Gen: Intubated, awake HEENT: left eye with large pupil, right pupil equally reactive to light Neck: elevated JVP CV: s1 s2 regular Resp: CTA x 2, no wheezes/crackles Abd: soft, +bs Ext: [**12-23**]+ edema to thighs, UE edema, +dp, pt pulses by doppler Neuro: moving all extremities Guiac neg in ED Pertinent Results: Labs On Admission: [**2167-1-3**] 11:42PM URINE HOURS-RANDOM UREA N-508 CREAT-296 SODIUM-30 [**2167-1-3**] 11:42PM URINE OSMOLAL-554 [**2167-1-3**] 10:22PM CK(CPK)-218* [**2167-1-3**] 10:22PM CK-MB-8 cTropnT-0.07* proBNP-[**Numeric Identifier **]* [**2167-1-3**] 10:22PM RHEU FACT-4 CRP-32.7* [**2167-1-3**] 07:07PM TYPE-ART RATES-/16 TIDAL VOL-500 PEEP-5 O2-100 PO2-283* PCO2-54* PH-7.32* TOTAL CO2-29 BASE XS-0 AADO2-396 REQ O2-68 -ASSIST/CON INTUBATED-INTUBATED COMMENTS-GREEN TOP [**2167-1-3**] 06:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.028 [**2167-1-3**] 06:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2167-1-3**] 06:50PM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE EPI-0-2 [**2167-1-3**] 05:40PM TYPE-ART RATES-/14 PEEP-5 PO2-298* PCO2-60* PH-7.28* TOTAL CO2-29 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED [**2167-1-3**] 03:36PM LACTATE-1.6 K+-4.8 [**2167-1-3**] 03:35PM GLUCOSE-160* UREA N-26* CREAT-1.4* SODIUM-141 POTASSIUM-4.8 CHLORIDE-97 TOTAL CO2-35* ANION GAP-14 [**2167-1-3**] 03:35PM estGFR-Using this [**2167-1-3**] 03:35PM ALT(SGPT)-42* AST(SGOT)-64* CK(CPK)-65 ALK PHOS-99 AMYLASE-51 TOT BILI-0.2 [**2167-1-3**] 03:35PM LIPASE-16 [**2167-1-3**] 03:35PM cTropnT-0.09* [**2167-1-3**] 03:35PM CK-MB-NotDone [**2167-1-3**] 03:35PM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-4.8* MAGNESIUM-1.9 [**2167-1-3**] 03:35PM WBC-7.2 RBC-4.06* HGB-12.5* HCT-39.8* MCV-98 MCH-30.8 MCHC-31.4 RDW-14.1 [**2167-1-3**] 03:35PM NEUTS-77.0* LYMPHS-14.6* MONOS-6.6 EOS-1.2 BASOS-0.7 [**2167-1-3**] 03:35PM HYPOCHROM-3+ MACROCYT-1+ [**2167-1-3**] 03:35PM PLT COUNT-287 [**2167-1-3**] 03:35PM PT-13.0 PTT-26.3 INR(PT)-1.1 [**2167-1-3**] 03:35PM PT-13.0 PTT-26.3 INR(PT)-1.1 [**2167-1-3**] 03:35PM SED RATE-12 . RADIOLOGY Final Report HAND (AP, LAT & OBLIQUE) BILAT [**2167-1-8**] 3:49 PM IMPRESSION: 1. No specific evidence of erosive arthropathy. 2. Chondrocalcinosis. Severe joint space narrowing of the ST-T joints bilaterally. . Microbiology: Urine Culture [**1-3**] no growth Blood Cultures x 2 [**1-3**] no growth . Imaging: CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2167-1-3**] 8:55 PM FINDINGS: There is normal opacification of the pulmonary arterial vasculature without evidence of filling defects to suggest the presence of pulmonary embolism. There is dilatation of the main and left pulmonary artery, measuring 4.4 and 4.7 cm, respectively, suggestive of underlying pulmonary arterial hypertension. The right pulmonary artery is borderline in diameter measuring 3.0 cm. There is backflow of contrast into the liver veins and coronary sinus, inicating right heart failure. There are multiple prominent mediastinal lymph nodes, the largest one located in the lower paratracheal lesion measuring 13 mm in short axis diameter (4, 31). Other lymph nodes in the upper paratracheal, prevascular and subcarinal regions do not meet CT size criteria for pathologic enlargement. There are coronary artery calcifications involving circumflex and LAD and scattered calcifications in the aortic root, aortic arch and origin of great vessels. There are small bilateral pleural effusions and bilateral dependent opacities, but given the early acquisition in the arterial phase it cannot be definitely determined if these represent atelectasis or pneumonia consolidations. There is moderate cardiomegaly. Images through the upper abdomen do not demonstrate acute pathological findings. There are atherosclerotic calcifications of the descending aorta. BONE WINDOWS: There are no suspicious lytic or blastic lesions. IMPRESSION: 1. No evidence of clinically significant PE. 2. Marked dilatation of pulmonary arteries, consistent with underlying pulmonary arterial hypertension. 3. Bilateral lower lobe opacities and mediastinal lymphadenopathy; given the patient's history, this may be consistent with aspiration pneumonia. 4. Very small bilateral pleural effusions. 5. Moderate cardiomegaly 6. Coronary artery calcifications of LAD and circumflex. . CT C-SPINE W/O CONTRAST [**2167-1-3**] 5:46 PM INDICATION: Altered mental status. CT CERVICAL SPINE: Degenerative changes are seen, with straightening of the normal lordosis of the spine, which can be compatible with degenerative change. Loss of disc space is seen at all levels; there is no malalignment. Anterior osteophytes are seen at C5-6, C6-7, C7-T1, and small posterior osteophyte at C5-6. Old healed fracture of the posterior process of the T1 vertebral body. The patient is intubated. A nasogastric tube is in place. Interstitial prominence in both lungs and fluid along the left major fissure is seen, which may represent fluid overload. A right internal jugular vein line is seen in a capacious right internal jugular vein. A small amount of dependent material surrounding the endotracheal tube in the posterior aspect is likely secretions. IMPRESSION: Degenerative changes of the spine, without fracture or malalignment. . CT HEAD W/O CONTRAST [**2167-1-3**] 5:45 PM INDICATION: Altered mental status. NON-CONTRAST HEAD CT: No priors for comparison. No hydrocephalus, shift of normally midline structures, intra- or extra-axial hemorrhage, or acute major vascular territorial infarct is identified. Hypodensities are seen scattered in both corona radiata and centrum semiovale, indicating chronic microvascular change. Cavernous carotid arteries are calcified. Scattered opacification of ethmoid air cells is seen. The patient is intubated. IMPRESSION: No acute intracranial hemorrhage or mass effect. Ethmoid air cell opacification likely due to intubation. . CHEST (PORTABLE AP) [**2167-1-3**] 3:28 PM AP CHEST RADIOGRAPH: Compared to prior radiograph from [**9-30**], [**2164**], there continues to be moderate cardiomegaly which is unchanged. No pleural effusion or pulmonary vascular redistribution is evident. The mediastinal and hilar contours are unchanged compared to prior study, including enlarged left pulmonary artery. The thoracic aorta is tortuous. Ill-defined opacification at the left lung base is present and which may represent patchy atelectasis versus early parenchymal consolidation. ET tube terminates approximately 4 cm above the carina and the tip of the NG tube is seen within the fundus of the stomach. IMPRESSION: 1. Patchy atelectasis versus air space consolidation at the left base. 2. Unchanged appearance of enlarged left pulmonary artery. . ECHO [**1-6**] MEASUREMENTS: Left Atrium - Long Axis Dimension: *5.4 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *6.5 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *6.6 cm (nl <= 5.0 cm) Left Ventricle - Ejection Fraction: 50% (nl >=55%) Aorta - Valve Level: *3.7 cm (nl <= 3.6 cm) Aortic Valve - Peak Velocity: 2.0 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A Ratio: 1.50 Mitral Valve - E Wave Deceleration Time: 285 msec TR Gradient (+ RA = PASP): *38 to 41 mm Hg (nl <= 25 mm Hg) INTERPRETATION: LEFT ATRIUM: Moderate LA enlargement. LEFT VENTRICLE: Normal LV cavity size. Mild regional LV systolic dysfunction. Mildly depressed LVEF. LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - akinetic; mid inferior - hypo; RIGHT VENTRICLE: Normal RV chamber size. AORTA: Mildly dilated aortic sinus. AORTIC VALVE: Moderately thickened aortic valve leaflets. Minimally increased gradient c/w minimal AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions: The left atrium is moderately dilated. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with basal to mid inferior/inferolateral hypokinesis/akinesis. Overall left ventricular systolic function is mildly depressed. Right ventricular chamber size is normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [**2165-10-4**], estimated pulmonary artery systolic pressure is now higher. Brief Hospital Course: Mr. [**Known lastname 105215**] is a [**Age over 90 **] yo man with a history of CAD, CHF (EF 40-45%), who presents with several weeks of worsening DOE, swollen hands and respiratory failure. . # Respiratory failure. Likely multifactorial given bilateral consolidations on chest x-ray, total body fluid overload (bnp >1200) (received 6L IVFs in ED) as well as hypercarbic respiratory failure secondary to central sleep apnea in the setting of CHF. Patient was intubated initially for tachypnea to the 40s and rapidly extubated the following day. After being extubated on the morning of [**2167-1-4**] the patient continued to mentated well however noted to be apneic during sleep and then again became tachypneic. He was also treated empirically with two days of Vanco/Zosyn for concern of pneumonia; however his sputum and blood cultures remained negative and antiobiotics were stopped. His CXR showed possible aspiration pneumonia with b/l lower lobe opacities as well as evidence of right heart failure with pulmonary arterial hypertension and cardiomegaly. He was diuresed with 40 mg IV lasix [**Hospital1 **] given good urine output. After leaving the ICU he was more than 4 liters negative. He was also started on isordil 30 mg q 6 hrs. He ruled out for MI with three sets of negative cardiac biomarkers. Patient was transferred to the floor saturating in the upper 90s-100% on face tent. He did not want to use BiPap due to discomfort. He should get an outpatient sleep study to better evaluate his apnea, however, at this time he states adamantly he does not want. He was transitioned to po lasix 40 mg po daily with continued diuresis. [**First Name8 (NamePattern2) 6**] [**Last Name (un) **] was added on [**1-6**]. He continued to have some desats o/n on the floor but continued to refuse BIPAP. On discharge he continues to mouth breath and require 2L NC to sat >93% at rest. . # Hand Swelling: Patient carries a possible diagnosis of PMR although very unclear, reportedly was having severe bilateraly hand pain and swelling prior to admission for several days. Patient's symptoms improved dramatically with aggressive diuresis. His RF was negative, [**Doctor First Name **] pending at this time. His ESR was within normal limits. His painful hand swelling was likely exacerbated by his peripheral edema which improved after diuresis. He was treated wtih Tylenol RTC and started on Prednisone 20 mg daily (start [**1-5**]) but subsequently d/ced the following day given lack of diagnosis and marked improvement. Three days afterwards, he started again to develop increased painful hand swelling. His hand films showed narrowing of joint spaces without erosive arthritis. He was started on prednisone 5mg as he had responded to prednisone previously. He was started on concomitant pantoprazole. He will follow up with his outpt. rheumatologist. . # CAD: No chest pain or anginal equivalents. EKG without change. Patient ruled out for MI with three sets of cardiac biomarkers, there is baseline elevation of TnT (0.07-0.09) with CKMB negative. Likely due to CHF and possibly CRI. Patient was continued on ASA and metoprolol. ACEI was considered however he reports a possibly allergy in the past. Started Losartan on [**1-6**]. . # HTN: Well controlled on beta blocker and nitrates, started [**First Name8 (NamePattern2) **] [**Last Name (un) **] . # Hypercholesterolemia: cont statin . # Insomnia: Continued Remeron . # elevated LFT's- mildly elevated initially then trended down, likely congestive hepatopathy in setting of right heart failure. . # GERD: continued protonix # CRI: baseline 1.1-1.3, remained stable with diuresis (peak 1.4 on [**1-4**]) discharged 0.8. Medications on Admission: 1. Eplerenone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Vitamin E 400 unit Capsule Sig: 0.5 Capsule PO EVERY OTHER DAY (Every Other Day). 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 13. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Tablet(s) 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO every other day. 15. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO every other day. 16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 4. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 8. Losartan 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Vitamin E 100 unit Capsule Sig: Two (2) Capsule PO QOD (). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain/fever. 13. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 2732**] & Retirement Home - [**Location (un) 55**] Discharge Diagnosis: CHF syncope _____ CAD HTN GERD IBS Hypercholesterolemia Osteoarthritis Discharge Condition: fair, tolerating pos, sitting up with assistance, 91-93% on RA, improves to 94% on 2L at rest Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2L. It is very important for you to adhere to a low salt diet and restrict your fluids to <2L, as not adhering will effect your breathing and hand and foot swelling Please seek medical attention should you develop chest pain, shortness of breath, lightheadedness, nausea, or increased leg swelling. Please also return should you develop fever, chills, GI bleeding, decreased urine output or other concerning symptoms. . Please take all medications exactly as prescribed. We have restarted your lasix which you should take every day and started you on atrovent nebulizer and losartan. We have also started prednisone and pantoprazole which you should take until otherwise directed. Otherwise, all your other medications at this time remain the same. Please follow up closely with Dr. [**Last Name (STitle) 5351**] and your rheumatologist as below Followup Instructions: Dr. [**Last Name (STitle) 5351**] will follow up with you. You should also follow up with your rheumatologist re: your hadn swelling, especially as we have started you on prednisone.

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

18126, 18216

11536, 15229

271, 306

18331, 18427

2658, 2663

19447, 19634

2181, 2267

16627, 18103

18237, 18310

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2282, 2639

224, 233

334, 1281

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2677, 7775

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1811, 2165

16,412

176,434

53124

Discharge summary

report

Admission Date: [**2198-7-12**] Discharge Date: [**2198-7-21**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: shortness of breath , cough Major Surgical or Invasive Procedure: R Chest tube placement R VATS, decortication, biopsy of cavitary lesion History of Present Illness: 84 yo M from [**Hospital3 **] w/ MMP incl COPD, Macronodular pulmonary amyloidosis, CAD, HTN, AAA, HTN presenting with several days cough and dyspnea, including increasing difficulty with activities of daily living. He also has some dyspnea at rest. he has a cough that started ~10 days PTA, productive of greenish-brown sputum, no hemoptysis. He has had no fevers. He denies chest pain or abdominal pain. . He is followed by Dr. [**Last Name (STitle) 21848**] for his pulmonary amyloidosis and COPD. He was seen in pulmonary clinic 2 days PTA for evaluation of these symptoms. A CXR showed increased nodularities and pathcy infiltrate. A CT of the chest was done which showed significant increase in size and number of pulmonary nodules with new cavitation, as well as loculated pleural effusion. The patient was started on augmentin. Consideration was for semi-urgent VATS. On the morning of admission, the patient "looked bad" to his daughter, and his vitals were noted to be 80/50, HR 120, RR 32, O2 88RA. At this time, the patient was transferred urgently by ambulance to [**Hospital3 **]. . At [**Hospital1 392**], noted to be afebrile with BP 94/48 and satting 90% on RA. Notable lab results were a WBC of 31.4, Cr of 4.3 and a K of 6.5. The patient was transferred to [**Hospital1 18**] ED for continuity of care. . In the ED, the patient was afebrile. His blood pressures were in the 80s-90s systolic, with a nadir of 68/45. Other VS include RR 18-22, Hr 80s-90s, Sat 94-96% 6L FM. His lactate was 2.5. He was pan cultured and started on Vanco, ceftriaxone and flagyl. A CT abdomen/pelvis was done to r/o leaking AAA as cause of his hypotension, and a bedside FAST exam was negative. A CXR showed loculated pleural effusion. Dr. [**Name (NI) **] placed a 28Fr CT in R chest wall with return of pus. The patient was then transferred to the MICU for further care. He recieved a total of 2350 IVF, and Had 800 UOP + 60cc from the CT. Past Medical History: 1. COPD followed by Dr. [**Last Name (STitle) 217**]. His FVC is 3.27 or 75% of predicted, FEV1 is 0.8 which is 30% of predicted, and his FEV1-FVC is 24% which is 39% predicted. 2. Coronary artery disease with one vessel disease of the right coronary with collaterals, status post catheterization in [**2195-8-4**]. 3. Hypertension. 4. Hypercholesterolemia. 5. Bilateral renal artery stenosis. 6. Abdominal aortic aneurysm status post repair with aortobi-iliac bypass graft [**2195-8-26**], complicated by trilobar pneumonia, high-grade four out of four bottles Staphylococcus bacteremia, enterococcus urinary tract infection associated with the bacteremia. 7. Peripheral [**Year (4 digits) 1106**] disease, status post bilateral stents and bypasses. 8. Atrial fibrillation/flutter status post ablation. 9. Macronodular pulmonary amyloidosis diagnosed with biopsy in [**2193-4-4**]. 10. Positive lupus anticoagulant. 11. Anterior neck mass, questionable etiology. 12. Hx Clostridium difficile. 13. s/p bronchoscopy in [**2195-1-4**], complicated by right pneumothorax. PAST SURGICAL HISTORY: Status post abdominal aortic aneurysm repair in [**2195-8-4**], status post bilateral femoral-tibial bypass in [**2184**] and [**2185**]. Family History: His father died at the age of 58 of an myocardial infarction. His mother had unknown malignancy Physical Exam: VS- 98.4 HR 77 BP 98/47 RR 17 Sat 98% 6L NC GEN- elederly, NAD, chronically ill appearing, A+O x 3 SKIN- warm, dry HEENT- MM dry, PERRL, no JVD, OP clear COR- RRR. no m/r/g PULM- Bilateral basilar dullness, reduced BS throughout. CT in place, intact in R CW, draining serosanguinous fluid. ABDOMEN- soft, NT, ND EXTR- [**2-5**]+ edema, pulses intact, not hyperdynamic NEURO- grossly intact, patient appropriately follows commands. Pertinent Results: STUDIES. [**7-12**] CXR - 1. Loculated right pleural effusion with lucencies within it consistent with air. 2. Nodular and parenchymal opacities predominantly in the right middle and right lower lung zones seen on the prior CT examination of [**2198-7-10**]. The differential diagnosis again includes infectious process, unusual manifestation of the patient's known pulmonary amyloidosis, Wegner's disease, and malignancy cannot be excluded. . [**7-12**] ABD/PELVIS CT - 1. No evidence of increase in the size of the abdominal aortic aneurysm. No evidence of aneurysmal leak. 2. Extensive consolidative opacity in the right lung base, primarily appearing pleural, which has increased in size over the past two days, and contains small cystic spaces. This is most concerning for an infection. Clinically correlate. . [**7-10**] CHEST CT - Significant interval increase in size and development of new nodules, several of which are now cavitary. The overall appearance is most worrisome for a superimposed infectious process, possibly septic, particularly given pleural reaction, loculated pleural fluid and adjacent opacities in the right lower lobe. This appearance may also be unusual manifestation of the patient's known pulmonary amyloidosis. The differential diagnosis radiographically would also include Wegner's or other [**Month/Day (4) 1106**] disease, rheumatoid or low-grade lymphoma. Lung cancer would also be included in differential. . ECHO [**2197-2-16**] 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). 3. The aortic valve leaflets are mildly thickened. Mild aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 5. Compared with the findings of the prior report (tape unavailable for review) of [**2195-12-21**], there has been no significant change. . CT abd/pelvis [**7-12**]: IMPRESSION: 1. No evidence of increase in the size of the abdominal aortic aneurysm. No evidence of aneurysmal leak. 2. Extensive consolidative opacity in the right lung base, primarily appearing pleural, which has increased in size over the past two days, and contains small cystic spaces. This is most concerning for an infection. Clinically correlate. 3. Likely cholelithiasis without evidence of cholecystitis. 4. Simple-appearing cysts in the right kidney. . CT chest [**7-14**]: IMPRESSION: Stable appearance of multiple cavity nodules in both lungs likely representing an infectious process, possibly septic. The differentials include [**Doctor Last Name **], rheumatoid or low-grade lymphoma. Lung cancer should also be included in the differential. Interval increase in the size of right-sided pleural effusion status post chest tube placement. This effusion now has multiple air bubbles, which could be secondary to the chest tube placement. However, a secondary superimposed infection cannot be excluded. Brief Hospital Course: 84 yo M w/ MMP incl. COPD, Macronodular pulmonary amyloidosis, others transferred from OSH w/ dyspnea, low sats, hypotension; rescently found to have worsening pulmonary infiltrates/pleural effusions. . #Resp Distress - likely due to baseline COPD/amyloidosis with superimposed acute infection, loculated effusion with pus drainage at time of chest tube placement. After drainage remained stable from respiratory standpoint, oxygenative well on RA. Chest tube without any evidence of air leak, approximately 100cc output, trailing off on second day. - Pleural fluid s/w exudate, cx pending, no orgs on GS - Cont Vanco/Zosyn empirically. - To OR for decortication once renal function and coagulopathy improved. (see below) . #Hypotension - Pt w/ hx hypertension. No AAA on abd CT, neg FAST. Resolved with IVF by the second hospital day, lactate trended down . #Coagulopathy - on coumadin for hx Aflutter. No recent dose changes. Poor po intake per family. Given Vitamin K x3 days with resolution of coagulopathy. . #ARF - baseline Cr 1.1-1.2 (last 1.2 in [**5-10**]). Cr 4.4 on admission, back to baseline with some IVF. . #COPD - FEV1/FVC 31 (50%) pred, FVC 3.00 (74% pred), FEV1 0.92 (37%pred). Treated wtih albuterol/atrovent nebs prn, fluticasone . #A.flutter - hx a flutter s/p ablation. Currently in SR. On coumadin prophylaxis, hold in preparatino for surgery. . #Hyperchol - cont lipitor . #DM/IGT - hold metformin in hospital. FSBS qid, HISS. . #HTN - hold lisinopril, lasix for SBP<100. . #FEN- cardiac/renal diet, IVF at 100cc/hr, follow lytes, replete prn. NPO p midnight if going to OR. . #PPx - pneumoboots, PPI . #Access- 18g PIV L forearm, 20g PIV R AC. Consider central access if cont to be hypotensive . #Code status - DNR/DNI - temporarily reversed for immediate perioperative course. . #Communication - Daughter [**Name (NI) **] is HCP ([**Telephone/Fax (1) 109436**]. Daughter [**Name (NI) **] [**0-0-**]. Addendum: Patient went to operating room on [**2198-7-16**] for right VATS/decortication and biopsy of cavitary lesion. The patient recovered well post-operatively. Chest tubes were removed on post op day 3 and 4 with no complications. The patient was screened for a rehabilitation center and deemed fit for discharge on post op day 5. Per ID recommendations, will be discharged on PO Levoflox and complete a 2 week course of antibiotics. Medications on Admission: Azmacort two puffs [**Hospital1 **] Atrovent two puffs qid Lipitor 40 mg qd Lasix 40 mg qd Lisinopril 5 mg qd Coumadin 5 mg qd MVI qd Tramadol 50mg prn metformin 500 mg qd ranitidine 150 qd Foradil two puffs qd Discharge Disposition: Extended Care Facility: [**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: Empyema, right lower lobe infiltrate Discharge Condition: Stable Discharge Instructions: The patient to call Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) **] office at [**Telephone/Fax (1) 65511**] if developing chest pain, shortness of breath, inability to swallow, fever, chills, nausea, vomiting, diarrhea, redness or drainage from the incisions. If you are unable to reach the thoracic service, please go to the emergency room. Followup Instructions: Please call Dr.[**Name (NI) 1816**] office to schedule a follow-up appointment, and to arrange a chest xray before the appointment (phone number above). Completed by:[**2198-7-21**]

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icd9cm

[ [ [] ] ]

[ "33.24", "34.04", "99.07", "34.51", "33.28" ]

icd9pcs

[ [ [] ] ]

9920, 10009

7287, 9658

304, 377

10090, 10099

4184, 7264

10514, 10698

3620, 3717

10030, 10069

9684, 9897

10123, 10491

3464, 3604

3732, 4165

237, 266

405, 2347

2369, 3441

3,708

133,058

7374

Discharge summary

report

Admission Date: [**2181-11-21**] Discharge Date: [**2181-11-26**] Date of Birth: [**2125-10-30**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 56 year-old gentleman with a history of olfactory groove meningioma. He also has a history of non Hodgkin's lymphoma status post chemotherapy and a resection of lymphoma in the neck. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Blood pressure 137/83. Pulse 83. In general, he was a young gentleman in no acute distress. His HEENT examination pupils are equal, round and reactive to light. Extraocular movements intact. Oropharynx was clear. No lymphadenopathy. No thyromegaly. His chest was clear to auscultation. Cardiovascular regular rate and rhythm. No murmurs, rubs or gallops. Abdomen no masses, nontender, nondistended. Positive bowel sounds. Extremities warm. No clubbing, cyanosis or edema. Neurologically awake, alert and oriented times three. Cranial nerves II through XII are intact. He had a nonfocal examination. HOSPITAL COURSE: He underwent a bifrontal craniotomy for excision of olfactory groove meningioma. Postoperatively, he was monitored in the Intensive Care Unit. Postoperatively, his vital signs were stable. He was afebrile. He was awake, alert and oriented times three. Moving all extremities with good strength. No drift. Face was symmetric. He had some right orbital edema. No evidence of cerebral spinal fluid leak. He remained stable. He had a repeat MRI and was transferred to the regular floor on postoperative day number two. He was seen by physical therapy and occupational therapy and found to be safe for discharge to home on postoperative day number four weaning off Decadron, tolerating a regular diet and voiding spontaneously. His incision remained clean, dry and intact. He will follow up with Dr. [**First Name (STitle) **] in the Brain [**Hospital 341**] Clinic on [**12-10**] and follow up with to Far Five on Monday [**12-2**] for staple removal. CONDITION ON DISCHARGE: Stable. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2181-11-26**] 12:33 T: [**2181-11-26**] 12:37 JOB#: [**Job Number 27144**]

[ "V10.79", "225.2" ]

icd9cm

[ [ [] ] ]

[ "01.51", "02.12", "02.04" ]

icd9pcs

[ [ [] ] ]

1060, 2023

426, 1042

163, 403

2048, 2340

14,768

151,044

50246

Discharge summary

report

Admission Date: [**2146-10-7**] Discharge Date: [**2146-10-20**] Date of Birth: [**2080-5-6**] Sex: M Service: [**Location (un) **] HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old gentleman is status post renal transplant in [**2146-5-31**] and a biopsy in [**2146-7-1**] which was initially complicated by delayed graft function and then by arteriovenous fistula formation and rejection in [**Month (only) 216**]. The patient also with a history of coronary artery disease and congestive heart failure (with an ejection fraction of 30% to 40%). The patient presented with a 2-month history of dry cough, listlessness, a 2-week history of increased glucose values, worsening cough, and increased peripheral edema, incontinence, and tremors. The patient with worsening in the last 24 hours to 48 hours prior to admission with a fever to 101 degrees Fahrenheit, increased shortness of breath, and increased dyspnea on exertion. His cough was nonproductive. He did have some paroxysmal nocturnal dyspnea and some orthopnea. In the Emergency Department, the patient received ceftriaxone, azithromycin, metoprolol, aspirin, amiodarone, regular insulin NPH, nitroglycerin drip, and pentamidine. REVIEW OF SYSTEMS: Review of systems was positive for a dry weight of 208. His appetite was okay. Fever for the past two days. No chest pain. No angina. No nausea. No vomiting. No diarrhea. Occasional constipation. Occlusion orthopnea. Mild paroxysmal nocturnal dyspnea. Intermittent edema. No melena. No bright red blood per rectum. PAST MEDICAL HISTORY: 1. Status post cadaveric renal transplant in [**2146-5-31**] complicated by delayed function. The patient had a biopsy in [**2146-7-1**] which showed chronic rejection and was complicated by an arteriovenous fistula. 2. End-stage renal disease secondary to autoimmune glomerulonephritis. 3. Coronary artery disease; status post myocardial infarction times two and status post coronary artery bypass graft with patent grafts as of [**2144-5-1**]. 4. Congestive heart failure (with an ejection fraction of 30% to 35%). 5. History of atrial flutter; status post ablation in [**2143-5-2**] with recurrent atrial fibrillation. 6. History of Nocardia (pulmonary) two years ago while on high-dose prednisone. 7. History of bladder cancer in [**2136**]; status post treatment. 8. History of deep venous thrombosis in his right internal jugular after a line complication. ALLERGIES: Allergies include BACTRIM, PRAVACHOL, MEVACOR, and VANCOMYCIN. MEDICATIONS ON ADMISSION: Medications on admission were Neoral, prednisone, Rapamune, Neurontin, Prilosec, Colace, metoprolol, Lipitor, aspirin, amiodarone, digoxin, Avandia, insulin (regular and NPH), and inhaled pentamidine monthly treatments. SOCIAL HISTORY: The patient worked previously at [**Company 2676**] and is in early retirement. He lives with his wife, and daughter, and grandmother. They have one cat at home. Positive history of tobacco, but he quit 25 years ago. No alcohol. No other drugs. FAMILY HISTORY: Family history includes mother with diabetes. Father with a myocardial infarction at the age of 56 and obesity. A brother who died at the age of 48 of cholesterol emboli. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed the patient's temperature was 102.7 degrees Fahrenheit, his heart rate was 101, his blood pressure was 123/65, his respiratory rate was 33, and his oxygen saturation was 99% on 4 liters via nasal cannula and requiring 6 liters via nasal cannula. In general, the patient was a middle-aged gentleman lying in bed. He was speaking in short sentences. In no acute distress. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. Pupils were equal, round, and reactive to light. Extraocular muscles were intact. The oropharynx with some thrush. No erythema. The neck was supple. No lymphadenopathy. No bruits. Cardiovascular examination revealed heart was irregularly irregular. Normal first heart sounds and second heart sounds. Pulmonary examination with positive rhonchi and significant upper airway nose. No wheezes. Adequate air movement. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. Extremity examination revealed 2+ edema to the knees with chronic venous stasis changes (right greater than left)). Neurologic examination revealed the patient was alert and oriented times three. Cranial nerves were intact. Strength and sensation were intact. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission revealed the patient's white blood cell count was 5.5, his hematocrit was 25.3, and his platelets were 374. His Chemistry-7 revealed sodium was 132, potassium was 4.8, chloride was 97, bicarbonate was 19, blood urea nitrogen was 58, creatinine was 3.8, and blood glucose was 341. His calcium was 8.6, his magnesium was 1.7, and his phosphorous was 3.4. Lactate dehydrogenase was 933. The rest of the liver function tests were normal. Troponin on admission was 0.13, creatine kinase was 687, and MB was 3. His amylase was 118. Urinalysis with a specific gravity of 1015, large blood, 100 glucose, and trace ketones. Blood cultures and urine cultures were pending on admission. A sputum culture was also sent. Arterial blood gas on 6 liters of nasal cannula revealed a pH of 7.45, a PCO2 of 26, and a PO2 of 74. PERTINENT RADIOLOGY/IMAGING: A chest x-ray with increased cardiac size, prominent vasculature, bilateral lung opacity blunting, small left pleural effusion. Electrocardiogram with atrial fibrillation with a rapid ventricular response and wide QRS. Significant change from [**2146-7-1**]. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The patient is a 66-year-old immunosuppressed gentleman status post transplant who presented with fever, cough, and hypoxia with multiple medical problems including congestive heart failure, chronic renal insufficiency, and atrial fibrillation (with rapid ventricular response) who subacutely decompensated likely due to infection versus cardiac causes. The patient was initially admitted to the Intensive Care Unit for further monitoring and further workup. 1. HYPOXIA ISSUES: Initially, the patient was treated aggressively with antibiotics and pentamidine for broad coverage and tolerated this well. Eventually, the patient had a bronchoscopy in the Intensive Care Unit. Many studies were sent including Pneumocystis carinii pneumonia, bronchial cultures, viral studies which all remained negative. No source was found per bronchoscopy. Initially, the patient was continued on pentamidine treatment until preliminary Pneumocystis carinii pneumonia came back negative. Pentamidine was discontinued; however, the patient spiked a temperature again while on ceftriaxone and Zithromax and was restarted on pentamidine. The patient completed a 7-day course of ceftriaxone and azithromycin which was then discontinued. Initially, in the Intensive Care Unit when he patient was being treated for empiric Pneumocystis carinii pneumonia, the patient was also started on high-dose prednisone. As the Pneumocystis carinii pneumonia initially came back negative, the high-dose prednisone was then discontinued and the patient remained on his previous home dose of prednisone. The patient was also diuresed during the course of his Medical Intensive Care Unit stay, to which he responded with increased urine output. In addition, his creatinine started to rise; unsure if this was secondary to his pentamidine treatment or further diuresis. Diuresis was held when the patient was transferred to the floor and continued to be monitored for fluid overload. As the patient became slightly more symptomatic on examination, with evidence of bilateral mild pulmonary edema, the patient was diuresed again on an as-needed basis. Eventually, pentamidine was restarted and then discontinued prior to discharge secondary to no evidence of Pneumocystis carinii pneumonia and a rise in creatinine likely secondary to nephrotoxicity from the pentamidine. The patient remained afebrile off the pentamidine and was otherwise stable. 2. PULMONARY ISSUES: From a pulmonary standpoint, after the patient's bronchoscopy, the patient was transferred from the Medical Intensive Care Unit and was stable on the floor. The patient remained on room air throughout the course of his stay on the floor. Otherwise, the patient was asymptomatic except with an occasional cough. The patient had a repeat chest x-ray which showed diffuse bilateral opacity and prominence of the pulmonary vasculature which remained pretty consistent throughout the course of his stay. The patient eventually had a computed tomography of his chest without contrast after some diuresis which did show some diffuse patchy areas of ground-glass opacity which was slightly greater on the right than on the left, which was determined to be consistent with his congestive heart failure or a diffuse infectious process which could be correlated clinically. On computed tomography scan, he was also found to have mild central lobar emphysema and small calcified granulomas in the right upper lobe as well as right lower lobe consistent with a prior granulomatous infection. He did have a note of his right adrenal lesion which had previously been evaluated by magnetic resonance imaging and appeared unchanged. For the patient's pulmonary status, the patient was followed by the Pulmonary team while on the floor and the Infectious Disease team. In the end, all further antibiotic treatment was discontinued, and the patient tolerated this fine without spikes in his temperature. 3. CARDIOVASCULAR ISSUES: The patient initially came in with atrial fibrillation with a rapid ventricular response. The patient was eventually rate controlled on his beta blocker and digoxin. The patient was discontinued off his amiodarone secondary to elevated liver function tests. The patient's digoxin levels remained stable. The patient remained rate controlled but remained in atrial flutter/atrial fibrillation. The patient was evaluated by the Electrophysiology team and Cardiology team, and plans were made to anticoagulate at present and return for cardioversion after three weeks' time after an echocardiogram was done to assess any change in his ejection fraction. The patient's echocardiogram on [**10-14**] revealed an ejection fraction of 40% which was slightly improved from his prior echocardiogram. Otherwise, echocardiogram showed that his left atrium and right atrium were both moderately dilated. He had some mild symmetric left ventricular hypertrophy and a mild global left ventricular hypokinesis. Based on this echocardiogram, the patient was considered to be at a moderate risk and recommended to be on prophylaxis for endocarditis prior to procedures. Secondary to complications from anticoagulation, the patient's anticoagulation was discontinued. The patient was to return in two to three weeks after followup with Cardiology for a possible transesophageal echocardiogram and cardioversion at that time since anticoagulation was not an option at this time. Otherwise, the patient was to continue on his beta blocker, metoprolol, and digoxin with levels to be followed and was otherwise stable from a cardiovascular standpoint at the time of discharge. 4. HYPERGLYCEMIA ISSUES: The patient's blood sugars were poorly controlled secondary to steroids, pentamidine, and sirolimus. However, the patient received consultation from the [**Hospital **] Clinic for evaluation of his insulin regimen. The patient was continued on a NPH morning and evening regimen with a Humalog sliding-scale which was tapered up and down as needed based on his medications. Eventually, the patient was discharged on a regimen of NPH 16 units subcutaneously in the morning and 10 units subcutaneously at bedtime with a Humalog sliding-scale. The patient was to follow up with the [**Hospital **] Clinic upon discharge for further education and monitoring of his blood sugars. 5. RENAL ISSUES: From a renal standpoint, the patient was followed the Renal Transplant Service and was continued on sirolimus with a lower dose of cyclosporine and prednisone at his previous home dose. The patient tolerated the immunosuppressive regimen without difficulties and did have a slight increase in his creatinine which was likely secondary to increased diuresis and increased nephrotoxic drugs (such as pentamidine). At the time of discharge, his creatinine was trending down and will be followed closely. He was to be seen in the Renal [**Hospital 1326**] clinic in two to three weeks as well. The patient did not have a biopsy done at this time, as there was a known cause for his increase in creatinine. Otherwise, the patient's urine output was monitored and remained stable. Otherwise, the patient was continued on his immunosuppressive regimen with slightly lowered Neoral (cyclosporine) dose with a goal cyclosporine level of less than 100 and sirolimus will be his primary immunosuppressive regimen which is less nephrotoxic. The patient's renal condition was also complicated by some incontinence during the course of his admission. The patient had a Urology evaluation and planned for followup with the patient's urologist who had performed his surgery in [**2136**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**]), and the patient was instructed to call telephone number [**Telephone/Fax (1) 990**] to schedule a follow-up appointment and urodynamic testing upon discharge to further evaluate. The patient should have this followup after his transplant anyway and was to continue with this. The patient's incontinence improved throughout the course of his stay and has been complicated by diuresis. The patient had urine cultures sent which were repeatedly negative. He did have urinalyses which were positive for hematuria which was likely consistent with anticoagulation with heparin and Coumadin. 6. HEMATOLOGIC ISSUES: The patient was started on anticoagulation for plans for cardioversion for the patient's atrial fibrillation; however, the patient had complications including gastrointestinal bleed and hematuria secondary to anticoagulation. Anticoagulation was discontinued, and the patient was to hold off on further anticoagulation. The patient will need to have Gastroenterology followup for a colonoscopy as things are more stable. 7. GASTROINTESTINAL ISSUES: Again, as above, the gastrointestinal bleed picture will require an outpatient colonoscopy and esophagogastroduodenoscopy as available. The patient's liver function tests were slightly elevated throughout the course of his stay; likely a combination of hepatotoxic agents. The patient's statin was discontinued, and other drugs were monitored. The patient's liver function tests did improve throughout the course of his stay. 8. PROPHYLAXIS ISSUES: For prophylaxis, the patient was continued on a proton pump inhibitor. At some point the patient was on anticoagulation and eventually received prophylaxis with pneumatic compression boots. CONDITION AT DISCHARGE: Condition on discharge was good. The patient was ambulating without difficulty. The patient was not requiring oxygen. DISCHARGE STATUS: Discharge status was to home with services. DISCHARGE DIAGNOSES: 1. Acute-on-chronic renal failure. 2. Congestive heart failure exacerbation. 3. Pneumonia. 4. Anemia. 5. Gastrointestinal bleed. 6. Atrial fibrillation. 7. Transaminitis. 8. Incontinence. 9. Hyperglycemia. MEDICATIONS ON DISCHARGE: (Discharge medications were) 1. Neurontin 100 mg by mouth once per day. 2. Colace 100 mg by mouth twice per day. 3. Avandia 4 mg by mouth once per day. 4. Digoxin 0.125 mg by mouth every other day. 5. Sirolimus 5 mg by mouth once per day. 6. Sodium bicarbonate 650 mg by mouth three times per day. 7. Cyclosporine (Neoral) one 125-mg tablet by mouth q.12h. 8. Pantoprazole 40 mg by mouth q.12h. 9. Calcium acetate 667-mg tablets times two tablets plus three times per day (with meals). 10. Metoprolol 25 mg by mouth twice per day. 11. Prednisone 5 mg by mouth once per day. 12. NPH insulin 16 units subcutaneously in the morning and 10 units subcutaneously in the evening. 13. Enteric-coated aspirin 325 mg by mouth once per day. 14. Humalog insulin per sliding-scale as directed. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with his primary care physician (Dr. [**Last Name (STitle) 410**] the following week. He will arrange for the patient's gastrointestinal followup for esophagogastroduodenoscopy and colonoscopy. He will also arrange for an outpatient magnetic resonance imaging urogram if the patient's incontinence continues. 2. The patient was also instructed to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**] (his urologist) for outpatient urodynamic testing. 3. The patient was instructed to follow up with his cardiologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 120**]) for his new atrial fibrillation in three weeks' time. 4. The patient was instructed to follow up with his renal transplant physicians and Dr. [**Last Name (STitle) **] in two to three weeks' time. 5. The patient was instructed to follow up with his nephrologist (Dr. [**Last Name (STitle) **] in two to three weeks' time. [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**] Dictated By:[**Name8 (MD) 264**] MEDQUIST36 D: [**2146-10-20**] 14:41 T: [**2146-10-21**] 12:22 JOB#: [**Job Number 104782**]

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icd9cm

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Discharge summary

report

Admission Date: [**2136-11-24**] Discharge Date: [**2136-11-27**] Service: FINAL DIAGNOSES: 1. Panischemic colitis. 2. Hypotension. 3. Sepsis. 4. Hypovolemia. 5. Respiratory failure. 6. Renal failure. PROCEDURE: Total abdominal colectomy with end ileostomy and Hartmann pouch. IMAGING STUDIES: 1. Upright chest x-ray. 2. Abdominal flat plate. 3. CT scan of abdomen and pelvis. HISTORY OF PRESENT ILLNESS: The patient is an 80 year old female who presented to [**Hospital1 69**] emergency room with diffuse diarrhea and hypotension. Patient has a complicated past medical history including most recently an admission for a pedestrian versus car accident where she suffered bilateral lower extremity fractures as well as a C-2 fracture which required immobilization. Patient was eventually discharged to rehabilitation after having fasciotomy for compartment syndrome of her lower extremities. She was being treated for multiple infections including urinary tract infection and pneumonia. Patient presented to [**Hospital1 69**] emergency room with a two day history of first constipation and then diffuse diarrhea. She had white count of 28,000 and abdominal tenderness. A general surgery consult was obtained. PAST MEDICAL HISTORY: Includes status post MVC, hypertension, hypercholesterolemia. MEDICATIONS ON ADMISSION: Albuterol nebulizer p.r.n., Prevacid 30 mg p.o. q.day, Synthroid 25 mcg p.o. q.day, Lasix 20 mg p.o. q.day, Lipitor 10 mg p.o. q.day, Lovenox 30 mg subcutaneously b.i.d., Lopressor 25 mg p.o. b.i.d., Flagyl 250 mg p.o. t.i.d., Percocet one to two tablets p.o. q.six hours p.r.n., Senokot two tablets p.o. b.i.d., sodium bisacodyl 100 mg p.o. t.i.d., Fleet enema p.r.n., milk of magnesia p.r.n., Tylenol p.r.n., Dulcolax p.r.n., Levaquin 500 mg p.o. q.day, vancomycin 1 gm IV q.day, ceftriaxone 1 gm IV q.day. PHYSICAL EXAMINATION: On admission temperature was 99.2, heart rate 108. Initially blood pressure was 70/40, then improved with 1 liter of saline to 90/60. Respiratory rate 36, sating 95% on a nonrebreathing face mask. Patient appeared generally cachectic in severe distress with a healing scar over the right eye and was in an immobilizing [**Location (un) 5622**] collar. Pupils were reactive, equal to light. Extraocular movements intact. Sclerae were anicteric. Oropharynx was dry. Carotids could not be palpated secondary to the collar. Lungs were coarse bilaterally with expiratory wheezing bilaterally with diminishment at the bases. Abdomen was distended with diffuse tenderness most markedly in the upper quadrants. Rectal exam was heme positive with diffuse diarrhea, no masses. Extremities were immobilized in knee immobilizers and had 2+ pitting edema in the upper and lower extremities. Patient was alert, oriented to person, place, time and predicament. LABORATORY DATA: White count was 28.6, hematocrit 42, platelet count 575. PT 13.9, PTT 38.7, INR 1.3. UA was positive for white cells and nitrites. CKs were negative, but with troponin of 1. Sodium 127, potassium 4, chloride 89, bicarb 21, BUN 36, creatinine 1.4 up from a baseline of 0.9, glucose 114. EKG showed sinus tachycardia with right bundle branch block with nonspecific ST depressions in V1 and aVL. KUB showed dilated loops of small bowel without evidence of obstruction. Chest x-ray showed bilateral pleural effusions with right lower lobe atelectasis. First gas was pH 7.36, PCO2 36, PO2 71, bicarb 21 on 100% nonrebreather. CT which was performed showed diffuse swelling and edema of her entire colon as well as her rectum with ascites, but no free air, consistent with either toxic C.diff or ischemic colitis. HOSPITAL COURSE: Initially after discussions with patient's and patient's proxy, she did not want surgical intervention, but after multiple discussions and the likelihood that medical therapy would not be successful, although the likelihood of surgical therapy had a low chance of being successful in her clinical condition, she elected for exploratory laparotomy and subtotal colectomy. Patient was surgically consented, taken to the operating room and through a midline laparotomy, total abdominal colectomy was performed with end ileostomy. At the time of surgery there were large amounts of ascites and a very edematous, but not perforated, colon. Patient was relatively stable during the operative course, but postoperatively in the intensive care unit she remained intubated and became fluid requiring and hypoxic. Patient required increasing doses of pressors. Her kidney function deteriorated. After two days of aggressive therapy, the proxy determined that given her multiorgan system failure, her age and her desire not to have intubation and prolonged ICU intervention, she was made comfort measures only. Pressors were withdrawn and on [**2136-11-27**] at 3:30 p.m. in the afternoon patient expired and was pronounced. Patient's proxy was informed. There were friends present during the expiration. Final diagnoses as above including ischemic colitis with sepsis and multisystem organ failure. [**Name6 (MD) 2467**] [**Last Name (NamePattern4) 10404**], M.D. [**MD Number(1) 10405**] Dictated By:[**Last Name (NamePattern1) 33621**] MEDQUIST36 D: [**2136-11-27**] 15:44 T: [**2136-11-30**] 10:13 JOB#: [**Job Number **]

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icd9cm

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[ "46.20", "45.8", "38.91" ]

icd9pcs

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312, 399

8,406

114,444

17750

Discharge summary

report

Admission Date: [**2149-4-25**] Discharge Date: [**2149-5-22**] Date of Birth: [**2117-6-28**] Sex: F Service: . ADMITTING DIAGNOSIS: Motor vehicle collision with severe head injury. HISTORY OF PRESENT ILLNESS: This is a 31 year old female who was in a motor vehicle collision, a car versus tree. She was the unrestrained driver of the vehicle and was found at the scene with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Scale of 3. She was unable to be intubated in the field and she was transferred to an outside hospital where the patient was intubated. She had a hypotensive episode of a systolic blood pressure down to 80 requiring four liters of Crystalloid and one unit of packed red blood cells. A computer tomography scan of the head was performed at the outside hospital which demonstrated pneumocephalus with intracranial hemorrhage and occipital condyle fracture. A computer tomography scan of the chest was also performed which showed no evidence of mediastinal pathology or pneumothorax. A computer tomography scan of the pelvis had a small amount of left perinephric fluid collection and question of a small area of free air at the dome of the liver without evidence of splenic or hepatic injury. The patient was transferred to the [**Hospital1 190**] Emergency Room for further care. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. ALLERGIES: She had no known drug allergies. MEDICATIONS: She took no medications. Upon arrival in the Trauma Bay, her vital signs were temperature of 98.4 F.; heart rate of 84; blood pressure 110/palpable; saturation of 100%. Her neurological examination was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of 3P. She had no movement to any stimulus. Her Head, Eyes, Ears, Nose and Throat examination was significant for equal and reactive pupils 3 to 2 millimeters bilaterally. There was blood exuding from the right ear. She had a scalp laceration; no facial lacerations. Her neck was in a hard collar. Her trachea was midline. Her chest was clear to auscultation bilaterally without any evidence of crepitants. Her cardiovascular examination was regular rate and rhythm. Her abdomen was soft and obese. Her extremities were cool without any deformities. Her laboratory values on initial examination were a white blood cell count of 19, a hematocrit of 34 with platelet count of 299. Her coagulation studies were an INR of 1.1 with a PTT of 21.3. Her Chemistries demonstrated a potassium of 3.3, a BUN of 8, and a creatinine of 0.6 with a glucose of 154. Her amylase was 62. She had a trace amount of blood on her urinalysis. Her arterial blood gas upon arrival demonstrated a pH of 7.35, pCO2 of 34, pO2 of 108, bicarbonate of 20 and a base excess of minus five. A CT scan of her head was obtained after a ventriculostomy drain had been placed and that demonstrated the following: Acute thalamic parenchymal hemorrhage on the right with mass effect and a leftward trans-falcine herniation as well as diffuse areas of subarachnoid hemorrhage in multiple sulci of both cerebral hemispheres and along the tentorium. There were also focal punctate areas of hemorrhage at the [**Doctor Last Name 352**]-white matter interfaces, likely from diffuse axonal shear injury. A right sided ventriculostomy catheter was present in the tip of the right lateral ventricle. There was diffuse sulcal effacement. There was a right occipital condyle fracture with multiple sphenoid fractures present from the base of the skull through the cella turcica. The sphenoid sinuses were nearly obliterated. There were bilateral temporal bone fractures through the mastoid air cells. She had a DPL also performed in the Trauma Bay to rule out hollow viscus injury secondary to blunt force trauma. At this point, the patient was admitted to the Intensive Care Unit with the diagnosis of a motor vehicle collision with severe closed head injury. From a Neurological standpoint, she was admitted for serial neurological examinations with cervical spine precautions. She was admitted for intracranial pressure monitoring with ventriculostomy and treatment of this intracranial hypertension with Mannitol and sedation to maximize her cerebral perfusion pressure and minimize her ICP. From a Cardiovascular standpoint, she was hemodynamically stable. A pulmonary artery catheter was to be placed if close monitoring of her volume status would be required. From a Respiratory standpoint, she was ventilator independent. Given the fact that she had potential pulmonary contusions and a lung injury, she was to be kept with plateau pressures less than 30 on light protective ventilation. From a Gastrointestinal standpoint, she was to be n.p.o. and DPL was pending. From a Genitourinary standpoint, we were to monitor her urine output; her hematocrit was stable and to be kept greater than 30 to maximize the oxygen carrying capacity of the blood. Fluids, Electrolytes were to be maintained. Her fluids were to be maintained as iso-osmolar and her prophylaxis included pneumoboots and Pepcid. An immediate Neurosurgical consultation was also obtained for placement of a ventriculostomy drain. The patient was transferred to the Intensive Care Unit. HOSPITAL COURSE: Prior to transfer to the Intensive Care Unit, the patient had a CT scan of the cervical spine which demonstrated a fracture through the right transverse process, inferior facet and right lamina of C7 with extensive skull base fractures. The patient was transferred to the Intensive Care Unit where a right ventriculotomy drain was placed by Neurosurgery. The patient was placed on Kefzol for antibiotic prophylaxis. She was also started on Sucralfate for gastrointestinal prophylaxis. On SICU day number two, her neurological examination was significant for what appeared to be decorticate posturing to painful stimulus. Her pupils were constricted, symmetric and dysconjugate; the left pupil rotating medially. Given her posturing and ventriculostomy drainage, she was continued on Mannitol until her sodium was greater than 150 or her osmolarity was greater than 320. She was also kept well sedated. A pulmonary artery catheter was placed and, on SICU day number three, the patient was placed in a Pentobarbital coma after sedation paralysis and Mannitol failed to control her intracranial pressures, which were intermittently up to 30 with compromised cerebral perfusion pressures. She was continued on Mannitol and she was also started on Norepinephrine to maintain a mean arterial pressure such that her cerebral perfusion pressures would be greater than 70 in the face of elevated intracranial pressures. An EEG was obtained to confirm burst suppression with the Pentobarb coma. The patient was continued on mechanical ventilation and was also started on vasopressin because she developed central diabetes insipidus with large amounts of extremely hyperosmolar urine. She was transfused packed red blood cells to maintain her hematocrit greater than 30. She was begun on total parenteral nutrition for nutritional support. She was continued on the Pentobarb coma for 24 hours but because her intracranial pressures remained elevated up to 40 to 50 despite burst suppression and a pentobarbital coma and continued therapy with Mannitol as well as vasopressors to maintain mean arterial pressures, the pentobarbital was stopped. A Xenon brain scan was obtained on SICU day number five, which was [**4-29**], and demonstrated normal flow to the brain despite this intractable intracranial hypertension. The patient was, at this point, started on Zosyn as well because she developed fevers overnight with sputums that were growing Gram positive cocci and a concern for a pneumonia in the setting of pentobarbital coma. She was also begun on SICU day number seven on Vancomycin. Pentobarb levels were checked on a daily basis to allow us to make decisions about her neurological status. We continued to support her both from a ventilatory and nutritional standpoint and by SICU day number eight, although she still had significant pentobarb on board, she was breathing spontaneously and her ICPs began to drift down wards to persistently below 20. She also began to maintain her mean arterial pressures in the 100 range off of any vasopressors. She was continued on the vasopressin for her central diabetes insipidus and by SICU day number ten, an attempt was made to turn off the vasopressin with return of large amounts of urine, approximately 400 cc. in 20 minutes, hence, reinstitution of her vasopressin for persistent central diabetes insipidus. Her pentobarb levels came down to within normal range and a neurological examination at that point performed with the Neurosurgeons demonstrated that she opened her eyes to noxious stimuli and had a flexion response of all four extremities to noxious stimuli without crossing of the midline. At this time, she had thoracic and lumbar spine films which demonstrated no evidence of fracture or dislocation of the thoracic or lumbar spine. She was on a pressure support mode for ventilation, and she was on total parenteral nutrition. The patient was begun on tube feeds on SICU day number eleven and underwent a four vessel angiogram on SICU day number eleven to evaluate for cervical blood vessel injury from her trauma. She was found to have a right internal carotid small dissection as well as a small right vertebral artery injury. Transcranial Dopplers were performed and demonstrated approximately eight embolic events per 15 minute period. She was started on aspirin for this and a Stroke Service consultation was obtained. Her tube feeds were then advanced to goal and her total parenteral nutrition was stopped. At this point, an MRI of her brain was obtained and the MRI demonstrated a moderate sized right thalamic hemorrhage with minimal mass effect and leftward shift of the normal midline structures, multiple bilateral tiny foci of susceptibility artifacts that suggest multiple small shear injuries and slight increased T2 signal within the pons of unclear etiology with flow present in all the major branches of the cerebral circulation. The patient was fairly stable at this point without any progression or deterioration of her neurological examination. Her ventriculostomy drain was subsequently clamped and removed and the family was approached about the direction of her care. They had an extensive discussion with the Intensive Care Unit team where they decided to continue full support and a percutaneous gastrostomy tube as well as a percutaneous tracheostomy were performed on SICU day number 15, which was [**5-9**]. These were without complication. The patient tolerated both procedures well. However, on the following day, the patient was noted to be febrile and was pan-cultured. The patient subsequently was noted to be growing E. coli and methicillin sensitive Staphylococcus aureus from her sputum and was started on antibiotics for this. She was also started on subcutaneously DDAVP to wean her off of her vasopressin drip. She tolerated this well and was doing fine until SICU day number 19, when she became tachycardic and moderately hypotensive and was pan cultured again for a fever and found to be growing Gram negative rods in her blood, for which she was started on Vancomycin and Zosyn. She was also found to be growing coagulase negative Staphylococcus from a central line as well as Klebsiella from her sputum. The Vancomycin and Zosyn were begun on [**5-13**] with a plan of a 14 day course, She subsequently had all central access removed and a PICC line placed and the patient has been doing very well since. Her current examination is that she opens her eyes to noxious stimulus. Her pupils are equal, round and reactive, going from 3 to 2 millimeters and she has weak withdrawal in both legs bilaterally as well as localization to noxious stimulus with her left extremity. She is on a trache collar with coarse breath sounds. She has a regular rate and rhythm; her abdomen is soft, nontender and nondistended. Her extremities are warm and well perfused without any edema. From a Neurological standpoint, she is with a severe closed head injury. Her likelihood of recovery is poor. She is stable from a cardiovascular standpoint requiring no pressors or any hemodynamic support. From a respiratory standpoint she does well on trache collar. From a gastrointestinal standpoint, she is tolerating her tube feeds which are the following: ProMod at 70 cc. an hour with 150 cc. of free water every six hours. From a genitourinary standpoint she is requiring subcutaneous desmopressins, 2 micrograms q. eight hours for her central diabetes insipidus. From a hematologic standpoint, she has a hematocrit that has been stable in the 30s on Epogen. She is also on aspirin for her carotid artery injury with microembolization. From an Infectious Disease standpoint, she is on day number eight of Vancomycin and Zosyn, requiring a completion of six more days for a 14 day course, and she has a PICC line place. Her prophylactic medications include: Subcutaneous heparin and venodynes. DISCHARGE DIAGNOSES: 1. Motor vehicle collision status post severe closed head injury. 2. Central diabetes insipidus. 3. Right internal carotid artery injury. 4. Right vertebral artery injury. 5. Status post percutaneous tracheostomy. 6. Status post percutaneous gastrostomy. DISCHARGE MEDICATIONS: 1. Sliding scale insulin. 2. Aspirin 325 mg p.o. q. day. 3. Heparin 5000 units subcutaneously q. 12 hours. 4. Zosyn 4.5 grams intravenously q. eight. 5. Artificial Tears, one to two drops to each eye q. six hours and p.r.n. 6. Bisacodyl 10 mg p.r. q.o.d. if not bowel movement. 7. Erythropoietin 40,000 units intravenously q. week. 8. Free water bolus 100 cc. q. six hours. 9. Vancomycin 1 gram intravenously q. 12 hours. 10. Desmopressin acetate 2 micrograms intravenously q. 12 hours. 11. Tube feeds at 70 cc. per hour. DISCHARGE INSTRUCTIONS: 1. She will have to follow-up with Dr. [**Last Name (STitle) 1132**] from Neurosurgery. 2. She will have to follow-up with Dr. [**Last Name (STitle) **] from Trauma Surgery. 3. She is to be maintained in a hard collar at all times for her cervical spine fractures. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18153**], M.D. [**MD Number(1) 18154**] Dictated By:[**Name8 (MD) 4720**] MEDQUIST36 D: [**2149-5-21**] 18:04 T: [**2149-5-21**] 20:23 JOB#: [**Job Number 49327**]

[ "967.0", "780.01", "996.62", "801.35", "253.5", "443.21", "811.00", "801.25", "038.49" ]

icd9cm

[ [ [] ] ]

[ "99.15", "45.13", "96.6", "02.2", "38.93", "43.11", "96.72", "33.23", "88.41", "31.1" ]

icd9pcs

[ [ [] ] ]

13278, 13540

13563, 14095

5328, 13257

14119, 14654

1416, 5310

236, 1360

156, 206

1384, 1391

25,941

138,950

3696

Discharge summary

report

Admission Date: [**2191-5-16**] Discharge Date: [**2191-5-22**] Date of Birth: [**2136-12-24**] Sex: F Service: MEDICINE Allergies: Vancomycin / Iodine; Iodine Containing / Tape / Ibuprofen / Levofloxacin Attending:[**First Name3 (LF) 15519**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Tracheal Aspiration History of Present Illness: 54 yo F with PMH sarcoidosis, tracheostomy [**3-14**] upper airway obstruction, dCHF, DM1, pulmonary HTN, CAD, morbid obesity presenting with acute onset dyspnea. She reports that she was resting at home last night when she noted sudden onset of shortness of breath. She denies any fever, cough or increased sputum production. She also reports diffuse abdominal pain which started around the same time. This morning she developed nausea and vomiting, which she feels is different from her gastroparesis. She reports that she has been passing gas and her last bowel movement was yesterday. She does endorse some increased tenderness at the site of her umbilical hernia. She also reports slight increase in bilateral lower extremity edema as well as migrain headache which started today. According to her partner who lives with her the onset of her dyspnea was more subacute occurring over 2-3 days accompanied by and productive cough. . On arrival to the ED T97 BP 184/94 HR 92 RR 24 88% on RA -> 98% on NRB. In the ED she was given nebulizers, solumedrol 125mg IV. CXR was done which showed worseing left mid and lower lung opacity concerning for pneumonia so she was given ceftriaxone 1gIV and azithromycin 500mg po. She was also given morphine 4mg IV for migraine headache and compazine 10mg x 2 for emesis x4. While in the ED she desatted to the mid 80's with ABG 7.32/66/58/36 on 100% trach collar so she was admitted to the ICU. Patient refused positive pressure ventillation in the ED. . Of note she was recently admitted from [**4-20**] - [**4-24**] for nausea, vomiting and migraine headache. She was also treated with zosyn for a catheter associated urinary tract infection, urine culture was negative thought due to administration of abx prior to culture. She was also felt to have a LLL pneumonia. On review of discharge summary antibiotics were not included on her discharge medications. . She was also admitted [**4-8**] - [**4-12**] for dyspnea thought multifactorial. She was treated with IV diuresis, IV followed by po steroids, nebulizer treatments and azithromycin. Past Medical History: Asthma Diastolic heart failure Diabetes mellitus Type 1 (since age 16): neuropathy, gastroparesis, nephropathy, & retinopathy Sarcodosis ([**2175**]) Tracheostomy - [**3-14**] upper airway obstruction, sarcoid. Arthritis - wheel chair bound Neurogenic bladder with chronic foley Asthma Hypertension Pulmonary hypertension Hyperlipidemia CAD s/p CABG [**2179**] (SVG to OM1 and OM2, and LIMA to LAD) last c. cath [**2187-2-28**]: widely patent vein grafts to the OM1 and OM2, widely patent LIMA to LAD (distal 40% anastomosis lesion). Chronic low back pain-disc disease Morbid obesity . s/p cholecystectomy s/p appendectomy Social History: The patient formerly lived alone and has a female partner for 25 years that visits frequently and is her HCP. She has been living at [**Hospital1 **] for the past week. The patient is mobile with scooter or wheelchair and can walk short distances. Remote smoking history <1 pack per day >30 years ago, denies EtOH or drug use. Family History: Father: [**Name (NI) **], Diabetes & MI in 60s Mother's side: Family history of various cancers & heart disease Physical Exam: VS: T97.9 HR 97 BP 168/86 RR 19 97% on 100% Trach mask GENERAL: obese, tachypnic, not speaking in full sentences, dry heaving HEENT: Normocephalic, atraumatic. left pupil 3mm, right pupil 2mm both reactive to light, EOMI, dry mucous membranes Neck: obese, Supple, No LAD, unable to appreciate JVP CARDIAC: slightly tachycardic, regular rhythm, no appreciable murmur LUNGS: decreased breath sounds at the bases, no appreciable wheezing or crackles ABDOMEN: Obese, slightly distended but soft, umbilical hernia with palpable hard mass and what feels like gas filled bowel, diffuse tenderness to palpation, positive bowel sounds, no rebound or gurding. EXTREMITIES: 1+ pitting edema to the knees bilaterally, trace dp's bilaterally, cool extremities. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**2-11**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2191-5-16**] 06:00AM URINE RBC-[**12-30**]* WBC-[**12-30**]* BACTERIA-MOD YEAST-NONE EPI-0-2 [**2191-5-16**] 06:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2191-5-16**] 06:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2191-5-16**] 06:00AM PLT COUNT-292# [**2191-5-16**] 06:00AM NEUTS-89.8* LYMPHS-6.6* MONOS-2.4 EOS-1.0 BASOS-0.2 [**2191-5-16**] 06:00AM WBC-13.8* RBC-4.05* HGB-12.3 HCT-36.1 MCV-89 MCH-30.3 MCHC-34.0 RDW-14.6 [**2191-5-16**] 06:00AM URINE GR HOLD-HOLD [**2191-5-16**] 06:00AM URINE HOURS-RANDOM [**2191-5-16**] 06:00AM CALCIUM-10.3* PHOSPHATE-5.2* MAGNESIUM-2.0 [**2191-5-16**] 06:00AM CK-MB-NotDone proBNP-1820* [**2191-5-16**] 06:00AM cTropnT-<0.01 [**2191-5-16**] 06:00AM LIPASE-11 [**2191-5-16**] 06:00AM ALT(SGPT)-26 AST(SGOT)-31 CK(CPK)-47 ALK PHOS-139* TOT BILI-0.4 [**2191-5-16**] 06:00AM estGFR-Using this [**2191-5-16**] 06:00AM GLUCOSE-104 UREA N-40* CREAT-1.1 SODIUM-137 POTASSIUM-4.6 CHLORIDE-96 TOTAL CO2-32 ANION GAP-14 [**2191-5-16**] 07:38AM freeCa-1.26 [**2191-5-16**] 07:38AM O2 SAT-85 CARBOXYHB-2 MET HGB-0 [**2191-5-16**] 07:38AM GLUCOSE-145* LACTATE-0.7 [**2191-5-16**] 07:38AM O2-100 PO2-58* PCO2-66* PH-7.32* TOTAL CO2-36* BASE XS-4 AADO2-589 REQ O2-97 [**2191-5-16**] 12:26PM D-DIMER-As of [**1-11**] [**2191-5-16**] 12:26PM PT-12.6 PTT-22.5 INR(PT)-1.1 [**2191-5-16**] 12:26PM D-DIMER-1750* [**2191-5-16**] 12:26PM CK-MB-7 cTropnT-<0.01 [**2191-5-16**] 12:26PM CK(CPK)-41 [**2191-5-16**] 09:00PM TYPE-[**Last Name (un) **] TEMP-37 O2-40 PO2-161* PCO2-49* PH-7.43 TOTAL CO2-34* BASE XS-7 INTUBATED-INTUBATED VENT-CONTROLLED . CXR ([**2191-5-16**]): Worsening left mid to lower lung opacity which likely is a combination of atelectasis, and/or pneumonia with superimposed effusion. No evidence of pulmonary edema. . CXR ([**2191-5-16**]): The current study demonstrates rapid development of bilateral widespread parenchymal opacities, consistent with rapidly developed moderate-to-severe pulmonary edema. The study is technically limited, and the lung bases were only partially included in the field of view, but bilateral pleural effusion is most likely present. The patient is after prior cardiac surgery. Tracheostomy tip is at the midline. No pneumothorax is seen. . LENI ([**2191-5-16**]): No DVT of the lower extremities. . CT Abdomen/Pelvis ([**2191-5-17**]): 1. Mild dilation of ileal small bowel loops with transition point near an umbilical hernia represents at least partial small-bowel obstruction. Early complete obstruction is a less likely possibility. 2. Stable extensive coronary artery atherosclerotic calcification and post CABG changes. 3. Pulmonary artery enlargement suggestive of pulmonary artery hypertension is unchanged since [**2191-1-3**]. 4. No evidence of pneumonia. Brief Hospital Course: 54 yo F with PMH sarcoidosis, tracheostomy [**3-14**] upper airway obstruction, dCHF, DM1, pulmonary HTN, CAD, morbid obesity presenting with dyspnea, nausea and vomiting. The following issues were investigated during this hospitalization: . #Dyspnea: Multiple hospitalizations for similar complaints and patient has always been approached from a multifactorial treatment strategy with Lasix, Steroids and nebulizers. During this hospitalization, she was given Lasix for pulmonary edema seen on CXR with gradual improvement. Overall etiology was felt to be pulmonary flash edema in the setting of hypertension. She was also suctioned through her trach and sputum was sent off for culture. Sparse growth of MRSA and pseudomonas was noted, but since patient was improving without antibiotics, had no clinical signs of pneumonia and only had sparse growth, she was not treated. Patient was called out to the floor where she continued to improve and was discharged home. . #.Nausea/Vomting: Felt to be due to gastroparesis in this patient with long-standing type 1 DM. Patient's symptoms improved with antiemetics. Medications on Admission: cozaar 25mg daily Citalopram 20 mg PO DAILY Fluticasone-Salmeterol 250-50 mcg/Dose one inh [**Hospital1 **] Multivitamin PO DAILY Omeprazole 20 mg PO BID Calcium Carbonate 500 mg PO DAILY Aspirin 81 mg PO DAILY Simvastatin 10 mg PO DAILY Benztropine 1 mg PO TID Metoprolol Succinate 100 mg PO DAILY Docusate Sodium 100 mg PO BID Psyllium One (1) Packet PO TID as needed for constipation. Clopidogrel 75 mg PO DAILY Senna 8.6 mg One (1) Tablet PO BID as needed. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: Five (5) ML Miscellaneous Q6H (every 6 hours) as needed for secretions. Hydrocodone-Acetaminophen 5-500 mg 1-2 Tablets PO Q8H prn Gabapentin 300 mg PO Q12H Lorazepam 2 mg TabletPO HS prn insomnia. Metoclopramide 20 mg Tablet AT BREAKFAST & DINNER Metoclopramide 10 mg One (1) Tablet PO AT LUNCH AND AT NIGHT (). Albuterol Nebulization One Inhalation Q6H prn Lasix 40 mg PO once a day Glargine 38 units, HISS Discharge Medications: 1. Losartan 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO TID (3 times a day). 6. Simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 8. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 9. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation QID (4 times a day). 10. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 11. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID (3 times a day) as needed. 12. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 14. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day). 15. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 16. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO DAILY (Daily). 17. Hydrocodone-Acetaminophen 5-500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 18. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 19. Slow-Mag 64 mg Tablet Sustained Release [**Last Name (STitle) **]: Three (3) Tablet Sustained Release PO twice a day. 20. Benztropine 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a day. 21. Psyllium Packet [**Last Name (STitle) **]: One (1) Packet PO TID (3 times a day) as needed for constipation. 22. Lorazepam 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 23. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) mL Injection three times a day. 24. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 25. Acetylcysteine 20 % (200 mg/mL) Solution [**Last Name (STitle) **]: Five (5) mL Miscellaneous every six (6) hours as needed for secretions. 26. Insulin Please resume your previous insulin regimen. 27. Nystatin 100,000 unit/g Powder [**Last Name (STitle) **]: apply powder Topical twice a day: Apply to skin folds at site of fungal infection. Keep area dry. Disp:*1 bottle* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Pulmonary Flash Edema Hypertensive Urgency Discharge Condition: Stable Discharge Instructions: You were seen and evaluated for shortness of breath. It's not entirely clear what this was due to, but was probably a combination of congestive heart failure and inflammation of the airways. This has now improved and you are being discharged home. Take all of your medications as directed. There were no changes to your medications. Keep all of your follow-up appointments. Call your doctor or go to the ER for any of the following: chest pain, shortness of breath, fevers/chills, nausea/vomiting/diarrhea or any other concerning symptoms. Followup Instructions: Call your primary care physician to schedule [**Name Initial (PRE) **] follow-up appointment within one week of your discharge.

[ "V55.0", "250.41", "536.3", "518.81", "428.0", "278.01", "428.32", "135", "401.0", "596.54", "346.90", "362.01", "250.51", "250.61", "272.4", "357.2", "416.8", "583.81", "599.0", "786.3", "493.90", "514" ]

icd9cm

[ [ [] ] ]

[ "96.71", "97.23" ]

icd9pcs

[ [ [] ] ]

12645, 12651

7589, 8702

343, 365

12738, 12747

4676, 7566

13338, 13469

3488, 3603

9682, 12622

12672, 12717

8728, 9659

12771, 13315

3618, 4657

296, 305

393, 2479

2501, 3127

3143, 3472

60,046

107,141

41168

Discharge summary

report

Admission Date: [**2133-4-8**] Discharge Date: [**2133-4-12**] Date of Birth: [**2068-5-1**] Sex: F Service: CARDIOTHORACIC Allergies: environmental Attending:[**First Name3 (LF) 1505**] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [**2133-4-8**] Mitral Valve Repair, PFO closure History of Present Illness: 64 year old female who was found to have a new heart murmur on physical exam in [**Month (only) 1096**]. An echocardiogram was performed which revealed severe posterior leaflet mitral valve regurgitation. She was referred to Dr. [**Last Name (STitle) 1655**] who performed a cardiac catheterization which showed no significant coronary artery disease however it confirmed severe mitral regurgitation noting severe pulmonary hypertension. Given the severity of her mitral valve disease, she has been referred for surgery. She presents today for pre-admission testing prior to surgery. Past Medical History: Mitral regurgitation Migraine headaches Arthritis Tubal ligation Periodontal surgery Social History: Race: Caucasian Last Dental Exam: Recently, undergoing extractions Lives with: Widowed x3 years. 2 Children. Lives in [**Location 47**]. Occupation: Admistrative Assistant Tobacco: [**2-15**] ppd quit in [**2098**] ETOH: None Family History: Noncontributory Physical Exam: Pulse: 62 O2 sat: 98% B/P Left: 137/80 Height: 5'3" Weight: 126lbs General: NAD 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 4/6 SEM radiating to carotids Abdomen: Soft [x] non-distended [x] non-tender [x]+ BS [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: Grossly intact- nonfocal exam 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- referred murmur Pertinent Results: [**4-8**] Echo: Pre Bypass: The left atrium is mildly dilated. No mass/thrombus is seen in 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. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The ascending aorta is mildly dilated and the st junction appears partially effaced. There are three aortic valve leaflets. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are myxomatous. There is partial Posterior mitral leaflet flail of P2 and possibly part of P3 with a torn chordae seen. An eccentric, anteriorly directed jet of Moderate to severe (3+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). Post Bypass: Patient is in sinus rhythm on phenylepherine infusion. There is a partial annuloplasty ring on the mitral valve, which is also status post partial posterior leaflet resection. There is trace/minimal mitral regurgitation. Peak mitral gradients 4, mean 1 mm Hg. AI remains mild. TR remains mild. PFO is now has tiny flow from left to right s/p closure. LVEF 50-55%. Aortic contours intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [**2133-4-12**] 06:35AM BLOOD WBC-5.2 RBC-2.82* Hgb-9.2* Hct-26.7* MCV-95 MCH-32.7* MCHC-34.6 RDW-14.2 Plt Ct-103* [**2133-4-8**] 01:43PM BLOOD WBC-8.1 RBC-2.14*# Hgb-6.9*# Hct-20.2*# MCV-94 MCH-32.1* MCHC-34.1 RDW-14.1 Plt Ct-94*# [**2133-4-12**] 06:35AM BLOOD PT-20.4* INR(PT)-1.9* [**2133-4-8**] 01:43PM BLOOD PT-15.3* PTT-36.6* INR(PT)-1.3* [**2133-4-12**] 06:35AM BLOOD UreaN-8 Creat-0.5 Na-138 K-3.5 Cl-102 [**2133-4-8**] 02:55PM BLOOD UreaN-10 Creat-0.4 Na-141 K-4.1 Cl-118* HCO3-20* AnGap-7* Brief Hospital Course: Ms. [**Known lastname **] was a same day admit after undergoing pre-operative work-up as an outpatient. On [**4-8**] she was brought to the operating room where she underwent a Mitral valve repair with a triangular resection of the middle scallop of the posterior leaflet/Mitral valve annuloplasty with a 28 mm Physio II ring/ Closure of PFO with Dr.[**Last Name (STitle) **]. Please refer to operative report for further details.She tolerated the procedure well and was transferred to the CVICU for further invasive monitoring in stable condition. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. Beta blockade and aspirin were resumed. All lines and drains were discontinued in a timely fashion. She was gently diuresed towards her preoperative weight. She continued to progress and was transferred to the step down unit for further monitoring on POD#1. The physical therapy service was consulted for assistance with her postoperative strength and mobility. On POD#2 she went into postoperative atrial fibrillation. She was administered Amiodarone and became bradycardic. Amiodarone was discontinued and her home medication, Nadolol, was resumed. Her atrial fibrillation was rate controlled and she was asymptomatic. After 24 hours of remaining in Atrial fibrillation anticoagulation was initiated with Coumadin. She continued to make steady progress and was discharged home on postoperative day #4. All follow up appoinments were advised. Medications on Admission: Nadolol 20mg daily Imitrex Vitamins Calcium Discharge Medications: 1. furosemide 20 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO once a day for 5 days. Disp:*5 [**Last Name (STitle) 8426**](s)* Refills:*0* 2. potassium chloride 10 mEq [**Last Name (STitle) 8426**] Extended Release Sig: Two (2) [**Last Name (STitle) 8426**] Extended Release PO once a day for 5 days. Disp:*10 [**Last Name (STitle) 8426**] Extended Release(s)* Refills:*0* 3. aspirin 81 mg [**Last Name (STitle) 8426**], Delayed Release (E.C.) Sig: One (1) [**Last Name (STitle) 8426**], Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 [**Last Name (STitle) 8426**], Delayed Release (E.C.)(s)* Refills:*2* 4. ranitidine HCl 150 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO BID (2 times a day). Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*2* 5. warfarin 1 mg [**Last Name (STitle) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] Once Daily at 4 PM: INR goal =[**3-19**] for postop Atrial Fibrillation. Disp:*90 [**Month/Day (3) 8426**](s)* Refills:*2* 6. warfarin 2.5 mg [**Month/Day (3) 8426**] Sig: One (1) [**Month/Day (3) 8426**] PO once a day for 2 days: 2.5 mg po today [**2133-4-12**] and 1 tab po [**2133-4-13**] . Disp:*2 [**Month/Day/Year 8426**](s)* Refills:*0* 7. nadolol 20 mg [**Month/Day/Year 8426**] Sig: Two (2) [**Month/Day/Year 8426**] PO DAILY (Daily). 8. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:*qs ML(s)* Refills:*0* 9. potassium chloride 20 mEq [**Month/Day/Year 8426**], ER Particles/Crystals Sig: One (1) [**Month/Day/Year 8426**], ER Particles/Crystals PO once a day for 5 days. Disp:*5 [**Month/Day/Year 8426**], ER Particles/Crystals(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Mitral regurgitation and PFO s/p Mitral Valve repair and PFO closure Past medical history: Migraine headaches Athritis s/p Tubal ligation s/p Periodontal surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] #[**Telephone/Fax (1) 170**], office will call you to arrange follow up appointment at MWMC Cardiologist: Dr. [**Last Name (STitle) 1655**] #[**Telephone/Fax (1) 6256**] -office will call you to arrange follow up appointment Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 349**] in [**5-19**] 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** [**Hospital 197**] Clinic at MWMC to be arranged for INR/Coumadin dosing INR 1st draw by VNA on Tues:[**2133-4-14**], Please call INR results to [**Hospital 88272**] [**Hospital 197**] Clinic# main number= [**Telephone/Fax (1) 6256**] INR goal [**3-19**] Indication: postoperative Atrial Fibrillation Completed by:[**2133-4-12**]

[ "427.89", "997.1", "745.5", "E942.0", "424.0", "346.90", "429.5", "427.31", "416.8" ]

icd9cm

[ [ [] ] ]

[ "35.71", "39.61", "35.12" ]

icd9pcs

[ [ [] ] ]

7436, 7495

4066, 5550

291, 340

7701, 7927

1998, 4043

8850, 9773

1320, 1337

5644, 7413

7516, 7586

5576, 5621

7951, 8827

1352, 1979

239, 253

368, 953

7608, 7680

1077, 1304

13,430

163,891

14812

Discharge summary

report

Admission Date: [**2127-10-8**] Death Date: [**2127-11-12**] Date of Birth: [**2080-6-25**] Sex: M Service: BLUE SURGERY PRESENT ILLNESS: A 47-year-old male from [**Country 3397**] presented with pruritus, nausea, diarrhea, ACOG stools and jaundice. An endoscopy and CT scan performed in [**Country 3397**] approximately one year ago showed leiomyoma of the stomach. On [**10-1**], the patient presented at [**Hospital 43512**] Hospital Medical intrahepatic and extrahepatic bile ducts. No extrahepatic disease was seen. An endoscopy at the outside institution showed a mass along the duodenum involving the ampulla of Vater. Pathology of that mass revealed invasive moderately well differentiated adenocarcinoma. An ERCP was done at that time and a stent was placed. The patient was transferred to the [**Hospital6 256**] for surgical PAST MEDICAL HISTORY: Hepatitis A as a child. PAST SURGICAL HISTORY: Tonsillectomy MEDICATIONS: 1. Tegretol for facial numbness. 2. Atarax 25 mg q4h prn itch 3. Periactin 4 mg po bid 4. Ciprofloxacin 500 mg po bid with two remaining doses 5. Vicodin prn ALLERGIES: No known drug allergies. SOCIAL HISTORY: Two glasses of wine per day, smoking a pack per day since age 15, quit two months ago. PHYSICAL EXAM: VITAL SIGNS: Temperature 99.4??????, heart rate 88, blood pressure 118/64, respiratory rate 16. GENERAL: He was jaundiced. HEAD, EARS, EYES, NOSE AND THROAT: Scleral icterus. COR: Regular rate and rhythm. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended, no hepatosplenomegaly appreciated. No edema. LABORATORY DATA ON ADMISSION: Hematocrit was 40.3. Sodium 139, potassium 4.1, chloride 100, bicarbonate 26, BUN 20, creatinine 0.9, glucose 111, AST 64, ALT 64, alkaline phosphatase 147, bilirubin 10.4, amylase 46. CEA is 3.0 and CA19-9 was 15. HOSPITAL COURSE: The patient went to the Operating Room on [**10-10**] and had a pylorus bearing Whipple performed. At this time, a cholecystectomy was performed as well. A replaced right hepatic artery injured during the procedure and a gastroduodenal artery interposition graft was placed. Postoperatively, the patient was transferred to the floor for surgical care. There, his hematocrits were stable. He had a temperature spike and those original cultures were negative. He was placed on subcutaneous heparin for prophylaxis, as well as on Protonix. His pain was controlled with intravenous Dilaudid PCA. The patient continued to do well until [**10-13**] where he was noted to have some tachycardia and abdominal pain. CT scan was done which revealed a large intraabdominal hematoma. On [**10-14**], the patient was brought back to the Operating Room, had an exploratory laparotomy and evacuation of an intraabdominal clot. During this procedure, there was a small bowel enterotomy which was repaired. After that surgery, the patient's hematocrit continued to remain stable. Cultures from the Operating Room revealed [**Female First Name (un) 564**] albicans. The patient was started on fluconazole at that time. Multiple ultrasounds were obtained of the liver which revealed good flow in the right and left hepatic arteries. The patient's cultures continued to be followed and a repeat CT scan was obtained on [**10-18**]. There was a moderate fluid collection. He started to grow out gram negative rods and micrococcus. At that point, he was started on Zosyn and vancomycin. Due to increased JP output, JP amylase was sent and this revealed a value of 29,000. Repeat ultrasounds were obtained which revealed a small amount of peritoneal fluid and no loculated fluid collections. JP fluid was again sent off on [**10-23**] which revealed a bilirubin of 12.1 and an amylase of 4,040. CT scan showed a large amount of fluid in the pelvis. It was decided the patient should be started on octreotide on [**10-23**]. The patient was also started on total parenteral nutrition. This was originally started on [**10-14**] and continued throughout his admission. It was decided to bring the patient back to the Operating Room on [**10-24**] as he continued to have persistent fever spikes and the above noted findings on CT scan. Procedure performed was an exploratory laparotomy and the findings at the time were intraabdominal hematoma with a breakdown of the pancreaticojejunal anastomosis. At that time, the jejunum was oversewed and a portion of the skin incision was left open and a portion was closed with Marlex mesh. The patient remained stable and on his antibiotics of Zosyn, fluconazole and vancomycin. The TPN was continued. The patient was then brought back to the Operating Room on [**10-31**] to remove the Marlex mesh and perform a wound debridement. The wound was then closed with a Marlex mesh. The patient was transferred to the floor for surgical care for this. His repeat cultures revealed no growth. He was essentially on the floor for a 10 day period of time where he was receiving wet to dry dressing changes to the skin incision. The Marlex mesh was used to close the fascia. The patient was doing well until [**11-10**] where he was found to be in extremis. A code was called and he was in PEA for a short period of time where he was given epinephrine and atropine. He then regained a pulse and was tachycardic to 140s and his blood pressures were in the 70s. He was brought emergently to the Operating Room where an exploratory laparotomy was performed. No definitive ............... bleeding was performed, though a large amount of intraabdominal clot was evacuated. His hematocrits continued to drop and on [**11-11**] he was brought to angiogram where it was revealed that there was extravasation from the right hepatic artery. Three coils were placed. The patient received large amounts of packed red blood cells and FFP transfusion during this time for continued dropped hematocrits. After his first angiogram, his [**Location (un) 1661**]-[**Location (un) 1662**] drain continued to have large amounts of sanguinous output. He was returned to angiogram where an additional coil was placed in the right hepatic artery as extravasation was seen. After this procedure he was stable for a short period of time until another liter of blood was seen in his [**Location (un) 1661**]-[**Location (un) 1662**] drains. He was brought back down to the angiography suite early on the morning of [**11-12**]. It was very difficult to cannulate his right hepatic artery and the intervention at the time was relatively unsuccessful. He was transferred back to the Intensive Care Unit where his hematocrits kept dropping. His acidosis progressively worsened. At that time, a family meeting was held with Dr. [**Last Name (STitle) **] and the patient's family. It was decided that the patient should be made comfort measures only. All support was removed at approximately 4 a.m. on [**11-12**]. The patient expired at approximately 5:15 on the morning of [**11-12**]. A postmortem will be obtained. DISCHARGE DIAGNOSES: 1. Status post Whipple for adenocarcinoma of ampulla of Vater which was moderately well differentiated and invasive. 2. Prolonged hospitalization course complicated by four return trips to the Operating Room and three trips to the angiography suite. The patient expired on [**11-12**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Name8 (MD) 1308**] MEDQUIST36 D: [**2127-11-12**] 11:50 T: [**2127-11-12**] 14:20 JOB#: [**Job Number 43513**]

[ "998.11", "152.0", "285.1", "998.6", "998.12", "518.5", "197.8", "998.2", "575.12" ]

icd9cm

[ [ [] ] ]

[ "88.47", "45.02", "45.13", "52.7", "51.22", "38.46", "54.19", "99.29", "54.63", "99.15", "03.90", "50.11", "54.3", "46.73" ]

icd9pcs

[ [ [] ] ]

7046, 7591

1881, 7025

936, 1166

1286, 1630

1645, 1863

887, 912

1183, 1271

42,715

189,186

38164

Discharge summary

report

Admission Date: [**2164-8-3**] Discharge Date: [**2164-9-4**] Date of Birth: [**2144-10-18**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: MVC Major Surgical or Invasive Procedure: [**2164-8-8**] trach/PEG/IVCF [**2164-8-3**] R Craniectomy History of Present Illness: 19 y/o male s/p roll-over MVC, driver, ejected, unknown restraint, unresponsive on EMS arrival. Taken to OSH by EMS. Transported with bag-mask ventilation. Exam on admission to OSH fixed pupils and decerebrate posturing, intubated and transferred to [**Hospital1 18**]. Head CT significant for skull fx, SDH, SAH, and midline shift. Pt admitted to TSICU Past Medical History: None Social History: Unknown Family History: Noncontributory Physical Exam: On admission: PHYSICAL EXAM: O: T:101 BP: 136/74 HR: 68 R 20 O2Sats 100% ET intubated Gen: Intubated, sedation held HEENT: Pupils: 3 minimal sluggish . R corneal, no L corneal + cough, no gag Neck: hard collar Abd: Soft, NT Extrem: IO in R LE Neuro: Mental status: no EO. Orientation: N/A Motor: extensor posturing b/l UE's. No mvmt LE's to noxious stimuli. Upon discharge: Will spontaneously open eyes. Pupils are equal and reactive. Extensor postures with all 4 extremities. Very rigid. Craniectomy site is C/D/I, area is sunken. Pertinent Results: [**8-3**] CT Head: Subdural, subarachnoid, and intraparenchymal hematoma with cerebral edema, leftward subfalcine herniation, and partial effacement of the basal cisterns. Multiple skull fractures as described above. Due to fracture involvement of the carotid canals bilaterally, recommend carotid CTA for evaluation of potential vascular injury. Temporal bone fractures bilaterally with ossicular disruption in the left middle ear cavity. [**8-3**] CT Spine: No cervical spine fracture or malalignment. ET tube positioned with tip at the thoracic inlet. Recommend advancement. Nasal trumpet in place. Extensive skull base fractures as detailed on concurrently performed head CT. Right upper lobe posterior consolidation also better assessed on CT torso. [**8-3**] CT Torso: L1 superior endplate compression fracture with only minimal loss of vertebral body height. Segmental collapse in the posterior segments of the right upper lobe and left lower lobe likely secondary to aspiration/atelectasis. ET tube tip positioned at the thoracic inlet. Advancement is recommended. NG tube in appropriate position. [**8-4**] CT head: Interval R craniectomy and evacuation of underlying SDH. Minimal residual subdural hyperdense blood products persist. Scattered SAH and parenchymal hemorrhagic contusions in the bilateral vertices and bilateral temporal lobes are grossly stable. New hemorrhage in the R frontal white matter and scattered foci at [**Doctor Last Name 352**]-white interfaces bilaterally likely reflecting diffuse axonal injury. Diffuse parenchymal edema and resultant mass effect with sulcal and ventricular effacement. New impingement upon the L supreasellar cistern is concerning for early uncal herniation. Extensive calvarial and skull base fractures are as previously delineated on the CT report from one day prior. [**8-5**] CXR - Endotracheal tube and feeding tube are in unchanged position. Of note, the proximal port lies near the GE junction. This could be further advanced for optimal placement. There has been placement of a left subclavian central venous line. There is no pneumothorax. The tip lies in the distal SVC. The heart size is unchanged. There is an increasing left retrocardiac opacity as well as probably a small left-sided pleural effusion. Partial right upper lobe atelectasis is nearly resolved. [**8-8**] CXR - Tracheostomy tube positioned 8.1 cm above the carina. Bilateral pleural effusions and bibasilar atalectasis, slightly worsened on the right. There appears to be relatively increased density to the entire right lung relative to the left, but this appears to be partially due to asymmetrically-placed overlying sheets. A repeat radiograph can be obtained if there is any concerning new asymmetry of breath sounds on examination. There is no pneumothorax seen. [**8-8**] CT head - IMPRESSION: Increased number and amount of hyperdense foci with surrounding hypodensity in the frontal, parietal and temporal lobes consistent with contusion, increased subdural fluid collection layering along the falx, significantly increased right hemispheric mass effect, opacification of bilateral mastoids. [**8-11**] Head MRI- IMPRESSION: 1. Extensive diffuse axonal injury in the corpus callosum bilaterally, the inferior frontal lobes bilaterally, and the left cerebral hemisphere. 2. Extensive bilateral hemorrhagic contusions with associated subarachnoid hemorrhage. 3. Unchanged extent of cerebral herniation through the large right craniotomy defect, with unchanged rightward shift of midline structures and associated distortion of the supratentorial ventricles. 4. Unchanged right anterior parafalcine subdural collection. [**8-15**] LENIS: No DVT [**8-20**] CTA Chest: No PE [**8-26**] LENIS: No DVT Brief Hospital Course: Patient was called in as a STAT trauma and brought to the trauma bay for management. He had been intubated on scene and had a gcs of 4t on arrival. He was admitted to the TSICU for management of his neurological injuries and a bolt was placed by the neurosurgical service until the patient could be taken to the operating room for a hemicraniectomy. [**8-3**]: Pt admitted to TSICU, bolt placed and ICP noted to be in the 40s. Pt taken to the OR for emergent RIGHT craniotomy for elevated ICP (40s) noted after bolt placed at bedside. Intra-op EBL estimated to be 4000 mL. Pt received 2100 mL pRBC, 1668 mL FFP, and 4700 mL crystalloid. Factor 7A also given. Required pressure support with phenylephrine bolus and gtt, epinephrine bolus, and norepinephrine gtt. [**Name (NI) **] pt with tachycardia and stable b/p. Lopressor given to decrease hr with good effect. Pt ICPs post-op have ranged from mid-teens to 20s. Neuro exam stable. [**8-4**] patient continues to be unresponsive, though neuro exam waxes and wanes with decorticate posturing and occasional withdrawal to pain. Started on Keppra and continued mannitol. Patient undergoing video EEG. Had slowly falling hematocrit and recieved 2 units pRBCs. [**8-5**] Unchanged neuro exam, occasional posturing. Fever > 101, arctic sun was applied, after couple of hours patient developed shivering, arctic sun was discontinued. Temperature remained less 101. New L SCV CVL placed, femoral CVL removed. EEG continued for another 24 hours. Pan cultured. [**8-6**] Unchanged neuro exam. Fever to 102.6, cultures sent, antibiotics started, arctic sun applied. Pt with shivering, propfol not sufficient, cisatracurium gtt added. [**8-7**] Decreased oxygen saturations in the morning. Obtained CXR that showed RLL infiltrate/collapse. Bronchoscopy was performed with copious thick secretions in right mainstem and down. BAL sent. Started on PCV ventilation. [**8-8**] - OR for trach/ PEG/ IVC filter, off paralysis in am, bronched - lots of thick yellow secretions, CT head, febrile at night, on arctic sun again, after an hour shivering, paralyzed now [**8-9**] cisatracurium changed to vecuronium IV bolus PRN for shivering [**8-10**] paralytics were discontinued. [**8-11**] Pt was hypertensive into the 170's on triple therapy therefore a nipride gtt was initiated. Staples were removed and an MRI was obtained which revealed extensive [**Doctor First Name **] and hemorrhagic contusions. [**8-13**] Pt was stable off ventilator and nipride gtt. [**8-14**] Neurologically and medically stable. Cleared for transfer to stepdown unit. TLSO and Helmet ordered. [**8-15**] Pt remained stable. PT and OT consulted pending helmet/brace arrival. LENI's ordered for routine screening were negative. [**8-16**] cipro/vaco/ceftaz course for PNA completed. [**8-17**] febrile 102.6 overnight, central line d/ced tip cx, pan cx, ID CONSULT, increased MSO4/Labetalol for poss PAID syndrome, autonomics consult, removed sutures at crani site [**8-19**] vanc 22.7 held pm dose /UA NEG [**8-20**] Autonomia team eval/ LP by IR [**8-21**] Med Consult. [**8-23**] LFT's increasing,per ID-> dc'd all antibxs [**8-24**] afebrile, LFT's improved. [**8-25**] febrile. sent blood cx, u/a, sputum. Baclofen started for spasm [**8-26**] febrile. [**8-27**] R direct tap of epidural space 20cc which finalized as no growth. [**8-30**] Infectious Disease determined there was no infectious process and fevers were central vs. secondary to an autonomic disorder [**8-31**] Rehab screening started [**9-3**] Repeat Head CT to eval for cranioplasty planning: Return to clinic in 4 wks w/head CT then schedule day. **** Patient shows what appears to be an autonomic disorder such as PAID: becomes hypertensive, tachycardia, increased respirations, increased temps (99-100 ax), diaphoretic, extensor posturing. We have been using Morphine/Baclofen/Clonidine to help with symptom management. A Autonomic Disorder consult was done but a the diagnosis of PAID could not be given as it is a diagnosis of exclusion and they felt that all medical work-up would need to be repeated in order for a formal diagnosis. Infectious Disease has cleared patient of an infectious etiology. Medicine was also consulted and could not find a medical reason for symptoms. He is currently managed on the above medications. He was sent to rehab on [**2164-9-4**] Medications on Admission: None Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-21**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Ibuprofen 100 mg/5 mL Suspension Sig: Forty (40) mL PO Q8H (every 8 hours) as needed for fever. 8. Acetaminophen 650 mg/20.3 mL Suspension Sig: One (1) PO Q6H (every 6 hours). 9. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours) as needed for pain. 10. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 17. HydrALAzine 10 mg IV Q6H:PRN hypertension to maintain SBP<160, hold for HR>100 18. Metoprolol Tartrate 10 mg IV Q4H:PRN SBP>160; HR>110 19. 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. 20. Morphine Sulfate 1-2 mg IV Q2H:PRN pain hold for RR < 12 Discharge Disposition: Extended Care Facility: [**Hospital3 1122**] Center - [**Hospital1 3597**] Discharge Diagnosis: Right Subdural Hematoma Multiple Brain Contusions Traumatic Brain Injury CSF Leak L1 Burst Fracture Respiratory Failure Discharge Condition: Activity Status: Bedbound. Mental Status: Nonverbal, no commands Level of Consciousness: Opens eyes spont Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, you may safely resume taking this after obtaining approval from your Neurosurgeon. ?????? TLSO brace when HOB > 45 or OOB. Must use helmet when OOB. Please logroll into brace. Followup Instructions: Please follow-up with Dr [**Last Name (STitle) 548**] in 4 weeks with a Head CT without contrast and a CT of the lumbar spine. Please call the Neurosurgery Office at [**Telephone/Fax (1) 2992**] to make this appointment. Completed by:[**2164-9-4**]

[ "780.61", "348.5", "518.5", "E816.0", "401.9", "707.03", "785.0", "337.1", "707.21", "803.15", "805.4" ]

icd9cm

[ [ [] ] ]

[ "43.11", "01.10", "96.72", "38.93", "96.6", "01.59", "33.24", "38.7", "31.1", "03.31", "02.02" ]

icd9pcs

[ [ [] ] ]

11503, 11580

5197, 9559

322, 383

11744, 11771

1429, 1439

12717, 12969

835, 852

9614, 11480

11601, 11723

9585, 9591

11876, 12694

896, 1124

279, 284

1250, 1410

411, 766

2554, 5174

881, 881

11786, 11852

788, 794

810, 819

27,580

111,443

34443

Discharge summary

report

Admission Date: [**2185-7-31**] Discharge Date: [**2185-8-17**] Date of Birth: [**2109-1-31**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: Bronchoscopy s/p repair of incarcerated ventral hernia w/o necrotic bowel ([**7-30**]) at OSH Tracheostomy PICC History of Present Illness: 76 F originally presented to [**Hospital1 **] ER with ambdominal pain and distension, known umbilical hernia, underwent open repair of incarcerated hernia (no necrotic bowel) on HD2, on HD3 (POD2) patient went into respiratory failure requiring intubation and ventilation, and was transferred here. Past Medical History: (1) Type II DM (2) Hypertension (3) MI x 2 (4) morbid obesity Social History: not available Family History: not available Physical Exam: V/S: 100.3, 90 131/69, 16, 95% RA Neuro: sedation c propofol CV: RRR Pulmonary: intubated, low O2 sats in the 90%. Abdomen: obeses, soft abdomen, incision [**Last Name (un) **] and intact. Abd binder in place. NGT in place Ext: +2 edema bilat Pertinent Results: [**2185-7-31**] 02:46PM BLOOD WBC-9.5 RBC-3.73* Hgb-11.1* Hct-34.7* MCV-93 MCH-29.7 MCHC-32.0 RDW-14.2 Plt Ct-297 [**2185-8-8**] 03:32AM BLOOD WBC-14.9* RBC-3.13* Hgb-9.5* Hct-28.7* MCV-92 MCH-30.3 MCHC-33.1 RDW-13.8 Plt Ct-333 [**2185-8-16**] 06:05AM BLOOD WBC-11.4* RBC-3.35* Hgb-10.2* Hct-32.0* MCV-96 MCH-30.4 MCHC-31.9 RDW-14.3 Plt Ct-493* [**2185-8-16**] 06:05AM BLOOD Glucose-174* UreaN-36* Creat-1.1 Na-144 K-4.1 Cl-104 HCO3-32 AnGap-12 [**2185-8-16**] 06:05AM BLOOD Calcium-9.2 Phos-5.8* Mg-2.5 [**2185-7-31**] 02:46PM BLOOD Triglyc-190* [**2185-8-5**] 02:00AM BLOOD TSH-2.6 . Radiology Report CHEST (PORTABLE AP) Study Date of [**2185-7-31**] 3:27 PM FINDINGS: In comparison with the earlier study of this date, there is little overall change in the appearance of the right hemithorax. There is still extensive opacification along the right side of the trachea. For further evaluation, CT would be required. . Radiology Report CHEST (PORTABLE AP) Study Date of [**2185-8-5**] 7:43 AM IMPRESSION: Little change. . Radiology Report CHEST (PORTABLE AP) Study Date of [**2185-8-9**] 4:29 AM FINDINGS: In comparison with the study of [**8-8**], there is little change in the appearance of the endotracheal tube. Nasogastric tube extends well into the stomach. There is enlargement of the cardiac silhouette with some vascular engorgement consistent with elevated pulmonary venous pressure. Atelectatic changes are seen at the bases and there are also small pleural effusions. . Radiology Report PORTABLE ABDOMEN Study Date of [**2185-8-12**] 6:53 PM Final Report HISTORY: Assess position of nasogastric tube. Single portable radiograph of the abdomen excludes the right lateral hemithorax and right lateral abdomen. There is a nasogastric tube present with its tip in the stomach. The visualized bowel is unremarkable. The regional soft tissues are unremarkable. . [**2185-8-16**] 06:05AM BLOOD WBC-11.4* RBC-3.35* Hgb-10.2* Hct-32.0* MCV-96 MCH-30.4 MCHC-31.9 RDW-14.3 Plt Ct-493* [**2185-8-16**] 06:05AM BLOOD Glucose-174* UreaN-36* Creat-1.1 Na-144 K-4.1 Cl-104 HCO3-32 AnGap-12 [**2185-8-16**] 06:05AM BLOOD Calcium-9.2 Phos-5.8* Mg-2.5 [**2185-7-31**] 02:46PM BLOOD Triglyc-190* Brief Hospital Course: This is a 76 F transferred from [**Hospital1 **] [**Location (un) 620**] s/p repair of incarcerated ventral hernia w/o necrotic bowel on [**7-30**], with acute respiratory decompensation @ [**Location (un) 620**], requiring intubation. Transferred for further management. Possible h/o aspiration perioperatively. Resp: She was transferred here intubated and sedated. She had partial right lung collapse and atelectasis. A Bronchoscopy showed some mucous plugs. She continued with aggressive pulmonary toilet and the ICU team was attempting to wean. She was trach'd on [**8-9**] after having difficulty weaning. On [**8-7**] BAL - staph aureus coag +, 3+ GPCs - Nafcillin sensitive. This was switched to Augmentin and should continue thru [**2185-8-20**]. She was then transitioned to a trach mask and was tolerating a Passe Muir Valve. CV: Stable with frequent PVC's. Continue with Lopressor. GI/ABD: She was NPO with NGT in place. She was started in tubefeedings via the NGT. She was evaluate by Speech and Swallow and started on pureed solids and thin liquids. Her incision was C/D/I with steri strips in place. Renal: After receiving initial fluid resuscitation, she was then diuresis with Lasix. Continue with diuresis as needed. Endo: She required insulin for post-op hyperglycemia. As she is able to tolerate more PO's, her home PO diabetic meds can be restarted and the NPH can be weaned down. Activity: She will continue to need PT as she had a prolonged ICU course and is morbidly obese. Medications on Admission: Insulin 38U qhs, HCTZ 25', procardia 30', amitriptyline 100', atenolol 100', plavix 75', synthroid 150', zocor 40', glyburide ER 10'', cozaar 50', isosorbide Mon (120 qam, 60 qhs), metformin 500'' Discharge Medications: 1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed. 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation QID (4 times a day). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 11. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days. 12. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection ASDIR (AS DIRECTED). 13. Furosemide 10 mg/mL Solution Sig: Two (2) Injection DAILY (Daily). 14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty Five (35) units Subcutaneous twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: incarcerated ventral hernia w/o necrotic bowel subsequent acute respiratory decompensation requiring tracheostomy Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily. * No heavy lifting (>[**10-26**] lbs) until your follow up appointment. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in [**3-15**] weeks. Call [**Telephone/Fax (1) 1231**] to schedule an appointment. Completed by:[**2185-8-17**]

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icd9cm

[ [ [] ] ]

[ "99.21", "96.6", "33.24", "96.72", "31.1", "38.93" ]

icd9pcs

[ [ [] ] ]

6448, 6520

3415, 4922

333, 447

6678, 6685

1201, 3392

8058, 8224

908, 923

5169, 6425

6541, 6657

4948, 5146

6709, 8035

938, 1182

274, 295

475, 776

798, 861

877, 892

27,540

180,802

32016

Discharge summary

report

Admission Date: [**2126-9-12**] Discharge Date: [**2126-9-15**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7223**] Chief Complaint: syncope Major Surgical or Invasive Procedure: Pacemaker dual chamber placement History of Present Illness: Brother [**Name (NI) **] is an 86-year-old male with a history of paroxysmal atrial fibrillation, CHF and dementia who was reported to have a syncopal episode at home on [**2126-9-11**]. History was obtained from Father [**Name (NI) 74998**] [**Name (NI) **] who is one of his caretakers and designated [**Name (NI) 18133**]. It was reported that Brother [**Name (NI) **] was in his usual state of health that morning when he suddenly slumped over in his wheelchair. He became unresponsive and "turned white." He was noted to be diaphoretic with open, non-tracking eyes. He remained unresponsive for ~5 minutes, during which time the priests [**Name (NI) 74999**] him. By the time EMS arrived, he had regained consciousness and had started babbling incoherently. . He was found by EMS to have 10 second pauses without a QRS complex so EMS externally paced him and transported him to the [**Location (un) **] ED. He had a transvenous pacer placed through the right subclavian vein. He is [**Age over 90 **]% paced with a rate of 70. . 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, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1) Paroxysmal atrial fibrillation 2) CHF 3) Esophogeal strictures, s/p unsuccessful balloon dilation in [**April 2126**] 4) CHB 5) Hypertension 6) Dementia 7) BPH 8) CRI, baseline Cr 1.6 Social History: Social history is significant for the absence of current or historical tobacco use. There is no history of alcohol abuse. Patient resides in St. [**Doctor First Name 75000**] Priory. Family history is non-contributory for history of premature coronary artery disease or sudden death. . Family History: nc Physical Exam: VS: T 96.9, BP 111/51, HR 70, RR 23, O2 94% on 2L NC Gen: cachectic elderly male in NAD, resp or otherwise, supine in bed. Oriented to person only but knows he's here for a pacemaker. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with no JVD. CV: PMI located in 5th intercostal space, midclavicular line. RR, with audible S1, S2. No S4, no S3. Chest: + scoliosis. Diffuse rhonchi with decreased breath sounds bilaterally. Abd: 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 Pertinent Results: EKG demonstrated v-pacing at rate of 60, with occasional evidence of intrinsic escape rhythm. TELEMETRY demonstrated: v-pacing at rate of 60 . 2D-ECHOCARDIOGRAM performed on [**9-12**] demonstrated: The left atrium is normal in size. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9 cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-18**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . CXR: Elevation of the left hemidiaphragm with loops of bowel projecting over the lower left hemithorax. Bilateral pleural effusions. Retrocardiac opacity that could represent combination of atelectasis and pleural effusion. Cannot rule out consolidation. . LABORATORY DATA: WBC 12.5, HCT 33.5, Plt 326 BUN/Cr 38/1.5 14.4/30.3/1.3 Digoxin 0.8 CK 188, MB 11, MBI 5.9, Trop 0.09 Brief Hospital Course: Complete Heart Block: Patient was admitted to the CCU with a complete heart block. His beta blocker and digoxin were held. EP was consulted and patient had a dual chamber pacemaker placed on [**9-13**] without complications. He had his pacemaker interrogated and cx-ray confirmed the placement of his PM. He received antibiotics for a 3 day course. His heart block is presumed to be secondary to sclerodegerative disease. . Atrial Fibrillation: Anticoagulation was held, initially, for pacemaker placement. However despite his [**Country **] 2 score of 3, due to his high fall risk, anticoagulation was discontinued on discharge. . Acute on chronic diastolic heart failure: Pt was mildly fluid overloaded on admission. TEE revealed a preseved EF of >55% and thus his heart failure is presumed to be diastolic in etiology. He was diursed prn with IV lasix. He was euvolemic on discharge. His digoxin was discontinued. . Medications on Admission: 1) Coumadin 1 mg daily 2) Omeprazole 20 mg daily 3) Celebrex 200 mg daily 4) Proscar 5 mg daily 5) Atenolol 50 mg daily 6) Flomax 0.4 mg daily 7) Digoxin 0.125 mg QOD 8) Senna PRN Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 2 days. Disp:*5 Capsule(s)* Refills:*0* 7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Celebrex 200 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home with Service Discharge Diagnosis: Cardiac arrest Complete heart block . Secondary: Chronic renal insufficiency Discharge Condition: Stable Discharge Instructions: You were diagnosed with complete heart block and had a pacemaker placed without complications. Your pacemaker was interrogated (tested) on this admission and was found to be working well. You were also treated with antibiotics for the pacemaker placement. You will need two more days of the antibiotic cephalexin. . Please come to the emergency department or call your PCP if you have any chest pain, shortness of breath, lightheadedness or fevers. . Note that your Coumadin and Digoxin were discontinued. Please do not rerestart them. You were started on Aspirin 325mg daily for your heart. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 11493**] within the next 1 week. His number is [**Telephone/Fax (1) 11650**]. He will direct you to an appointment with device clinic for your new pacemaker. You need to follow up with device clinic in 1 week. . Completed by:[**2126-9-29**]

[ "600.00", "593.9", "427.5", "294.8", "V58.61", "426.0", "427.31", "401.9" ]

icd9cm

[ [ [] ] ]

[ "37.83", "37.72" ]

icd9pcs

[ [ [] ] ]

6424, 6443

4528, 5457

270, 305

6565, 6574

3256, 4505

7216, 7510

2428, 2432

5688, 6401

6464, 6544

5483, 5665

6598, 7193

2447, 3237

223, 232

333, 1897

1919, 2108

2124, 2412

1,859

116,293

25445

Discharge summary

report

Admission Date: [**2168-7-19**] Discharge Date: [**2168-8-2**] Date of Birth: [**2121-6-20**] Sex: F Service: CARDIOTHORACIC Allergies: Amoxicillin / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1505**] Chief Complaint: SOB Major Surgical or Invasive Procedure: Cardiac cath History of Present Illness: 47 year old female with known aortic stenosis was seen at OSH ED for recent development of shortness of breath. In the days preceding her ED visit the patient developed shortness of breath when walking distances or up stairs. Her SOB was associated with chest tightness, dizziness, changes in vision, and on one occurence, loss of urine. There has not been any syncope with these episodes. She saw her PCP the day of her admission where CXR showed CHF and she was then sent to the ED for further work up and diuresis. ECHO in the ED showed critical aortic stenosis. Patient was transferred to [**Hospital1 18**] for cardiac cath in preparation for future valve surgery. Cath showed mild disease in coronaries and critical AS with an aortic valve area of 0.27 and gradient of 26.63. She was also noted to have [**1-10**]+MR, severe pulmonary HTN, LV diastolic heart failure with LVEF of 45-50%. Pressures: RA - 14, RV - 71/19, PA - 71/37, PCWP - 32, AO - 100/54, CO - 2.29, CI - 1.19. Past Medical History: Anxiety Alcohol abuse Back pain Anemia secondary to chronic alcohol use Aortic stenosis Social History: Patient lives with her husband and two sons. She has a 30 ppy tobacco hx, and recurrent alcohol abuse. She has presenty been sober for 8 months, is involved in AA and therapy. Family History: Father - aortic stenosis, bovine valve replacement, multiple CABGs, CHF, CEA Mother - hx of silent MI 3 Siblings - healthy Physical Exam: Vit: T 97.3 HR 85 BP 136/59 RR 20 PO2 95%RA 2L Gen: milddle aged woman, lying flat on bed, in NAD HEENT: MM slightly dry, PERRLA, EOMI Neck: soft, + JVD CV: RR, [**3-13**] blowing holosystolic murmur radiating to the carotids, early diastolic murmur Pulm: CTAB anteriorly, no w/c/r Abd: + BS, soft, NT, ND Ext: no peripheral edema Skin: + telangectasias on face Neuro: AAO x 3, CN II-XII grossly intact Pertinent Results: [**2168-8-2**] 06:10AM BLOOD WBC-7.7 RBC-3.50* Hgb-11.3* Hct-33.9* MCV-97 MCH-32.2* MCHC-33.3 RDW-15.6* Plt Ct-104* [**2168-8-2**] 06:10AM BLOOD PT-21.3* PTT-74.9* INR(PT)-3.0 [**2168-8-2**] 06:10AM BLOOD UreaN-11 Creat-0.8 K-4.3 Brief Hospital Course: Taken to OR on [**2168-7-21**] for AVR (mechanical), found to have significant MAC, therefore, MVR was also done at that time. Post-op course stable, transferred to telemetry floor on POD # 2, started on Coumadin, lopressor and lasix. Heparin gtt initiated on POD # 3. On POD # 6, INR was elevated to 3.5 (from 1.8), but on the following day, she dropped to < 2.0, and heparin was restarted. She remained in the hospital waiting for therapeutic INR. During that time, her lasix and KCl were d/c'd, she progressed with PT, and she is now [**Last Name (un) **] to be discharged home. Her INR today is 3.0. SHe will receive 5 mg on Coumadin today and tomorrow, then have her INR checked, and called to Dr. [**Last Name (STitle) 656**] who will continue dosing for a target INR 3.0-3.5. Medications on Admission: Folate MVI Remeron ASA 81 mg Vit B12 shots 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. 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: 5 mg on [**8-2**] & [**8-3**],then INR to be checked and called to Dr.[**Name (NI) 42421**] office for continued dosing (target INR 3.0-3.5). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: Severe AS, MAC s/p AVR(), MVR()-mechanical Etoh abuse anxiety Discharge Condition: Good. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 2 lbs in one day or five in one week Call with temperature greater than 100.5, redness or drainage froim incision. No driving or lifting more than 10 pounds until follow up appointment. [**Month (only) 116**] shower, wash incision with mild soap and water, pat dry, do not aply lotions, creams or powders, no baths, keep out of the sun. Adhere to 2 gm sodium diet Followup Instructions: Dr. [**Last Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) 656**] 2 weeks Dr. [**Last Name (STitle) **] 2 weeks Completed by:[**2168-8-2**]

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icd9cm

[ [ [] ] ]

[ "89.68", "89.64", "88.56", "99.05", "37.23", "93.90", "35.24", "99.07", "88.53", "35.22", "99.04", "39.61", "88.72" ]

icd9pcs

[ [ [] ] ]

4405, 4443

2492, 3284

304, 318

4549, 4556

2238, 2469

5034, 5181

1662, 1786

3377, 4382

4464, 4528

3310, 3354

4580, 5011

1801, 2218

261, 266

346, 1341

1363, 1452

1468, 1646

42,186

181,043

9915+9916

Discharge summary

report+report

Admission Date: [**2179-7-31**] Discharge Date: [**2179-8-3**] Date of Birth: [**2150-5-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2009**] Chief Complaint: Intentional ingestion Major Surgical or Invasive Procedure: Intubation History of Present Illness: Limited hx obtained from patient because he is a poor historian. Wife not present in the room. Additional hx obtained from ED report and MICU admission note. 29 y.o. male with history of depression and prior suicide attempts who was found unresponsive in his car at work with empty pill bottles. Patient stated around 1400 hours yesterday, he went to [**Location (un) 535**] and "may have bought some sleeping pills." [**Known firstname **] stated he remembers taking "bunch of pills" around 1430 hours while sitting in his car in work parking lot. Patient was last seen at 1500 hours at work. At 1700 hours, he was found in his car in the parking lot with 4 empty pill bottles. 3 were benadryl which he had purchased a few hours before (receipt in the car with him) as well as an empty bottle of unidentified pills. He doesn't recall events afterwards. About 2 weeks ago, he went to his primary care physican endorsing increasing depressive symptoms and SI. [**Known firstname **] stated he was initiated on fluoxetine in [**2-/2179**] by his PCP, [**Name10 (NameIs) **] still struggled with ongoing depression and SI. He has a history of cutting his wrist multiple times in college. Patient was evaluated by a neurologist for twitches, with a negative EEG and pending read on an MRI. His neurologist attributed his symptoms to ADD, and he was started on adderal 3 weeks prior to good effect. [**Known firstname **] is on fluoxetine for depression and adderal for ADD both of which were home. He took his usual dose of fluoxetine and denies overdosing on fluoxetine. . In [**Hospital1 18**] ED, inital vials were: T 98.9, HR 102, BP 145/81, RR 27, 100% on RA. FS 117. He was reported to have roving eye movements, diaphoretic skin, moving to painful stimuli. While he had a gag present, due to concern that he may not be able to protect his airway, he was intubated. Non-contrast CT-H and C-spine were negative. EKG: Vent rate 68 bpm, QRS 110 ms, QTc 484 ms. [**Name13 (STitle) **] was given an of sodium bicarb without EKG changes to see if his QRS narrows. Utox/Serum tox negative. He was admitted to [**Hospital Unit Name 153**] for futher management. . Today, pt was seen and examined at bedside. He was extubated around 0900 hours and currently awake and in no acute distress. He has a blunted affect and has suicidal ideation. He c/o mild throat pain. . Past Medical History: Depression ? Prior Suicide Attempt -- cutting behaviour Myoclonic jerking Social History: Recently married. Social drinker, recently started smoking again. No illicit drug use Family History: Patient's paternal gradfather with a history of depression and suicidal ideation. Father with a history of alcoholism. No other psychiatric illness. Physical Exam: Physical Exam: Vitals: T 96, P 59-84, BP 115-134/63-86, RR 14-22, Pox 99-100% General: Extubated, awake, blunted affect HEENT: NC/AT, Pupils at 5 mm minimally reactive b/l, no nystagmus, Sclera anicteric, moderately dry mmm Neck: Supple, no LAD Lungs: CTAB, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: FROM x 4; Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: No clonus/hyperreflexia, no gross motor/sensory deficit . Pertinent Results: Head CT no contrast:' IMPRESSION: No acute intracranial abnormality, including no acute intracranial hemorrhage. [**2179-7-31**] 07:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2179-7-31**] 07:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG EKG on discharge [**8-2**], normal sinus rhythm. No qt prolongation. Brief Hospital Course: The patient is a 29 year old with a history of depression presenting to ICU with a toxic ingestion. # Overdose: Patient found unresponsive and obtunded, with 3 bottles of benadryl. Toxodrome not consistent with anticholingeric toxicity, however. He had unresponsive pupils and rotary nystagmis consistent with benadryl overdose. Urine and serum oxicology screens negative. Other laboratory studies unremarkable and patient was hemodynamically stable. He was intitially intubated to protect airway and extubated on hospital day 2. EKG was followed for QT prolongation, but normalized by discharge. . # Suicide Attempt: Prior hx of depression and suicidal ideation. He had one-to-one sitter while inpatient. When extubated, psychiatry saw him, and reported pt has major depressive disorder, severe without psychotic features. They felt pt was clearly a danger to self, medically stable and in need of psychiatric placement to initiate comprehensive evaluation and treatment. He met criteria for commitment and was transferred to an inpatient psychiatric facility on HD #3. Medications on Admission: Dextroamphetamine 10mg daily Fluoxetine 40mg daily. Discharge Medications: None Discharge Disposition: Extended Care Discharge Diagnosis: Suicide attempt Depression Acute encephalopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted after an overdose of medication to try to injure yourself. You are being transferred to a psychiatric hospital for care for your depression. . No changes to your medications. . Follow up with your primary care doctor after you leave the hospital. Followup Instructions: Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital 22163**] MEDICAL Address: [**Male First Name (un) 22164**], [**Location (un) **],[**Numeric Identifier 33235**] Phone: [**Telephone/Fax (1) 22166**] Appointment: Tuesday [**2179-8-31**] 11:10am Admission Date: [**2179-8-3**] Discharge Date: [**2179-8-18**] Date of Birth: [**2150-5-22**] Sex: M Service: PSYCHIATRY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9098**] Chief Complaint: Depression leading to a Benadryl overdose (suicide attempt) Major Surgical or Invasive Procedure: Intubation and ventilation History of Present Illness: Mr. [**Known lastname 33236**] is a 29 year-old married man who was brought by EMS on [**2179-7-31**] after he was found unresponsive within his car in his workplace garage and with empty bottle of sleep aid and a newly purchased Benadryl bottle. He needed to be intubated due to unresponsiveness, however notes report he had gag reflex. On [**2179-8-1**] patient was extubated. Toxicology considers that he is medically stable. Patient vital signs have been stable. The patient's wife reported being increasingly concerned about him since last year when she noticed him to be depressed but was very surprised about the severity of his symptoms and the fact that he has had suicidal ideas. Mr. [**Known lastname 33236**] reported that he has not felt well for over 6 months and that back in [**Month (only) 404**] his PCP put him on Fluoxetine at which he was now at 40 mg a day, but denied any improvement. He reported that he has had a hard time finding a psychiatrist to monitor his treatment. He reports having a counselor in [**Location (un) 1475**] with whom he meets every week. He was also put on Adderall recently by a Neurologist to help with symptoms of ADHD. Patient reported that he got to see the neurologist in the first place due to tics. On [**2179-8-3**], Mr. [**Known lastname 33236**] reported depressed mood, crying spells, anhedonia, lack of motivation and energy, pessimistic view of himself. Patient reported that sleep and appetite have been variable and that is why he was also getting sleeping pills. He reported on and off suicidal ideas and yesterday clear intent to kill himself to terminate his life. He reported feeling this way back in High School, and cutting his wrists but reportedly did not need to be hospitalized. Patient denied homicidal ideas, any type of hallucinations, paranoia, alcohol or substance abuse. In [**Hospital1 18**] ED, inital vials were: T 98.9, HR 102, BP 145/81, RR 27, 100% on RA. FS 117. He was intubated. Non-contrast CT-H and C-spine were negative. EKG: Vent rate 68 bpm, QRS 110 ms, QTc 484 ms. [**Name13 (STitle) **] was given an of sodium bicarb without EKG changes to see if his QRS narrows. Utox/Serum tox negative. He was admitted to [**Hospital Unit Name 153**] for futher management and [**Hospital 33237**] transfered to [**Hospital1 **] 4. Past Medical History: Depression ? Prior Suicide Attempt -- cutting behaviour Myoclonic jerking Social History: Recently married. Social drinker, recently started smoking again. No illicit drug use Family History: Patient's paternal gradfather with a history of depression and suicidal ideation. Father with a history of alcoholism. No other psychiatric illness. Physical Exam: PHYSICAL EXAMINATION [**2179-8-3**]: VS T 96, P 80, BP 120/80, RR 16, Pox 99-100% MENTAL STATUS EXAM: --appearance: Young CM, unshaven but otherwise good grooming and good eye contact --behavior/attitude: psychomotor retardation, but cooperative --speech: slowed speech, low volume, no dysarthria or aphasia --mood (in patient's words): "I'm sad." --affect: flat affect, appropriate to mood --thought content (describe): no preoccupations, delusions obvious --thought process: linear, logical, and organized --perception: denies AH, VH --SI/HI: +SI but no current plan, denies HI, verbalizes safety plan --insight: intact, realizes he needs to be hospitalized currently --judgment: fair COGNITIVE EXAM: --orientation: alert to person, place, time, situation --attention/concentration: able to recite days of week forwards and backwards --memory (ball, chair, purple): registers [**4-7**] objects and recalls [**4-7**] --calculations: intact --language: fluent, no aphasia, normal prosody, comprehension intact --fund of knowledge: full --proverbs: provided accurate interpretations of "look before leap," PE: General: appears stated age, NAD HEENT: Normocephalic. PERRL, EOMI. Oropharynx clear. Neck: Supple, trachea midline. No adenopathy or thyromegaly. Back: No significant deformity, no focal tenderness. Lungs: Clear to auscultation; no crackles or wheezes. CV: Regular rate and rhythm; no murmurs/rubs/gallops; 2+ pedal pulses Abdomen: Soft, nontender, nondistended; no masses or organomegaly. Extremities: No clubbing, cyanosis, or edema. Skin: Warm and dry, no rash or significant lesions. Neurological: *Cranial Nerves- I: Not tested II: Pupils equally round and reactive to light bilaterally, 4mm to 2mm. 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 [**6-9**] throughout. No pronator drift *Sensation- Intact to light touch bilaterally *Reflexes- [**Hospital1 **] 2+ Tri 2+ Pa 2+ Ach 2+ bilaterally *Coordination- Normal on finger-nose-finger. Gait intact, able to perform tandem gait. Pertinent Results: [**2179-8-2**] 07:35AM GLUCOSE-76 UREA N-17 CREAT-1.1 SODIUM-144 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-25 ANION GAP-15 [**2179-8-2**] 07:35AM CK(CPK)-123 [**2179-8-2**] 07:35AM CALCIUM-9.0 PHOSPHATE-3.5 MAGNESIUM-2.2 [**2179-8-2**] 07:35AM WBC-9.9 RBC-4.38* HGB-12.8* HCT-38.1* MCV-87 MCH-29.1 MCHC-33.6 RDW-13.4 [**2179-8-2**] 07:35AM PLT COUNT-299 Brief Hospital Course: 1. Psychiatric Upon initial presentation to the unit, patient reported depressed mood, crying spells, anhedonia, lack of motivation and energy, and pessimistic view of himself. The crying spells quickly resolved, but he remained depressed and anhedonic. Due to concerns about possible bipolar disorder, he was switched from Prozac to Lamictal and Seroquel. He was also started on unilateral right sided ECT, three times a week. After bipolar disorder was ruled out, based on history and supported by psychological testing, Lamictal was switched to Effexor and dosing of Seroquel was switched to PRN for sleep and ultimately discontinued. He was started on Low dose trazadone which he tolerated well for sleep. Effexor was chosen to assist with his chronic anxiety, depression, and pain. He tolerated this medication well without side effects. With treatment, patient's mood has improved and he feels less depressed, recognizes his negative thinking, and is no longer suicidal.He is future oriented, and appropriately planning for the future. Patient is open to further therapy and improving coping skills and will continue ECT after discharge. 2. Chronic Pain - On [**8-10**] patient described chronic neck, back, and joint pain (primarily in the hands) that he rates as [**5-15**], flaring to [**9-14**]. Seems to have improved with treatment and patient now rates pain as [**4-14**]. 3. Safety/Behavior - Patient has been pleasant and well behaved throughout stay. Rarely participated in groups but kept busy by [**Location (un) 1131**], writing, and drawing. While on unit, was on 15 minute checks. Patient has expressed desire to live and plans to reserve more time for his interests and take up exercising after discharge. He has also noted desire to continue ECT, see outpatient therapist/psychiatrist, and improve coping skills. 4. Psychosocial/Family - Wife has visited several times, as has several close friends. [**Name (NI) **] was done to assist him in being able to utilize this support. Patient feels that wife will ensure that he keeps his outpatient appointments, particularly for ECT, and that family members will be able to transport him to and from ECT appointments. 5. Legal - Patient signed in on CV. Medications on Admission: Dextroamphetamine 10mg daily Fluoxetine 40mg daily Discharge Medications: 1. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*3* 2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO qHS prn as needed for insomnia for 2 weeks.Disp:*15 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: AXIS I: Major Depressive Disorder, possibly with dysthymia AXIS II: deferred AXIS III: s/p attempted suicide by Benadryl overdose AXIS IV: moderate stressors AXIS V: (current): 52 (on admission, this was 30) Discharge Condition: Normal mental status exam. He was ambulatory at the time of discharge. When Mr [**Known lastname 33236**] was discharged, he did not have suicidal ideation, he tolerated his Venlafaxine and Trazadone prn well. He describes himself being in a good mood. Discharge Instructions: You were admitted to inpatient psychiatry due to your suicide attempt, as a result of severe depression. You need to follow-up with your therapist, outpatient psychiatrist, and your PCP. Prior to discharge, you had no ideas about harming yourself. You mentioned that your sleep and appetite were good prior to discharge. Dr [**Last Name (STitle) **] [**Last Name (NamePattern4) **], who is covering for Dr [**Last Name (STitle) 2109**], mentioned that you will need outpatient ECT treatments, the exact number of which need to be determined as an outpatient. Followup Instructions: You have an ECT appointment on Friday [**2179-8-20**] at 9 am - at [**Hospital Ward Name 33238**] ([**Hospital1 **] 2, Rm 208). The [**Hospital **] clinic number is: [**Telephone/Fax (1) 2134**]. After ECT, you cannot drive a car, go to work, drink alcohol or make important decisions regarding your occupation or personal affairs. Psychiatry follow-up: Appointment with: Dr. [**Last Name (STitle) 33239**] Date: [**2179-8-30**] Time: 5 PM Phone: [**Telephone/Fax (1) 33240**] Address: [**Street Address(2) 33241**] [**Location (un) 33242**],MA Appointment with: [**First Name8 (NamePattern2) 1785**] [**Last Name (NamePattern1) 15655**] Date: [**2179-8-19**] Time: 6:30 PM Phone: [**Telephone/Fax (1) 33243**] Fax: [**Telephone/Fax (1) 33244**] [**First Name8 (NamePattern2) 5321**] [**Last Name (NamePattern1) 33245**],LMFT& Associates (Couples therapist)-please call to organize an appointment [**Location (un) 33246**]., East [**Hospital1 789**],[**Numeric Identifier 33247**] phone: ([**Telephone/Fax (1) 33248**] fax: ([**Telephone/Fax (1) 33249**] Please organize a follow-up appointment with a primary care physician. [**Name10 (NameIs) 2172**] wife had mentioned that she is trying to organize an appointment with her PCP. Completed by:[**2179-8-23**]

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Discharge summary

report

Admission Date: [**2105-7-22**] Discharge Date: [**2105-8-9**] Date of Birth: [**2052-9-21**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 106**] Chief Complaint: fever, chills Major Surgical or Invasive Procedure: Pacemaker explant Insertion of temporary external pacemaker PICC line placement R History of Present Illness: Mr. [**Known firstname 487**] [**Initial (NamePattern1) **]. [**Known lastname **] is a very nice 52 year-old gentleman with history of bicuspid aortic valve and ascending aortic aneurysm s/p mechanical [**Hospital3 **] AVR on coumadin, h/o CHB s/p PPM who comes with malaise, HA and fever up to 102 with peripheral vision loss. He underwent surgery succesfuly in [**1-21**], which was complicated by recurrent pericardial effusion that was treated with a pericardial window. He was discharged home on [**2105-2-21**] and was doing well, able to play golf and purposely losing some weight. Six days ago he started noticing fever up to 102, chills, rigors, loss of apetite and night sweats. He almost had no symptoms during the day. He went and saw his PCP 3 days ago who did blood work and sent him home. His PCP labs included gluc 11, BUN 8, Creat 0.68, Na 136, K 4.1, Cl 102, CO2 26, Ca 8.8, Prot 6.4, Alb 3.4, AP 87, AST 38, ALT 34, Bil 0.7. UA negative for UTI, but with mild proteinuria and keytones. He got blood cultures drawn that came back positive 1/2 bottles (anaerobic) with GPCs in chains and was called to go to the ER. . At [**Hospital **] Hospital his VS were stable. He received in Vancomycin 1 gm IV once morphine and zofran. WBC 9.7, HCT 25, PLT 191, no bands. He was transfered to our ER for further work up. . In our ER his initial VS were T 103.1 F, BP 124/70 BPM, HR 90 BPM, RR 18 X', SpO2 96% on RA. His initial exam showed normal JVP, clear lungs, no edema. He received gentamycin 120 mg IV, tylenol PO at 6 AM, 8 mg of morphine IV, 4 mg of zofran and 5 mg of IV Vit K. During his ED stay he reports loss of vision in the left upper visual field in his left eye. Stroke service was consulted. Repeat CT scan showed 15 mm lesion without any new lesions. Minimal perihemorrhagic edema. Reconstruction is pending to eval for mycotic aneurysm. Ophtalmology evaluated patient and saw no abnormalities after dilation. The differential includes TIA, compromised circulation to occipital area, embolic event is also possible. He is admitted to the CCU service. Her received 2 FFPs. His VS prior to transfer were VS: HR 85, RR 12, BP 109/68, 96% 2L. . Of note, he denies any recent dental procedures, skin infections, URI-symptoms, sick contacts, IVDU, changes in his medications (other than stopping Toprol XL and ranitidine). No recent travel. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: None. -PACING/ICD: PPM, 2 leads in place. PAST MEDICAL HISTORY: Complete Heart Block(PPM) Postop DVT in LUE [**2104-3-12**] following lead extraction Hyperlipidemia s/p Dual chamber pacemaker placement in [**2087**] s/p replacement of PM generator [**2096**] s/p Lead extraction and reimplantation of PPM [**3-/2104**] Hernia repair as child s/p AVR(mechcanical)Ascending Aortic arch replacment on [**2105-2-3**] with 25-mm St. [**Hospital 923**] Medical Regent mechanical valve secondarily to bicuspid aortic valve diagnosed in 7th grade and progressing ascending aortic aneurysm of 5.4cm at time of surgery. Surgery was complicated by tamponade and required Subxiphoid pericardial window on [**2105-2-18**]. s/p CABG LIMA-LAD in [**2105-2-3**] h/o DVT Social History: He lives with his wife, daughter, son and son in law in [**Name (NI) 1727**]. He works in a shipyard, but denies any exposure to asbestos. He quit smoking 2 years ago and has history of 30-40 pack-year. He denies any current or past alcohol intake or illegal substance use. He plays golf as excercise. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Father had first MI in his 60s and died of emphysema. Mother died of a blood clot (unknown location). Physical Exam: VITAL SIGNS - Temp 97.8 F, BP 123/67 mmHg, HR 77 BPM, RR 26 X', O2-sat 98% 2 L NC GENERAL - well-appearing man in NAD, Oriented x3, comfortable, Mood, affect appropriate. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear, Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, mechanical S2. Mild SEM [**1-17**] RUSB radiating towards both carotids. No r/g. No thrills, lifts. No S3 or S4. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), No c/c/e. No femoral bruits. SKIN - no rashes or lesions. No stasis dermatitis, ulcers, scars, or xanthomas. No osler nodes or signs of embili. LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-15**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, gait not evaluated, normal eye exam on confrontation and 20/20 bilateraly. Pertinent Results: [**2105-7-22**] 10:38AM BLOOD WBC-7.6 RBC-3.63* Hgb-10.1* Hct-29.9* MCV-82 MCH-27.7 MCHC-33.7 RDW-15.0 Plt Ct-166 [**2105-7-23**] 04:30AM BLOOD WBC-9.1 RBC-3.62* Hgb-9.9* Hct-30.7* MCV-85 MCH-27.2 MCHC-32.1 RDW-14.5 Plt Ct-173 [**2105-7-24**] 07:00AM BLOOD WBC-8.4 RBC-4.17* Hgb-11.6* Hct-35.0* MCV-84 MCH-27.8 MCHC-33.1 RDW-15.0 Plt Ct-251 [**2105-8-4**] 06:00AM BLOOD WBC-12.5* RBC-3.43* Hgb-9.4* Hct-28.3* MCV-83 MCH-27.4 MCHC-33.2 RDW-14.7 Plt Ct-374 [**2105-8-5**] 06:02AM BLOOD WBC-11.1* RBC-3.32* Hgb-9.3* Hct-27.0* MCV-81* MCH-28.2 MCHC-34.6 RDW-14.3 Plt Ct-356 [**2105-7-22**] 06:00AM BLOOD PT-46.6* PTT-38.9* INR(PT)-5.0* [**2105-7-22**] 10:38AM BLOOD PT-24.6* PTT-33.5 INR(PT)-2.4* [**2105-7-22**] 09:07PM BLOOD PT-14.9* PTT-27.3 INR(PT)-1.3* [**2105-7-22**] 10:38AM BLOOD ESR-45* [**2105-7-22**] 10:38AM BLOOD Ret Aut-0.9* [**2105-7-22**] 06:00AM BLOOD Glucose-109* UreaN-8 Creat-0.7 Na-136 K-4.4 Cl-102 HCO3-23 AnGap-15 [**2105-7-23**] 04:30AM BLOOD Glucose-113* UreaN-6 Creat-0.7 Na-133 K-4.2 Cl-100 HCO3-25 AnGap-12 [**2105-7-24**] 07:00AM BLOOD Glucose-101* UreaN-6 Creat-0.6 Na-136 K-4.3 Cl-97 HCO3-31 AnGap-12 [**2105-8-4**] 06:00AM BLOOD Glucose-113* UreaN-9 Creat-1.0 Na-129* K-4.4 Cl-96 HCO3-27 AnGap-10 [**2105-8-5**] 06:02AM BLOOD Glucose-121* UreaN-10 Creat-1.1 Na-131* K-4.1 Cl-96 HCO3-28 AnGap-11 [**2105-7-22**] 10:38AM BLOOD ALT-29 AST-36 LD(LDH)-364* AlkPhos-56 TotBili-0.4 [**2105-7-27**] 06:30AM BLOOD ALT-94* AST-60* LD(LDH)-406* AlkPhos-73 TotBili-0.3 [**2105-7-28**] 06:35AM BLOOD ALT-94* AST-57* LD(LDH)-414* AlkPhos-72 TotBili-0.3 [**2105-8-5**] 06:02AM BLOOD ALT-33 AST-18 LD(LDH)-329* CK(CPK)-28* AlkPhos-70 TotBili-0.3 [**2105-7-22**] 06:00AM BLOOD cTropnT-<0.01 [**2105-7-22**] 10:38AM BLOOD Albumin-3.2* Calcium-7.9* Phos-2.6* Mg-1.7 [**2105-7-23**] 04:30AM BLOOD Calcium-8.0* Phos-2.0* Mg-1.9 [**2105-8-5**] 06:02AM BLOOD Albumin-3.0* Calcium-8.8 Phos-4.5 Mg-2.1 [**2105-7-24**] 09:20AM BLOOD Iron-22* [**2105-7-24**] 09:20AM BLOOD calTIBC-225* VitB12-1376* Folate-14.9 Ferritn-388 TRF-173* [**2105-7-22**] 10:38AM BLOOD RheuFac-13 CRP-215.5* [**2-11**] blood cultures drawn on the day of admission showed the same culture results. Blood Culture, Routine (Final [**2105-7-24**]): BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Sensitivity testing performed by Sensititre. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ BETA STREPTOCOCCUS GROUP B | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>4 R PENICILLIN G----------<=0.06 S VANCOMYCIN------------ <=1 S Anaerobic Bottle Gram Stain (Final [**2105-7-22**]): GRAM POSITIVE COCCI IN CHAINS. REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 1715 ON [**2105-7-22**]. Aerobic Bottle Gram Stain (Final [**2105-7-23**]): GRAM POSITIVE COCCI IN CHAINS. EKG [**7-22**]: Sinus rhythm with atrial sensed and ventricular paced rhythm. Since the previous tracing of [**2105-2-18**] there is no significant change. CTA Head: IMPRESSION: 1. Stable 15 mm right frontal parenchymal hematoma with slight increase of peripheral zone of edema; a small underlying mass cannot be entirely excluded. 2. No CT angiographic "spot sign" to suggest impending enlargement of hemorrhage. 3. No evidence of cerebral venous thrombosis. 4. No new focus of hemorrhage. 5. Patent anterior and posterior circulation vasculature without evidence of vascular malformation or aneurysm larger than 2 mm. TEE [**7-23**]: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. A bileaflet aortic valve prosthesis is present. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. [The amount of regurgitation present is normal for this prosthetic aortic valve.] The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is a trivial/physiologic pericardial effusion. IMPRESSION: No vegetations seen on mitral valve, tricuspid valve, pulmonic valve. There is small (3mm) relatively fixed echodensisty adjacent to the aortic root side of the mechanical aortic valve near the non-coronary cusp which was present in the immediate post operative TEE on [**2105-2-3**] and is likely a suture. Compared with the prior TEE study (images reviewed) of [**2105-2-3**] there are no significant changes. . TEE [**7-30**]: The left atrium is markedly dilated. The left atrium is elongated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage.There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is inferolateral and inferior wall hypokinesis but overall left ventricular systolic function is normal (LVEF>55%). Right ventricular systolic function is normal with good free wall contractility.The aortic root is moderately dilated at the sinus level. A mechanical aortic valve prosthesis is present. The valve appears to be well-seated without perivalvular leaks, however, the individual prosthetic leaflets cannot be adequately assessed due to artifact. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Peak/mean gradients are 64/36 mmHg. Mild-moderate aortic regurgitation is seen. There is a mobile 7mm x 6 mm mass on the upstream surface of the aortic valve, most likely on the right cusp. This is also the area which shows the AI. It is consistent with a vegetation. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is no pericardial effusion. . TTE [**7-29**]: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. A bileaflet aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal disc motion and transvalvular gradients. Trace aortic regurgitation is seen. [The amount of regurgitation present is normal for this prosthetic aortic valve.] The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior focused study (images reviewed) of [**2105-2-20**], the pericardial effusion has resolved. The absence of endocarditis on a transthoracic echo does not exclude the diagnosis if clinically suggested. If clinically suggested, a TEE may be more sensitive for identifying vegetations. . Cerbral angiography: IMPRESSION: No evidence of aneurysm, arteriovenous malformation, or active extravasation. In particular, no abnormality identified in the region of the right frontal parenchymal hemorrhage. . LENI [**8-3**]: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) **] of bilateral common femoral, superficial femoral, and popliteal veins were performed. There is appropriate compressibility, flow, and augmentation. IMPRESSION: No evidence of DVT. . PICC: IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double lumen PICC line placement via the right brachial venous approach. Final internal length is 37 cm, with the tip positioned in SVC. The line is ready to use. . LLE U/S: STUDY: Left lower extremity soft tissue ultrasound. FINDINGS: Multiple grayscale images of the left groin, left thigh and left calf demonstrate no fluid collection. IMPRESSION: No evidence for fluid collection. . CXR [**8-5**]: Lung volumes are normal. Lungs are clear without focal consolidations. Heart size is normal. Hilar and mediastinal silhouettes appear stable. No pulmonary edema, pleural effusions or pneumothoraces are identified. Pacemaker lead projects over right ventricle. Two radiopaque densities are seen projecting over right ventricle, which may represent fragmented leads, and are unchanged since [**2105-1-23**] study. Right PICC line tip is obscured by pacemaker lead, it is visible at upper to mid SVC. IMPRESSION: No acute cardiopulmonary process. . CT L-Spine 1. No evidence of epidural or paraspinal abscess in the lumbosacral spine. 2. Mild degenerative changes of the lumbar spine, worse at L4-L5 level, with discogenic disease and osteophytes causing thecal sac indentment and neural foraminal narrowing bilaterally. ATTENDING NOTE: Although CT without contrast is not sensitive to detect epidural disease, no obvious deformity of thecal sac seen to suggest abscess. Bilateral moderate foraminal narrowing seen at L4-5. Brief Hospital Course: Mr. [**Known firstname 487**] [**Initial (NamePattern1) **]. [**Known lastname **] is a very nice 52 year-old gentleman with history of bicuspid aortic valve and ascending aortic aneurysm s/p mechanical [**Hospital3 **] AVR on coumadin, h/o CHB s/p PPM who comes with malaise, HA and fever up to 102 with peripheral vision loss and positive blood cultures for GPCs. # Endocarditis: The patient came from an outside hospital with positive blood cultures. He was immediately started on vancomycin and gentamicin. The vancomycin was then switched to ceftriaxone and he was continued on the gent. He had an initial TEE that showed no evidence of a thrombus or vegetation in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] leads. CT surgery did not want to intervene at this time as he was stable. His first 3 blood cultures all returned positive for group B streptococcus that was sensitive to ceftriaxone. The patient had a CT head at an OSH that showed a frontal lobe hemorrhage, this was followed by CT and showed small interval change after the first. A cerebral angiogram was also obtained per neurology which showed no evidence of mycotic aneurysm, or other irregularities. Neurology recommended re-imaging only if there was change on physical exam, which there was not. The patient had repeated fevers spikes so a TTE was done which showed no evidence of vegetation. A repeat TEE was done which showed a 7mm x 6 mm vegetation on the aortic valve. CT surgery was reconsulted and again deferred intervention until he had a longer treatment with abx. The patient had his pacer and leads explanted with EP and a temporary external pacemaker was placed. CT A/P was obtained which showed no focus of infection in the abdomen. He developed intermittent back and left leg pain which ID was concerned for abscess/phlegmon. A CT L-spine showed no evidence of abscess, discitis, or osteomyelitis. U/S of the left thigh and DVT studies were obtained which showed no evidence of fluid collection or DVT. It was thought this pain was MSK and was managed with pain control and hot packs. The patient had a PICC line inserted under IR with no complications. His gentamicin was stopped in house after a 2 week course and he was to continue ceftriaxone for a total of 6 weeks. Follow-up was scheduled with Dr. [**Last Name (STitle) **] on [**8-27**]. # Embolic Stroke - The patient had a head CT at an OSH that showed a frontal lobe hemorrhage. The patient's coumadin was held and he had a repeat CT head and CTA which showed a small interval increase in hemorrhage from previous. A cerebral angiogram showed no irregularities as above. Neurology recommendations were to hold his coumadin for 1 week and then start a heparin drip to bridge to a therapeutic INR. He was also started on aspirin 81mg daily. INR therapeutic at 2.3 on Coumadin 12mg daily on [**8-9**]. Pt discharged. . # Follow up: Pt requires CT abdomen for evaluation of abscesses [**1-13**] septic emboli from endocarditis as outpatient. Cardiology Device Clinic at [**Hospital **] Hospital for evaluation of device within 1 week following discharge. ID f/u per appts. INR checks with f/u with PCP, [**Name10 (NameIs) **] home INR machine and titrate medication based on PCP [**Name Initial (PRE) 2742**]. Cardiology f/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] per appt. CT surgery f/u [**Doctor Last Name **] per appt. Medications on Admission: Aspirin 81 mg Daily Colace 100 mg PO BID Coumadin 10 mg 3 days per week and 11 mg 4 days per week Simvastain 40 mg, PCP switching to [**Name9 (PRE) **] Discharge Medications: 1. Ceftriaxone 2 gram Recon Soln Sig: Two (2) gram Intravenous every twenty-four(24) hours for 27 days. Disp:*qs 27 doses* Refills:*0* 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 5. Warfarin 10 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Home With Service Facility: [**Hospital6 486**] of Southern [**State 1727**] Discharge Diagnosis: Endocarditis - AV vegetation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you during your hospitalization. You were admitted for infection of your aortic valve and blood stream. You were started on antibiotics to treat the infection and it was decided by the cardiology and electrophysiology teams to remove your pacemaker as well since it was a potential focus of infection. A temporary pacemaker was placed in your neck until you finish your course of antibiotics and can have a new pacemaker replaced. You were also started on blood thinning medications called warfarin and IV heparin. You became therapeutic on wafarin on [**8-9**]. Dr. [**Last Name (STitle) **] advised you to go rehab with your temporary pacemaker until surgical replacement of your pacer could occur after you finished the course of IV antibiotics. The reason for this is your heart rhythm is pacer dependent and if your pacer is disrupted, it could result in lifethreatening consequences. You declined discharge to long-term acute care and stated preference to be discharged to home. . We recommend that you get an abdominal CT scan to evaluate for possible abscess formation as an outpatient. Please schedule this through your PCP [**Name Initial (PRE) 3726**]. . The following changes were made to your medications: STARTED CeftriaXONE 2 gm IV Q24H Day 1 [**2105-7-23**] INCREASED Coumadin 12mg daily . Please follow up with your physicians at the appts states below: Followup Instructions: Department: CARDIAC SURGERY When: THURSDAY [**2105-8-27**] at 1:45 PM With: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD [**Telephone/Fax (1) 170**] Building: LM [**Hospital Unit Name **] [**Location (un) 551**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: TUESDAY [**2105-9-22**] at 3:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Dr. [**Last Name (STitle) **] wants pt to see device clinic 2 weeks post op according to [**Doctor First Name **]( Dr.[**Initials (NamePattern4) 1565**] [**Last Name (NamePattern4) **]) when she spoke to him. Department: INFECTIOUS DISEASE When: TUESDAY [**2105-8-25**] at 9:00 AM With: [**Name6 (MD) 9462**] FLASH, MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: TUESDAY [**2105-9-8**] at 10:30 AM With: [**Name6 (MD) 9462**] FLASH, MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Please follow up with your Cardiology Device Clini At [**Hospital **] Hospital, call for appointment within 1 week of discharge. Call for appt: [**Telephone/Fax (1) 83782**] . INR checks on your warfarin medication: please check levels using your home INR machine. Follow up with your PCP who will titrate your medication appropriately.

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icd9cm

[ [ [] ] ]

[ "38.93", "37.89", "88.72", "88.41", "37.78" ]

icd9pcs

[ [ [] ] ]

19891, 19970

15456, 18365

284, 368

20043, 20043

6104, 15433

21655, 23408

4562, 4779

19092, 19868

19991, 20022

18915, 19069

20194, 21632

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3406, 3507

18376, 18889

231, 246

396, 3296

20058, 20170

3529, 4227

4243, 4546

31,418

180,543

31405

Discharge summary

report

Admission Date: [**2147-7-19**] Discharge Date: [**2147-8-2**] Date of Birth: [**2073-8-15**] Sex: F Service: MEDICINE Allergies: Novocain Attending:[**First Name3 (LF) 3233**] Chief Complaint: Aplastic anemia Major Surgical or Invasive Procedure: Bone marrow biopsy endotracheal intubation Central line placement Arterial line placement History of Present Illness: Pt is a 73 yo woman who is transferred from [**Hospital **] Hospital for further evaluation and treatment of her newly diagnosed aplastic anemia. Pt reported that she presented to OSH two weeks ago Tuesday with 7 episodes of loose stool mixed with sig. amounts of bright red blood. At the time her plt ct was reportedly 5,000 and HBG was 10; she received 1 unit of plts with increase to 60,000 and 2 units of PRBCs. Heme/onc was consulted, and she had a bone marrow aspirate with flow cytometry that showed aplastic anemia with 5-10% celularity, no sig. blast population, cytogenics pending. Viral serologies were obtained for hepatitis A, B, C, EBV, CMV, and parovirus and was only sig. for parvovirus IgG antigen of 19 c/w prior infection. No colonscopy was performed as she had one 2 years ago without sig. findings. Pt was discharged on the following Friday. . On Monday, she went for routine lab work that was sig. for plt ct of 11; she was transfused, which increased the plt ct to 51. The following Thursday, she went for another routine lab work, and ANC was noted to be 324. She was told to monitor her temperature at home. She noted a temperature of 101.5 on Friday. At home, pt did not note any URI sxs inc. cough and SOB, diarrhea, abdominal pain, and dysuria. Pt was told to go to the Emergency Department. In the [**Name (NI) **], pt reported that she was noted to be neutropenic for the first time. She was started on Ceftazidime. CXR was reportedly unremarkable and U/A and UCx grew 10^5 gram positive growth, which was presumed to be contamination. ID was consulted. She defervesced and was d/c'd off abx on [**7-17**], her fever returned the next day at 102, and she was placed back on abx. Repeat CXR was also unremarkable. CT scan of the chest from [**7-5**] did show a pulmonary noudle in the subpleural R lung. During the hospital course she also reported received plt transfusions (plt ct 5,000), empiric trial of G-CSF 300 SQ daily since admission, and T and spectra cell transfusion. Course has been c/b nausea, relieved by Zofran. . Prior to the admission 2 weeks ago, pt did not believe she was more fatigued. Pt's daughter noticed that she fell asleep more quickly during the day starting about 1 month ago while on vacation in [**State 108**]. No fever/chills then. No sig. weight changes. She noticed easy brusing 1 week prior to first admission but no bleeding. ROS otherwise only sig. for mild frontal HA, [**2-11**]. Past Medical History: 1. PMR: Pt reported arthralgia for the pat year, particularly in shoulders, low back, and hips. She was finally diagnosed in [**Month (only) 547**] with PMR and started on prednisone [**9-13**]. This was recently tapered to [**5-9**]. 2. HTN 3. Hypercholesterolemia 4. Osteoporosis 5. ?TIA 6 years ago with L sided tingling and numbness 6. h/o RA as a child, treated with steroids. Social History: Pt lives with her daughter and grandchildren in [**Name (NI) **], [**Name (NI) 1727**]. She is very active and leads an senior exercise program 3x/wk. She was in [**State 108**] about 1 month ago. Tob: 40 yrs x 1.5 ppd, quit 16 years ago. ETOH: glass of wine/wk. Recreational drugs: none. Herbal supplements/OTC: none. Family History: Father with [**Name2 (NI) 499**] cancer diagnosed at age 60, died of "blocked arteries in neck" at 69. Mother with "sickness everywhere." The healthy daughters. Physical Exam: VS: T100.3/102.4, P94, R18, BP160/82 Gen: NAD, pleasant woman HEENT: conjunctiva clear, sclera nonicteric, MMM, white patch on R side of tongue and on R buccal mucosa. Neck: supple without LAD CV: RRR, no murmurs Pulm: CTAB, no crackles or wheezes Abd: +BS, soft, NT, ND, no HSM noted Ext: warm, no edema, 2+ DP pulses Neuro: CN II-XII grossly intact, Muscle strength 5/5 and equal Skin: slight petechial rash on LEs. Pertinent Results: Admission labs: [**2147-7-19**] 05:42PM GLUCOSE-128* UREA N-15 CREAT-1.0 SODIUM-135 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-24 ANION GAP-14 [**2147-7-19**] 05:42PM estGFR-Using this [**2147-7-19**] 05:42PM ALT(SGPT)-17 AST(SGOT)-17 LD(LDH)-258* ALK PHOS-56 TOT BILI-1.0 [**2147-7-19**] 05:42PM ALBUMIN-3.5 CALCIUM-8.7 PHOSPHATE-2.3* MAGNESIUM-1.9 URIC ACID-3.8 [**2147-7-19**] 05:42PM RBC-2.95* HGB-9.3* HCT-24.6* MCV-83 MCH-31.6 MCHC-37.9* RDW-14.8 [**2147-7-19**] 05:42PM PT-12.4 PTT-28.8 INR(PT)-1.1 [**7-26**]. Chest CT. IMPRESSION: Extensive pulmonary consolidation is most likely a combination of pulmonary hemorrhage and pneumonia, rather than cardiogenic edema. Brief Hospital Course: Pt is a 73 yo woman with PMHx sig. for PMR who is transferred from [**Hospital **] Hospital for further evaluation and treatment of her newly diagnosed aplastic anemia. This was thought to be due to hemophagocytic syndrome based on bone marrow biopsy results. She did not respond to cyclosporin and decadron. The family decided on [**8-2**] to extubate patient. She was made comfortable and soon expired on [**8-2**]. . 1. Pancytopenia: Patient had pancytopenia, likely secondary to hemophagocytic syndrome. Was treated with decadron and cyclosporin. On [**8-1**], she was given one dose of IV methlyprenisolone and etopiside. She remained persistently pancytopenic. Patient was transfused several units of PRBCs and platelets. . 2. Pulmonary hemorrhage. Patient was intubated for respiratory failure secondary to pulmonary hemorrhage in setting of low platelets. She was extuabated for one day, but was tachypneic and alkalotic and so was reintubated. 3. Febrile Neutropenia. Patient was treated with caspofungin and meropenem for febrile neutropenia. There were no positive cultures. A source of fever was never found. . 4. HTN. Patient was hypertensive during hospital stay. She was treated with amlodipine and metoprolol. . 5. C diff colitis. Patient was treated with continue Vanco and Flagyl for C. diff colitis Contact: [**Name (NI) **] [**Name (NI) 73975**], daughter, [**Telephone/Fax (1) 73976**] cell Medications on Admission: Medications on transfer: ceftazidime 2 gm Iv q8 hrs Colace 200 mg po qhs Zofran 8 mg IV po q6 hours Clonidine 0.1 mg po bid Prilosec 20 mg po daily Tylenol prn G-CSF 300 SQ daily . Medications at home: Prednisone [**5-9**] Prilosec OTC Lipitor 20 mg Lisinopril 30 mg Fosamax 10 mg ASA 81 mg MTV Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: hemophagocytic syndrome pulmonary hemorrhage Discharge Condition: patient expired Discharge Instructions: N/A. Followup Instructions: N/A.

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icd9cm

[ [ [] ] ]

[ "96.72", "99.05", "41.31", "99.04", "38.91", "96.07", "38.93", "33.24", "96.04" ]

icd9pcs

[ [ [] ] ]

6790, 6799

4983, 6417

284, 375

6887, 6904

4277, 4277

6957, 6964

3651, 3814

6762, 6767

6820, 6866

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3829, 4258

229, 246

403, 2877

4293, 4960

6468, 6624

2899, 3291

3307, 3635

63,383

191,404

55155

Discharge summary

report

Admission Date: [**2194-7-27**] Discharge Date: [**2194-8-8**] Date of Birth: [**2149-8-20**] Sex: F Service: MEDICINE Allergies: multiple / Amoxicillin / baclofen / Cephalexin / doxycycline / Erythromycin Base / Hydralazine / Meperidine / Polystyrene Sulfonate / povidone-iodine / valproic acid / Verapamil / Nifedipine / cefuroxime / Labetalol / ciprofloxacin / omeprazole / loratadine / loratadine / amlodipine / metformin / sumatriptan / fexofenadine / bee venom (honey bee) / esomeprazole / Penicillins / Sulfa(Sulfonamide Antibiotics) / IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 16851**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: intubation right femoral cvc [**2194-7-30**]- RIGHT CHEST PORT CATHETER FIBRIN SHEATH STRIPPING AND REMOVAL OF RIGHT GROIN CVL History of Present Illness: Ms. [**Known lastname 28003**] is a 44 year old female with Factor V Leiden and multiple prior pulmonary emboli who was transferred from [**Hospital1 **] to [**Hospital1 18**] ED for evaluation of pleuritic chest pain radiating to the back and dyspnea. Per the record she also had two days of flank pain radiating to the groin, and dysuria. She was transferred for a study to rule out pulmonary embolism. She is anticoagulated on coumadin, currently with an INR of 2.2. Vitals at [**Hospital1 **]: bp 149/96, p 72, rr 18, sat 98%, t 98.4 . Her initial [**Hospital1 18**] ED vitals were: 98.1 76 184/83 16 98%. Based on her symptomotology, aortic dissection became a concern. In the ED she was electively intubated because she is clautrophobic and needed the MRI. An MRA was contraindicated due to the risk for gadolinium induced nephrogenic systemic sclerosis. A TEE was considered; however, this would not interrogate the entire aorta and there is report that the patient also had two days of flank pain. Transfer vitals: 136/84, p 74, bp 136/84, rr 16, o2 sat 99% on cmv/ac . On arrival to the MICU, she was intubated and sedated. Past Medical History: 1. Factor V Leiden gene mutation 2. Pulmonary emboli 3. IDDM 4. Hypertension 5. ESRD on HD via left subclavian HD line, schedule unknown 6. Hypothyroidism 7. Atrial myxoma s/p resention 8. atrial fibrillation 9. Reflex sympathetic dystrophy/chronic regional pain syndrone 10. Fasciotomy of right forearm [**2180-5-16**], left forearm [**2194-4-15**] 11. Permanent IVF filter placed on [**2186-7-10**] Social History: Patient is from [**Location (un) 15739**], NY. She is currently on disability. Lifelong nonsmoker. Denies EtOH or illicits Family History: She denies a family history of kidney disease. Father had MI and CABG in his 50's. No FH of premature CAD, SCD, or arrhythmia. Physical Exam: ADMISSION EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . DISCHARGE EXAM: General: NAD AOx3 HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, +CVA tenderness on left that is stable x4 days GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Pertinent Results: ADMISSION LABS: [**2194-7-27**] 04:55PM BLOOD WBC-5.3 RBC-3.50* Hgb-10.2* Hct-31.5* MCV-90 MCH-29.0 MCHC-32.3 RDW-19.4* Plt Ct-176 [**2194-7-27**] 04:55PM BLOOD Neuts-59.7 Lymphs-20.2 Monos-5.0 Eos-14.2* Baso-1.0 [**2194-7-27**] 04:55PM BLOOD PT-23.5* PTT-33.7 INR(PT)-2.2* [**2194-7-27**] 04:55PM BLOOD Glucose-132* UreaN-29* Creat-6.2* Na-136 K-5.3* Cl-100 HCO3-23 AnGap-18 [**2194-7-27**] 04:55PM BLOOD cTropnT-<0.01 [**2194-7-28**] 06:08AM BLOOD CK-MB-3 cTropnT-0.22* [**2194-7-28**] 12:12PM BLOOD CK-MB-4 cTropnT-0.20* [**2194-7-27**] 04:55PM BLOOD CK(CPK)-39 [**2194-7-28**] 06:08AM BLOOD CK(CPK)-90 [**2194-7-28**] 12:12PM BLOOD CK(CPK)-103 . DISCHARGE LABS: . [**2194-8-3**] URINE CULTURE (Final [**2194-8-5**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. [**2194-8-8**] 06:04AM BLOOD WBC-4.5 RBC-3.36* Hgb-10.4* Hct-31.0* MCV-92 MCH-31.0 MCHC-33.6 RDW-18.3* Plt Ct-211 [**2194-8-8**] 06:04AM BLOOD PT-19.9* PTT-40.9* INR(PT)-1.9* [**2194-8-7**] 06:48AM BLOOD PT-21.8* PTT-133.1* INR(PT)-2.1* [**2194-8-6**] 05:12AM BLOOD PT-20.9* PTT-147.1* INR(PT)-2.0* [**2194-8-8**] 06:04AM BLOOD Glucose-140* UreaN-52* Creat-8.6*# Na-138 K-5.4* Cl-98 HCO3-28 AnGap-17 [**2194-8-8**] 06:04AM BLOOD Calcium-9.8 Phos-8.0* Mg-2.3 . IMAGING: [**2194-7-27**] CXR: Single portable view of the chest. No prior. Endotracheal tube is seen with tip approximately 5 cm from the carina. Nasogastric tube is also seen with side port in the region of the GE junction. Left-sided central venous catheter is seen with tip in the right atrium. Right-sided subclavian line is seen with tip in the mid SVC. Lungs are grossly clear, given significant rotation and portable supine technique. Median sternotomy wires again seen. Cardiac silhouette is enlarged but likely accentuated due to technique and positioning. Osseous and soft tissue structures are unremarkable. IMPRESSION: Endotracheal tube tip approximately 5 cm from the carina. . [**2194-7-28**] MRA Torso: 1. No MR evidence for aortic dissection. 2. No central pulmonary embolism in the main, right or left pulmonary arteries, the lobar and smaller order pulmonary arteries cannot be assessed on this non-contrast study. 3. Right lower lobe atelectasis or consolidation. 4. Multiple renal cysts with small shrunken kidneys consistent with the patient's chronic renal disease. 5. Positioning of the central venous catheters is not clear, at least one catheter appears to terminate in the right atrium or extend into the IVC. Recommend a chest radiograph to confirm catheter tip placement. TTE (Complete) Done [**2194-7-29**] 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 probably mildly depressed with mid anteroseptal hypokinesis but views are suboptimal for assessment of wall motion. Right ventricular chamber size is normal with mildly depressed function (but views are subopitmal). The aortic valve leaflets (probably 3) appear structurally normal with good leaflet excursion. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. An small (approximately 1 cm diameter) echodense structure is visualized posterior to the left atrium in a modified four chamber view which represent a portion of a wall of a pulmonary vein. No definite intracardiac mass identified but views are suboptimal. If clinically indicated, a transesophageal echocardiographic examination is recommended. CHEST (PORTABLE AP) Study Date of [**2194-7-28**] INDICATION: Evaluate right Port-A-Cath and central venous catheter locations due to positioning within the right atrium noted prior MRI of the chest. COMPARISON: Chest radiogram from [**2194-7-27**] and MRA of the torso from [**2194-7-28**]. FINDINGS: A bedside AP radiograph of the chest demonstrates that the double-lumen catheter terminates well within the right atrium, approximately 7 cm below the expected location of the cavoatrial junction. It is unchanged in position from the prior study. The right subclavian line terminates in the mid SVC, also unchanged. The patient has been extubated. The lungs are clear. There continues to be enlargement of the right atrium. There is no pneumothorax or pleural effusion. Pulmonary vascularity is normal. Sternotomy cerclage wires are intact. IMPRESSION: The double-lumen Port-A-Cath should be retracted approximately 7 cm to ensure proper positioning in the lower one-third of the SVC. [**2194-7-31**] Radiology RENAL U.S. FINDINGS: The right kidney measures 9 cm. The left kidney measures 9.5 cm. Several cysts are seen in both kidneys. A 1.9 cm left upper pole cyst has a single septation. The bladder is clear. There is no stone, mass or hydronephrosis in either kidney. IMPRESSION: No hydronephrosis, stone or perinephric fluid collection. [**2194-8-1**] Radiology CHEST (PA & LAT) Two views of the chest were obtained. The lungs are well expanded and clear without pleural effusion or pneumothorax. The heart is normal in size with normal cardiomediastinal contours. Right-sided Port-A-Cath and left-sided hemodialysis catheter are in unchanged position. Cardiac size is stably enlarged. Brief Hospital Course: HOSPITAL COURSE: Ms. [**Known lastname 28003**] is a 44 year old female with Factor V Leiden and multiple prior pulmonary emboli who was transferred from [**Hospital1 **] for evaluation of pleuritic chest pain radiating to the back and dyspnea. Ruled out for serious thoracic pathology (PE/dissection/ACS). MWF HD was continued throughout stay on floors. Given hx of Factor V Leiden, started on Heparin drip with bridging to warfarin. Reported constant left flank pain. In conjunction with falling hemoglobin, this prompted CT Abd/Pelv which ruled out retroperitoneal bleed. Transfused one unit and hemoglobin was stabilized for remainder of admission. While waiting for INR to become therapeutic, previous UCx grew >100,000 CFUs Enterococcus, treated with vancomycin at HD. INR became therapeutic x3 days, heparin gtt stopped and pt was discharged on day 14 of admission with followup with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**First Name8 (NamePattern2) **] [**Last Name (Titles) 15739**]. ACTIVE ISSUES: Chest Pain: The patient described substernal chest pain radiating to her back that was worrisome for PE, acute MI, or aortic dissection. Patient was electively intubated in the ED and subsequent MRI negative for aortic dissection or large pulmonary embolism. Recurrent subsegmental pulmonary embolism possible as patient has had this occur on warfarin with therapeutic INR and with IVC filter in place. Acute myocardial infarction was also a concern. Initial ECG was within normal limits; however, serial ECG showed development of IVCD with no overt ischemic changes. Troponin was initially negative; however, cTropnT < 0.01 --> 0.22 --> 0.20 with negative CK-MB index. Other points in the differential would include pericarditis or myocarditis given troponin leak. Non-cardiac or pulmonary etiologies could be esophageal spasm. The patient has a history of an atrial myxoma so that was also on the differential. An ECHO was performed given concern for ischemia or atrial myxoma and showed mild symmetric LVH with LV systolic function probably mildly depressed with mid anteroseptal hypokinesis, mildly depressed RV funtion and no definite intracardiac mass. Views were all suboptimal though. The patient was evaluated by cardiology who recommended that the patient follow up as an outpatient for possible stress test. Flank Pain: The patient complained or left sided flank pain. She has a history of pyelonephritis. UA and culture on admission were normal, however the patient continued to have flank pain so a renal ultrasound was ordered and a repeat urinalysis and culture. A renal ultrasound revealed no hydronephrosis, stone or perinephric fluid collection. Subsequent UCx grew >100,000 Enterococcus but patient clinically stable and afebrile. Regardless, treated with vancomycin at HD. Hypertension/Hypotension: Home anti-hypertensive medications were initially held due to borderline blood pressures. She was started on metoprolol 25 mg XL per cardiology recommendation for history of atrial fibrillation as well and tolerated this well initially. However, complaints of dizziness on standing prompted reduction of antihypertensive dosing. At d/c Lisinopril was 20mg daily, Metoprolol was 12.5mg daily. Factor V Leiden gene mutation with multiple pulmonary emboli: We initially held warfarin while ruling out aortic dissection, but then restarted it after MRI was negative. The patient was subsequently started on a heparin drip due to high risk of clot and subtherapeutic INR. INR increased slowly and became therapeutic x3 days before discharge. ESRD: Patient was seen and evaluated by renal and dialyzed per home M/W/F schedule without complication. INACTIVE ISSUES: Pain control: Patient tolerated home dose of q3h 20mg Dilaudid. IDDM: The patient was placed on a sliding scale. Atrial fibrillation- The patient has history of atrial fibrillation related to atrial myxoma in the past. She was seen and evaluated by cardiology who recommended metoprolol xl 25 mg. EKG's performed and telemetry monitoring revealed sinus rhythm. The patient was anticoagulated as described above. Hypothyroidism: There was no evidence of clinical hypothyroidism and the patient was continued levothyroxine. TRANSITIONAL ISSUES: f/u dosing on antihypertensives/cardiac meds *Please note we discontinued digoxin and propranolol and went down on lisinopril and metoprolol. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. HYDROmorphone (Dilaudid) 20 mg PO Q3H pain 2. Nephro-Vite *NF* (B complex-vitamin C-folic acid) 0.8 mg Oral daily 3. Lisinopril 40 mg PO BID 4. Digoxin 0.125 mg PO MWF 5. sevelamer CARBONATE 1600 mg PO TID W/MEALS 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Propranolol LA 120 mg PO DAILY 8. Montelukast Sodium 10 mg PO DAILY 9. Aciphex *NF* (RABEprazole) 20 mg Oral daily 10. Lantus Solostar *NF* (insulin glargine) 30 units Subcutaneous HS 11. NovoLOG *NF* (insulin aspart) sliding scale Subcutaneous slidinc scale 12. Doxazosin 2 mg PO HS 13. Lorazepam 1 mg PO Q6H:PRN anxiety 14. Promethazine 25 mg PO Q6H:PRN nausea 15. Ondansetron 8 mg PO BID:PRN nausea 16. Frova *NF* (frovatriptan) 2.5 mg Oral PRN migraines 17. Xopenex Neb *NF* 1.25 mg/0.5 mL Inhalation Q4H PRN 18. Ferrous Sulfate 325 mg PO DAILY 19. DiphenhydrAMINE 50 mg PO Q4H:PRN itching 20. Docusate Sodium 100 mg PO BID 21. Denavir *NF* (penciclovir) 1 % Topical q6h rash 22. Warfarin Dose is Unknown PO DAILY16 Based on INR 23. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Ferrous Sulfate 325 mg PO DAILY 3. HYDROmorphone (Dilaudid) 20 mg PO Q3H pain 4. Levothyroxine Sodium 125 mcg PO DAILY 5. Lisinopril 20 mg PO DAILY hold for SBP < 100 6. Lorazepam 1 mg PO Q6H:PRN anxiety 7. Metoprolol Succinate XL 12.5 mg PO DAILY hold for SBP < 100 or HR < 60 8. Warfarin 8 mg PO DAILY16 9. Xopenex Neb *NF* 1.25 mg/0.5 mL Inhalation Q4H PRN 10. Aspirin 81 mg PO DAILY 11. Aciphex *NF* (RABEprazole) 20 mg Oral daily 12. Denavir *NF* (penciclovir) 1 % Topical q6h rash 13. DiphenhydrAMINE 50 mg PO Q4H:PRN itching 14. Doxazosin 2 mg PO HS 15. Frova *NF* (frovatriptan) 2.5 mg Oral PRN migraines 16. Lantus Solostar *NF* (insulin glargine) 30 units Subcutaneous HS 17. Montelukast Sodium 10 mg PO DAILY 18. Nephro-Vite *NF* (B complex-vitamin C-folic acid) 0.8 mg Oral daily 19. Ondansetron 8 mg PO BID:PRN nausea 20. Promethazine 25 mg PO Q6H:PRN nausea 21. Propranolol LA 120 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Atypical chronic chest pain Factor V Leiden with history of PEs (+IVC filter) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 28003**], Thank you for choosing us for your care. You were admitted for chest pain that, in conjunction with your Factor V Leiden, was concerning for a pulmonary embolism. We have done many tests to rule out this possibility, as well as other dangerous conditions causing chest pain including aortic dissection and heart attack. To do one of these tests, we needed to sedate and intubate you. Despite the extensive workup we are unsure what is causing your chest pain and shortness of breath at this time. You also reported burning on urination and left sided flank pain. We performed a CT scan to make sure there was no bleeding into your flank. This was negative. We performed several tests to rule out a UTI or an infection of your kidney, which can present with flank pain. Your urine grew some bacteria, but this can be common in people dependent on dialysis. Regardless, we have treated it with vancomycin. In the hospital we have continued to give you dialysis to compensate for your chronic kidney disease. Please continue to do so at your usual dialysis center. We had been anticoagulating you on heparin while we waited for your warfarin to raise your INR above 2.0. Please continue to take your warfarin after discharge to maintain an INR above 2.0. We have made an appointment with your primary care doctor [**First Name8 (NamePattern2) 11320**] [**Last Name (NamePattern1) **] in [**Location (un) 15739**]. Please see her to adjust your medications. We have lowered your dose of Lisinopril to 20mg daily and your dose of Metoprolol to 12.5mg daily. We have STOPPED your digoxin. Please do not continue to take it. Please continue to take your other medications as you had before you went to [**Hospital3 **]. Followup Instructions: [**First Name8 (NamePattern2) 11320**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 94080**] Creek Family Medicine [**Apartment Address(1) 112512**] [**Location (un) 15739**], [**Numeric Identifier 112513**] Appointment: (585) 275-URMC Fax: ([**Telephone/Fax (1) 112514**] Date: Thursday [**8-14**] Time: 2PM Completed by:[**2194-8-8**]

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Discharge summary

report

Admission Date: [**2119-6-28**] Discharge Date: [**2119-7-7**] Date of Birth: [**2050-2-14**] Sex: F Service: MEDICINE Allergies: Penicillins / Morphine Sulfate / Lipitor Attending:[**First Name3 (LF) 2901**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: IVC filter placement [**2119-6-29**] History of Present Illness: 69 yo F w/ history of CAD and DM who presents with acute onset of shortness of breath this morning. She felt well when she first got out of bed, but felt acutely dyspneic after getting up from breakfast. She tried to leave the house but was out of breath getting into her car. She had no cough, chest pain, diaphoresis or calf pain. She has had no recent travel, surgeries or trauma, though her physical activity has been very limited by chronic back and left hip pain. She had superficial thrombophlebitis during her three pregnancies but has never had any other abnormal clotting. Initial ED vital signs 98.3, 97, 122/68, 18 and 95RA. ED exam notable for mild tachycardia, guaiac negative. Initial labs concerning for elevated DDimer > 1063 and mild anemia Hct 34.7. EKG with sinus tachycardia, RBBB but no e/o RV strain. Obtained CTA that revealed large thrombus in right main pulmonary artery. Given Dilaudid 1mg IV, Plavix 600mg PO (for initial presumed ACS), Heparin bolus & gtt and Integrillin bolus (did not continue on gtt). Has gotten approximately 1L fluid in IV medications. No Echo performed while in ED. Of note, patient recently saw Rheumatology for evaluation of a [**First Name9 (NamePattern2) 9374**] [**Doctor First Name **]. Initial labs revealed normal CBC, ESR, CRP and negative [**Doctor First Name **], anti-Sm, RNP, RO and LA. She was also recently told that she has iron deficiency anemia and should start taking iron. She has had chronic stable angina for over a decade that has not been an issue for the last 3 months, partly due to decreased activity. She has chronic back and left hip pain that restricts her movements. Her right ankle occasionally swells, and was swollen yesterday. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: - CAD, per Kannum note [**2107-8-23**] has single vessel disease with a tight proximal coronary lesion - Type II DM - Hypertension - Hyperlipidemia - Hypothyroidism - s/p laminectomy x2 - s/p appendectomy and cholecystectomy - s/p TAH and oophorectomy - s/p multiple hernia operations - s/p total knee replacement - s/p tonsillectomy Social History: Lives with husband and son in [**Name (NI) 4628**]. Has three children and three grandchildren. -Tobacco history: smoked 2-3 packs/day for 15 years, quit 20+ years ago. -ETOH: rare EtOH -Illicit drugs: none Family History: No family history of abnormal clotting. One brother died of an MI in his early 50s. Father died of MI at 71, mother of leukemia at 63; otherwise non-contributory. Physical Exam: VS: T=98.9 BP=115/61 HR=95 R=20 O2 sat= 99% on 2L GENERAL: Obese female breathing comfortably. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. tachycardic but regular, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Obese, soft, NTND. No HSM or tenderness. No abdominal bruits. EXTREMITIES: Mild right calf pain, no left calf pain. No peripheral edema. SKIN: Mild LE venous insufficiency. No ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+ Pertinent Results: [**2119-6-28**] 10:45AM WBC-6.9 HCT-34.7 PLT COUNT-242 COAGs: PT-12.1 PTT-25.0 INR(PT)-1.0 CE: CK-MB-6 cTropnT-0.03* CK(CPK)-206* 137 | 101 | 15 4.4 | 25 | 0.8 [**2119-6-28**] 01:01PM D-DIMER-1063* UCx ([**2119-7-1**]): Proteus mirabilis [**2119-6-30**] 11:20 am URINE Source: CVS. **FINAL REPORT [**2119-7-2**]** URINE CULTURE (Final [**2119-7-2**]): PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S DISCHARGE LABS [**2119-7-7**] 07:00AM BLOOD WBC-10.3 RBC-4.11* Hgb-10.8* Hct-34.3* MCV-83 MCH-26.2* MCHC-31.5 RDW-16.3* Plt Ct-233 [**2119-7-7**] 07:00AM BLOOD Glucose-123* UreaN-14 Creat-0.6 Na-133 K-4.3 Cl-98 HCO3-25 AnGap-14 [**2119-7-6**] 06:50AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.9 [**2119-7-1**] 07:35AM BLOOD TSH-1.0 [**2119-7-7**] 07:00AM BLOOD PT-14.8* PTT-89.5* INR(PT)-1.3* IMAGING CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2119-6-28**] 1:44 PM 1. Large pulmonary embolus in the right main pulmonary artery extending into the lobar branches. No evidence of right heart strain or pulmonary infarct. 2. Fatty liver. 3. Prominent anterior mediastinal nodes not meeting CT criteria for pathologic enlargement; however, recommend CT followup in six months to ensure stability. LENIs ([**2119-6-29**]) 1. No evidence of acute DVT. 2. Chronic thrombus within the greater saphenous vein on the right from the mid thigh to the calf. This has improved from prior. Abd/Pelvis CT non-contrast ([**2119-7-1**]): 1. Large right proximal/medial thigh hematoma, located in the adductor compartment. No intra-abdominal retroperitoneal hematoma. 2. Degenerative change in lumbar spine. Superior endplate depression at L2 which is unchanged from prior MRI. Portable TTE (Complete) Done [**2119-6-29**] at 11:06:09 AM FINAL The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). The right ventricular cavity is moderately dilated with focal basal free wall hypokinesis. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [**2117-6-7**], the right ventricle is more dilated with basal hypokinesis and evidence of volume overload. The left ventricular function is similar. Brief Hospital Course: # PULMONARY EMBOLISM: Patient w/ acute onset shortness of breath, CTA showed large amount of clot in the right main pulmonary artery extending into the lobar branches. Patient was hemodynamically stable and was oxygenating well on nasal cannula. She was started heparin gtt to maintain PTT between 60 and 100 seconds. She was started on bridge to coumadin on [**2119-6-29**]. TTE on [**2119-6-29**] showed right ventricle dilated with basal hypokinesis and evidence of volume overload. The left ventricular function was similar to prior study in [**2116**]. Bilateral lower extremity ultrasound showed no DVT but a large thrombus in the right saphenous vein, present on prior study in [**2116**], thought to be improved. Vascular and interventional cardiology were contact[**Name (NI) **] about the possibility of this chronic superficial thrombus being the culprit for her large PE. As this was a possibility, an IVC filter was placed on [**2119-6-29**]. Patient remained stable and was transferred to the floor on [**2119-6-30**]. Patient continued to have pain at right groin after procedure that was caused by a large thigh hematoma. Of note she is up to date on breast and colon cancer screening, is not taking HRT, is a non-smoker and has no family history of clotting. Most likely contributing factor is immobilization after lumbar surgery and chronic pain issues. She will need at least 6 months of anticoagulation for an unprovoked pulmonary embolus. A hypercoagulable workup is not indicated at this time as patient has already started heparin. # RIGHT THIGH HEMATOMA: Patient complained pain the morning of [**2119-7-1**] and had a tense ecchymosis on the underside of her right thigh. Her Hct fell overnight from 34 to 28, so a non-contrast abdominal and pelvic CT was done, revealing a 11 by 11cm hematoma in her right thigh. A total of 4U PRBC were transfused. A tensor bandage was also placed on [**2119-7-1**]. Once HCT stable, Warfarin was resumed and physical activity was advanced without evidence of further bleeding. # CORONARIES: Patient had no chest pain and cardiac enzymes were negative. She was continued on Aspirin and simvastatin. Home doses of diltiazem and lisinopril were initially held in setting of acute PE. # PUMP: There were no signs of RV overload on physical exam or on CTA. TTE showed EF>55% stable from last echo in [**2116**]. # RHYTHM: Patient had sinus tachycardia on telemetry throughout most of stay in CCU and mildly sinus tach on [**Hospital Ward Name 121**] 3 (HR 90s), likely compensatory. # HYPONATREMIA: Patient became hyponatremic in the CCU. Urine LYTES showed an osm of 616 and Na 52. UA showed glucose, could partially explain high Osms but dilution by osmosis outwards would also be expected. In summary, pt likely in SIADH which was treated with fluid restriction (<1600cc free water, broth and fortified drinks). her Na at time of d/c was 133. # DIABETES MELLITUS: Patient reports that she is well controlled with insulin and metformin. On admission, Metformin was held for 72 hours after dye load of CTA. Continued home doses of insulin NPH as well as Humalog insulin sliding scale. # MICROCYTIC ANEMIA: No melena or BRBPR. Patient was started on ferrous sulfate. # CHRONIC BACK PAIN: Patient was continued on home doses of Vicodin and gabapentin for chronic back pain s/p laminectomies. Pt also preferred stay in a chair to manage her back pain. # HYPERLIPIDEMIA: Continued simvastatin 20mg Qdaily and ezetimibe 10mg Qdaily # GERD: Continued omeprazole 20mg # HYPOTHYROIDISM: TSH [**5-/2119**] was normal. Continued levothyroxine 137 mcg. # Lymphadenopathy on CT: CT showed prominent anterior mediastinal nodes not meeting CT criteria for pathologic enlargement; however, recommend CT followup in six months to ensure stability. Medications on Admission: Alendronate 70 mg Tablet one Tablet(s) by mouth every week BD 31G NEEDLES FOR HUMULIN PEN AS DIRECTED [**2117-11-23**] Clomipramine [Anafranil] 50 mg Capsule 2 (Two) Capsule(s) by mouth once a day Diltiazem HCl [Cardizem SR] 120 mg Capsule, Sust. Release 12 hr 1 tab Capsule(s) by mouth twice a day Ezetimibe-Simvastatin [Vytorin [**10-10**]] 10 mg-20 mg Tablet 1 Tablet(s) by mouth once a day Fexofenadine 60 mg Tablet one Tablet(s) by mouth twice a day Gabapentin 300 mg Capsule one Capsule(s) by mouth three times a day Insulin Lispro [Humalog] 100 unit/mL Solution per sliding scale four times a day Levothyroxine 137 mcg Tablet one Tablet(s) by mouth daily Lisinopril 20 mg Tablet 1 Tablet(s) by mouth once a day Metformin 500 mg Tablet two Tablet(s) by mouth twice a day Nitroglycerin 0.4 mg Tablet, Sublingual 1 Tablet(s) sublingually once a day Omeprazole 20 mg Capsule, Delayed Release(E.C.) one Capsule(s) po daily Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet one packet by mouth twice a day * OTCs * Aspirin 325 mg Tablet one Tablet(s) by mouth daily Calcium Carbonate 600 mg (1,500 mg) Tablet 1 Tablet(s) by mouth twice a day Insulin NPH Human Recomb [Humulin N] 100 unit/mL Suspension 22 units every morning, 42 units at night Psyllium [Metamucil] 0.52 gram Capsule one Capsule(s) by mouth daily Discharge Medications: 1. Outpatient Lab Work Please check your INR on [**2119-7-8**] and call results to Dr.[**Name (NI) 14510**] office at [**Telephone/Fax (1) 3393**] 2. Clomipramine 50 mg Capsule Sig: Two (2) Capsule PO once a day. 3. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a day. 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). 7. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Psyllium Packet Sig: One (1) Packet PO BID (2 times a day). 11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: Do not take more than 8 tablets per day. [**Month (only) 116**] cause drowsiness, no driving . Disp:*30 Tablet(s)* Refills:*0* 12. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Disp:*90 Tablet(s)* Refills:*2* 13. Vytorin [**10-10**] 10-20 mg Tablet Sig: One (1) Tablet PO once a day. 14. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 15. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 16. Lovenox 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous twice a day. Disp:*6 syringes* Refills:*2* 17. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Pulmonary Embolisism Right thigh hematoma (adductor compartment) Diabetes Mellitus type 2 Hypertension Hypothyroid Discharge Condition: stable, ablt to ambulate Hct 34, Na 133, INR 1.3 Discharge Instructions: You had a large blood clot in your lungs that caused you to be short of breath. You were started on a heparin drip and transitioned to coumadin, a strong blood thinning pill. You will need to be on coumadin for at least 6 months and probably longer. It is important that the coumadin level (INR) be between 2.0 and 3.0. Until your coumadin level is 2.0 or more, you will need to take Lovenox injections twice daily. Your coumadin dose will need to be adjusted by Dr.[**Name (NI) 14510**] office. You should call Dr. [**First Name (STitle) **] if your breathing worsens again or if you develop chest pain. also call Dr. [**First Name (STitle) **] for any fevers, chills, bloody or dark stools, vomiting blood, a racing pulse or any other concerning symptoms. Medication changes: 1. Lovenox 110 mg twice daily 2. Coumadin 7.5 mg daily 3. Vicodin for pain. Please take only as needed, will make you constipated so eat fiber and take colace and senna as needed. No driving while taking this medicine. There were enlarged lymph nodes noted in your chest. These are probably not significant but the radiologist has recommended that a chest CAT scan be repeated in 6 months. Followup Instructions: Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**7-11**] at 11:30 am. You can reach her office at: [**Telephone/Fax (1) 3393**] Please follow-up with your cardiologist, Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] on [**2119-10-31**] at 11 am. You can reach his office at: [**Telephone/Fax (1) 5068**]. You also have an appointment with your psychiatrist, Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 12056**] on [**9-7**] at 10:40am. You can reach her office at: [**Telephone/Fax (1) 1387**] You also have an appointment with your orthopedic physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) 7111**] on [**2121-4-18**] at 9:30am. You can reach his private office at [**Telephone/Fax (1) 11262**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "276.1", "453.8", "250.00", "785.6", "415.19", "413.9", "530.81", "280.9", "998.12", "338.29", "E879.8", "244.9", "414.01", "272.4", "724.2", "401.9" ]

icd9cm

[ [ [] ] ]

[ "38.7" ]

icd9pcs

[ [ [] ] ]

14730, 14787

7883, 11700

308, 346

14946, 14997

4274, 7860

16216, 17223

3209, 3375

13079, 14707

14808, 14925

11726, 13053

15021, 15781

3390, 4255

15801, 16193

261, 270

374, 2612

2634, 2969

2985, 3193

21

111,970

7238

Discharge summary

report

Admission Date: [**2135-1-30**] Discharge Date: [**2135-2-8**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: Transfer from Nursing home for fever and elevated white count Major Surgical or Invasive Procedure: none History of Present Illness: 87 yo M with PMH of DM, CAD, ESRD on HD who was transferred from [**Hospital 26563**] Rehab to ED for eval of Fever. . Per referal note, patient 2 days ago developed increase leukocytosis and delirim. Apparently, he was started on iv vancomycin, Flagyl and Ceftazidime for PNA. On day of admission patient developed a fever to 101.2, pulse 76 BP 102/68R 18 and sat 92%. Blood Cx and Urine Cx were drawn. . Of note he was recently operated on by vascular [**Doctor First Name **] for a R sup femoral and [**Doctor Last Name **] angioplasty and stenting along with Left femoral patch angioplasty with bovine patch. He was discharged home on Levoflox for probable RLL PNA . In the ED, VS 100.8 HR 85 BP 81/28 RR 20 Sats 95%. A femoral line was placed and he was given 1000 cc NS. Given pooor response, and after CVP measure 12, patient was started on levophed and transfer to [**Hospital Unit Name 153**]. Past Medical History: PAST MEDICAL HISTORY: 1. ESRD secondary to hypertensive nephrosclerosis s/p right upper extremity AV graft 9'[**56**]'[**33**] in preparation for dialysis. Graft placement was complicated by cellulitis, for which he was treated with keflex 2. DM, on glyburide and glipizide at home 3. HTN, on clonidine, lisinopril, nifedipine 4. PVD s/p aortic bypass 5. CVA, with residual weakness of his left side 6. R CEA 7. Secondary hyperparathyroidism 8. Chronic anemia on procrit injections 9. Prostate CA on Lupron 10. Gout Social History: Denies past or present Tob, EtOH, or Illicit drug use. Was living at a senior facility in [**Location (un) 745**] with his wife prior to last admission. Now at [**Hospital 100**] Rehab. Family History: NC Physical Exam: T 99.7 BP 114/60 Hr 78 RR Sats 98% 4 L NC General: Patient in mild apparent distress, alert, responding to questions HEENT: dry oral mucose, no LAD, JVD Lungs: crackles bilaterally CV: Regular heart sounds, soft holosystolic murmur RLSB Back: sacral ulcers Abdomen: BS +, soft, non tender non distended Extremities: cold, distal pulses decreased, heel ulcers bilaterally, necrotic. 3-4th underneath nail toe right foot black. RU extremiti AVF , no trhill, no erythema. Left upper extremity- picc line Right femoral line in place Neuro: patient alert, oriented to person, movilizing grossly all extremities. Pertinent Results: [**2135-1-30**] 07:18PM LACTATE-1.6 [**2135-1-30**] 07:05PM GLUCOSE-200* UREA N-49* CREAT-4.2*# SODIUM-137 POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-23 ANION GAP-19 [**2135-1-30**] 07:05PM CORTISOL-19.5 [**2135-1-30**] 07:05PM WBC-30.5*# RBC-3.05* HGB-9.1* HCT-29.6* MCV-97 MCH-29.8 MCHC-30.7* RDW-16.9* [**2135-1-30**] 07:05PM NEUTS-89* BANDS-1 LYMPHS-5* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2135-1-30**] 07:05PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ [**2135-1-30**] 07:05PM PLT SMR-NORMAL PLT COUNT-275 [**2135-1-30**] 07:05PM PT-18.1* PTT-31.7 INR(PT)-1.7* Brief Hospital Course: Assessment and plan: 87 yo M with MMP including DM, HTN, CAD, PVD on HD with L arm fistula presents with septic shock. . 1. Sepsis: The pt was found to be hypotensive and febrile in the ED and admitted through sepsis protocol. He was infused with muliple boluses of normal saline, put on levophed for blood pressure support. He was covered with broad spectrum antibiotic empirically as culture data was sent. Blood cultures were found to be positive for gram postive cocci which was ultimately shown to be VRE. Vancomycin was changed to linezolid. The pt remained hypotensive on pressors for the next several days and a work-up was initiated to determine the source of infection. MRI of the foot was pursued to r/o osteomyelitis, and a CT of the abdomen was down to r/o an abdominal source of infection. The CT Abdomen and pelvis showed possible abscess in liver and spleen. There was also pancolitis. GI and Surgery were [**Year/Month/Day 4221**] for assistance in the management of these problems. For the pancolitis, the pt was kept NPO and he was treated for possible c. diff infection while c. diff cultures were sent and found to be positive. A RUQ U/S [**2135-2-2**] was pursued which showed evidence of hypoechoic lesion could be flegmon or mass. It was unable to be confirmed on imaging whether these lesions on CT which were new compared with a previous scan in [**10-1**] were abscesses vs possible mets from an unknown primary. IR was [**Date Range 4221**] for possible drainage or biopsy, however option declined given localization of lesions and the pts significant bleeding risk. The GI team suggested an MRI to further evaluate the liver lesions although this was unable to be pursued because the pt was too unstable requiring pressors for bp support. A TTE Echo was done to r/o endocarditis or abscess and was negative. Head CT was negative for abscess as well. . 2. CMO: On the morning of [**2135-2-6**], the ICU team discussed with Mr [**Known lastname **] wife and daughter the different alternatives for Mr [**Known lastname **] care. It was explained that the feeling of the medical staff and nurse staff was that Mr [**Known lastname **] has been extremily uncomfortable with all the procedures that he undergoes during the day. Despite giving pain medicines he has shown signs of a lot of discomfort. We explained to the family that we would need a NGT place in order to feed him and give him some of his medicines now that he is having trouble swallowing given his mental status. Also we have explained that we still not have a clear dx on his liver lesions, and in order to obtained a dx he might need a surgical intervention for biopsy. It would be a long road ahead before he is able to go back to where he was previously. Ms [**Known lastname **] feels that her husband would not want to have all this procedures done along the road and that we should change the focus of care towards making him as comfortable as possible. The antibiotics and pressors were d/c'ed. The plan was to have no more dialysis. There were no more lab draws. A morphine drip was started for pain. The pt remained arousable though sleepy. His blood pressure was in the 80s-90s systolic off pressors and his extremities continued to show evidence of perfusion. On the evening of [**12-10**], he skin became more pale and his sensorium less alert. At 2:08 am he was found to have ceased respirations and was without a heart rate on the monitor. By 2:15 am he was pronounced deceased. . 2. CAD: h/o MI. Continued sinvastatin, aspirin until made CMO. BB and BP medications were held in the setting of hypotension . 3. Peripheral vascular disease: continued plavix, Aspirin until CMO The vascular team followed the pt. . 4. DM: insulin sliding scale was continued before the pt was made CMO. . #. ESRD: The pt continued to recieve periodic dialysis sessions while in house until he was made CMO. . #. FEN: He was kept NPO given the colitis and sepsis. . # Hypothyroidism: continued levothyroxine until CMO. . # PPX: Pantoprazole, pneumoboots until CMO. . #Code: DNR-DNI was changed to CMO on [**2-6**] . # Communication: Next of [**First Name8 (NamePattern2) **] [**Known lastname **], [**First Name3 (LF) **] wife, [**Numeric Identifier 26800**] Medications on Admission: 1. Clopidogrel 75 mg qday 2. Docusate Sodium 100 mg [**Hospital1 **] 3. Epoetin Alfa Injection 4. Sertraline 100 mg daily 5. Fexofenadine 60 mg [**Hospital1 **] 6. Amiodarone 200 mg qd 7. Aspirin 325 mg qday 8. Insulin Glargine 10u/hs. 9. Lisinopril 5 mg day 10. Multivitamin daily. 11. Oxycodone 5 mg q4h-6h 12. Pantoprazole 40 mg /day 13. Senna 8.6 mg [**Hospital1 **] 14. Levothyroxine 50 mcg /daily 15. Metoprolol Succinate 25 mg sustain release 16. Simvastatin 40 mg /daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: gram positive VRE sepsis Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "443.9", "995.92", "008.45", "511.9", "250.00", "V09.80", "427.31", "682.3", "274.9", "707.09", "244.9", "414.01", "785.52", "438.89", "285.9", "998.59", "572.0", "038.8", "E878.8", "403.91", "185" ]

icd9cm

[ [ [] ] ]

[ "00.14", "39.95", "89.61" ]

icd9pcs

[ [ [] ] ]

8137, 8146

3322, 7577

323, 329

8214, 8224

2670, 3299

8277, 8410

2024, 2028

8108, 8114

8167, 8193

7603, 8085

8248, 8254

2043, 2651

222, 285

357, 1262

1306, 1802

1818, 2008

27,102

173,070

19149

Discharge summary

report

Admission Date: [**2200-10-17**] Discharge Date: [**2200-10-22**] Date of Birth: [**2123-12-6**] Sex: M Service: SURGERY Allergies: Lisinopril / Macrobid Attending:[**First Name3 (LF) 1556**] Chief Complaint: Patient admitted with 10 hours of abdominal and back discomfort. Major Surgical or Invasive Procedure: Image guided percutaneous drainage of the gallbladder with percutaneous transhepatic cholecystostomy drain placement - [**2200-10-18**]. History of Present Illness: HPI: 76 year-old M with history of prostate CA presents with abdominal and back discomfort that began at 10 hrs ago. Pain was associated with nausea but no vomiting. He has not been hungry over the past 10 hrs. Patient reports he has had pain like this on several occasions before. The pain this time is lasting longer than most of his prior episodes and is causing more back discomfort. At the time of examination, he states his back pain is worse than his abdominal pain. The pain in his abdomen is in his RUQ and RLQ. He has not have fevers but he has felt chills. Past Medical History: Adenocarcinoma of the prostate- biopsy [**2199-6-24**] ([**Doctor Last Name **] 9+10 prostate cancer recently started on casodex will be transitioned to lupron) Benign Prostatic Hypertrophy s/p TURP with GreenLight [**10-8**] COPD Low back pain Type II Diabetes - not on insulin Diastolic Congestive Heart Failure - echo [**2197**] with EF 55%, resting regional wall motion abnormalities include basal inferior akinesis. Coronary Artery Disease: Mild, reversible inferior wall defect on stress MIBI [**6-5**] Hypertension GERD Obstructive Sleep Apnea on CPAP (intermittently) Migraine Headaches Hypercholesterolemia Social History: The patient has never smoked. He previously used alcohol but quit many years ago. He is married and lives with his wife. [**Name (NI) **] previously worked in aggriculture but is now retired. Family History: His mother is deceased and had heart disease. His father is also deceased but had no health problems to the patient's knowledge. Physical Exam: VS: T 99.2, HR 75, BP 188/93, RR 14, 99%RA GEN: NAD, A&O x 3 LUNGS: decreased BS B/L, wheezing R>L CV: RRR, nl S1 and S2 ABD: Soft, mildly TTP in RUQ and RLQ, RUQ>RLQ, no guarding, no rebound, obese EXT: 1+ edema of LE B/L Pertinent Results: [**2200-10-17**] 01:00AM BLOOD WBC-12.0*# RBC-4.12* Hgb-10.1* Hct-31.8* MCV-77* MCH-24.6* MCHC-31.8 RDW-15.5 Plt Ct-373 [**2200-10-19**] 04:10AM BLOOD WBC-12.4* RBC-3.31* Hgb-8.3* Hct-25.0* MCV-76* MCH-25.1* MCHC-33.2 RDW-15.9* Plt Ct-282 [**2200-10-22**] 06:40AM BLOOD WBC-11.1* RBC-3.80* Hgb-9.5* Hct-28.1* MCV-74* MCH-24.9* MCHC-33.7 RDW-15.8* Plt Ct-394 [**2200-10-21**] 07:00AM BLOOD Neuts-63.5 Lymphs-25.4 Monos-6.8 Eos-3.9 Baso-0.5 [**2200-10-18**] 09:41AM BLOOD PT-13.5* PTT-28.0 INR(PT)-1.2* [**2200-10-18**] 07:40AM BLOOD PT-13.5* PTT-28.1 INR(PT)-1.2* [**2200-10-17**] 01:00AM BLOOD Glucose-158* UreaN-21* Creat-1.2 Na-137 K-6.1* Cl-102 HCO3-24 AnGap-17 [**2200-10-22**] 06:40AM BLOOD Glucose-100 UreaN-12 Creat-1.0 Na-140 K-3.5 Cl-100 HCO3-27 AnGap-17 [**2200-10-22**] 06:40AM BLOOD ALT-25 AST-38 AlkPhos-128* TotBili-0.4 [**2200-10-17**] 01:00AM BLOOD Lipase-62* [**2200-10-20**] 06:25AM BLOOD Lipase-37 [**2200-10-17**] 01:00AM BLOOD Albumin-4.1 Calcium-8.5 Phos-3.4 Mg-2.0 [**2200-10-22**] 06:40AM BLOOD Calcium-7.7* Phos-3.2 Mg-2.1 [**2200-10-17**] ultrasound - IMPRESSIONS: As before, there is echogenic material seen at the neck of the gallbladder which does not move on left lateral decubitus positioning. Density, including tiny punctate calcific density, was seen in this region also on prior CT. This probably represents a sludge ball, with at least a tiny stone. However, given persistence and unchanged appearance and location of findings over multiple studies, MRCP is recommend at this time to exclude enhancing mass. Brief Hospital Course: Patient admitted to hospital, ultrasound and labs obtained. Because of the patient's extensive history including cardiac disease it was decided that the best course of treatment would be to place a PTC to drain area. This was accomplished on [**2200-10-18**]. Patient was given antibiotics and fluid, serial abdominal exams were performed using interpreter. Patient's pain gradually resolved and he is now on his diabetic/cardiac diet. We will discharge him to home with VNA services to monitor his PTC drain. Drain teaching has been done via interpreter. He will also receive physical therapy to strengthen to prehospital status. He will continue antibiotics for a total course of 10 days. Follow up with Dr. [**Last Name (STitle) **] has been arranged for [**2200-10-31**], we will check his CBC at this time. All discharge instructions have been given to him via spanish interpreter. Medications on Admission: 1. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-7**] hours as needed for fever or pain. 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 14. Maalox 200-200-20 mg/5 mL Suspension Sig: 15-30 mL PO every six (6) hours as needed for heartburn. 15. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 16. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Medications: 1. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-7**] hours as needed for fever or pain. 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 14. Maalox 200-200-20 mg/5 mL Suspension Sig: 15-30 mL PO every six (6) hours as needed for heartburn. 15. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 16. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 17. K-Dur 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:*2* 18. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 6 days: In Spanish please. Disp:*18 Tablet(s)* Refills:*0* 19. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days: In Spanish please. Disp:*12 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. Cholelithiasis 2. Acute cholecystitis Discharge Condition: Good Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-11**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. . General Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. *Wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 305**] Date/Time:[**2200-10-31**] 1:30. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**]. . Other Appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2200-11-25**] 1:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2200-12-31**] 10:20 Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) 4322**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2201-1-13**] 11:00 Completed by:[**2200-10-22**]

[ "327.23", "428.32", "414.01", "724.5", "041.89", "346.90", "600.00", "574.00", "428.0", "V87.41", "530.81", "185", "493.20", "272.4", "401.9", "250.00" ]

icd9cm

[ [ [] ] ]

[ "51.01" ]

icd9pcs

[ [ [] ] ]

8169, 8227

3918, 4808

348, 487

8312, 8319

2347, 3895

11079, 11790

1957, 2088

6277, 8146

8248, 8291

4834, 6254

8343, 9798

9814, 11056

2103, 2328

244, 310

515, 1088

1110, 1728

1744, 1941

28,494

199,133

33303

Discharge summary

report

Admission Date: [**2198-2-10**] Discharge Date: [**2198-2-23**] Date of Birth: [**2119-3-20**] Sex: F Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3190**] Chief Complaint: Hypotensive, bradycardic, hypoxic and unresponsive on evaluation at rehab unit. Major Surgical or Invasive Procedure: I&D posterior cervical hematoma X 2 Trach & PEG History of Present Illness: 78 yo female recently underwent posterior cervical laminectomy [**2-5**] at OSH with subsequent discharge to rehab. At rehab was found hypotensive, bradycardic, hypoxic and unresponsive. Was taken to [**Hospital1 18**] for emergent management. Past Medical History: Breast CA Spinal stenosis HTN Dysphagia Syncope Seizure [**12-23**] to ETOH abuse ?peritoneal carcinomatosis ?afib Social History: +EtOH in past Family History: N/C Physical Exam: Patient intubated and arousable Able to follow commands Right forehead ecchimosis; staples intact posterior c-spine BUE- no movement spontaneously and does not withdraw to pain; biceps, triceps reflexes absent BLE- moves spontaneously and withdraws to nail bed pressure; upgoing toes on Babinski; no clonus; patellar reflexes 2+ bilaterally + rectal tone Pertinent Results: [**2198-2-15**] 01:47AM BLOOD WBC-13.4* RBC-3.25* Hgb-9.7* Hct-27.6* MCV-85 MCH-30.0 MCHC-35.2* RDW-17.3* Plt Ct-189 [**2198-2-14**] 02:41AM BLOOD WBC-15.1* RBC-3.17* Hgb-9.9* Hct-26.6* MCV-84 MCH-31.3 MCHC-37.2* RDW-16.6* Plt Ct-154 [**2198-2-13**] 04:17PM BLOOD Hct-24.9* [**2198-2-13**] 01:10AM BLOOD WBC-17.4* RBC-3.66*# Hgb-11.1*# Hct-30.4*# MCV-83 MCH-30.4 MCHC-36.7* RDW-15.5 Plt Ct-114* [**2198-2-12**] 08:13PM BLOOD WBC-13.9* RBC-2.81* Hgb-8.7* Hct-23.4* MCV-83 MCH-30.9 MCHC-37.0* RDW-15.5 Plt Ct-113* [**2198-2-12**] 04:08PM BLOOD Hct-22.2* [**2198-2-12**] 08:07AM BLOOD Hct-26.5* [**2198-2-15**] 01:47AM BLOOD Plt Ct-189 [**2198-2-15**] 01:47AM BLOOD PT-10.0* PTT-33.2 INR(PT)-0.8* [**2198-2-14**] 02:41AM BLOOD PT-10.2* PTT-33.4 INR(PT)-0.8* [**2198-2-15**] 01:47AM BLOOD Glucose-120* UreaN-33* Creat-1.0 Na-139 K-3.8 Cl-107 HCO3-18* AnGap-18 [**2198-2-13**] 01:10AM BLOOD Glucose-113* UreaN-29* Creat-1.2* Na-135 K-4.2 Cl-105 HCO3-23 AnGap-11 [**2198-2-12**] 02:12AM BLOOD Glucose-141* UreaN-25* Creat-1.0 Na-136 K-4.6 Cl-109* HCO3-21* AnGap-11 [**2198-2-11**] 10:05AM BLOOD Glucose-195* UreaN-25* Creat-0.9 Na-139 K-4.4 Cl-108 HCO3-21* AnGap-14 [**2198-2-15**] 01:47AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.1 [**2198-2-13**] 01:10AM BLOOD Calcium-8.2* Phos-4.2 Mg-1.9 [**2198-2-15**] 01:47AM BLOOD WBC-13.4* RBC-3.25* Hgb-9.7* Hct-27.6* MCV-85 MCH-30.0 MCHC-35.2* RDW-17.3* Plt Ct-189 [**2198-2-14**] 02:41AM BLOOD WBC-15.1* RBC-3.17* Hgb-9.9* Hct-26.6* MCV-84 MCH-31.3 MCHC-37.2* RDW-16.6* Plt Ct-154 [**2198-2-13**] 01:10AM BLOOD WBC-17.4* RBC-3.66*# Hgb-11.1*# Hct-30.4*# MCV-83 MCH-30.4 MCHC-36.7* RDW-15.5 Plt Ct-114* [**2198-2-12**] 08:13PM BLOOD WBC-13.9* RBC-2.81* Hgb-8.7* Hct-23.4* MCV-83 MCH-30.9 MCHC-37.0* RDW-15.5 Plt Ct-113* Brief Hospital Course: Ms [**Known lastname **] was stabilized in the EW and a CT scan was performed. A large collection measuring approximately 4.4 x 7.2 cm in the axial dimension and 4.5 cm in a craniocaudad dimension is extending along the posterior elements of C2, C3, C4, C5, and C6. This collection demonstrates fluid-fluid level with hematocrit effect consistent with hematoma. The fluid collection compresses the cord at multiple levels, which is most prominent at the level of C3, C4, and C5. The patient is status post laminectomy at the level of C3, C4, C5. The surgical clips of the recent laminectomy are still noted in the soft tissue of the posterior part of the neck. The Orthopaedic Spine service was consulted and the patient was emergently taken to the OR for an I&D of the posterior cervical hematoma. Please see opertive report for procedure in detail. Ms. [**Known lastname 77310**] hematocrit was noticed to be unstable and a CT of the abdomen was obtained. Her blood coagulation levels were non-therapeutic and these were corrected. CT: There are massive high-density fluid collections in the left chest wall, extending from the upper aspect of the chest wall down to the level of the T12. The collection extends anteriorly, laterally, and posteriorly. The large chest wall hematoma was not present the previous day. Extensive subcutaneous edema is seen, compatible with third spacing. A vascular surgery consult was sought and recommendations followed. She was subsequently transfused to a stable hematocrit with 10 units PRBC, 7ffp and 1 platelets. She was placed in the T/SICU for further monitoring. A follow up CT scan was administered which showed a recollection of the cervical hematoma. She was taken back to the OR for repeat evacuation of the hematoma. Intra-operatively her left wrist was noticed to be unstable and this was imaged. No fracture was identified and a wrist splint was placed for possible ligamentous/soft tissue injury. Multiple attempts to wean Ms. [**Known lastname **] failed as she became apneic during each attempt. She required pressors to maintain blood pressure at 120mmHg systolic. A trach/PEG/IVC filter were placed and tube feeds started. Hematocrit was stable and the chest wall hematoma from the left subclavian injury was unchanged. Upon discharge she was able to move legs bilaterally and perform spontaneous flexion of right hand. She was discharged in stable condition. Medications on Admission: Lisinopril 5' decadron taper prilosec ASA lopressor 25'' HCTZ MVI Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Known lastname **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Known lastname **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Magnesium Hydroxide 400 mg/5 mL Suspension [**Known lastname **]: Thirty (30) ML PO Q6H (every 6 hours) as needed. 4. Chlorhexidine Gluconate 0.12 % Mouthwash [**Known lastname **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 5. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1) syringe Injection ASDIR (AS DIRECTED). 6. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Hospital1 **]: One (1) inj Injection Q8H (every 8 hours) as needed for nausea. 9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs PO Q4H (every 4 hours) as needed. 10. Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN 10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 11. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a day). 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 13. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 14. Lorazepam 0.5-1 mg IV Q4H:PRN anxiety Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Post-operative hematoma, posterior cervical surgical site Left anterior abdominal wall hematoma from Left subclavian artery injury Discharge Condition: Stable Discharge Instructions: Please continue to take your pain medications with an over the counter laxative. Call the clinic if you notice any redness or discharge from the incision site. Call the clinic for any additional concerns or if you experience a fever over 100.4. Physical Therapy: Activity: Out of bed to chair as tolerated Cervical collar: when OOB Treatments Frequency: Please continue to change the dressing daily with dry, sterile gauze. Followup Instructions: Please follow up in the Orthopaedic Spine clinic in two weeks. Call [**Telephone/Fax (1) 11061**] to schedule an appointment. Completed by:[**2198-2-23**]

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Discharge summary

report

Admission Date: [**2117-4-15**] Discharge Date: [**2117-6-12**] Date of Birth: [**2058-1-16**] Sex: M Service: MEDICINE Allergies: Vancomycin / Penicillins Attending:[**First Name3 (LF) 30**] Chief Complaint: Intraparenchymal hemorrhage in patient with recurrent falls secondary to primary progressive MS Major Surgical or Invasive Procedure: Lumbar puncture G-tube Intubation/extubation History of Present Illness: 59 yo man with MS initially admitted with left basal ganglia hemorrhage, then developed hemorrhage on the right side with persistent encephalopathy, now with elevated wbc count and bilateral obturator muscle abscess who is being transferred to the medicine service from the MICU for overnight monitoring for hypotension/tachycardia and concern for sepsis. . Hospital course: Initially admitted on [**2117-4-15**] with recurrent falls and found to have bilateral basal ganglia hemorrhages. Prior to the admission he had been feeling unwell for 3-4 days with increase in baseline cough, increased urinary frequency, and dysuria, worsening lower extremity weakness, and falls while attempting transfer from wheelchair to bed. . He has had persistent encephalopathy (of multifactorial etiology, pna/uti/nite-day cycle reversal. He was tx for a LLL infiltrate (MRSA PNA) and finished a 10 day course of linezolid (vanco allergy), levofloxacin and metronidazole for presumed aspiration pneumonia). On [**5-17**] he was transferred to the MICU for hypotension and an elevated wbc count (21). The fever workup was most notable for an abdominal CT which revealed a fluid collection in the bilateral obturator muscles, for which he underwent an IR guided biopsy on [**5-26**]. He was initially treated for this with levo/flagyl. This was switched to linezolid and zosyn but he developed a rash and eosinophilia and was switched back to levo/flagyl on [**5-21**]. . He was continuing to remain stable with an unclear etiology for the obturator abscesses, when on [**6-2**] he became hypotensive to the 80's systolic and sinus tachycardia to the 130's-140's. His labs that day were also notable for an increase in the WBC from 10 to 23. He was given 2 L NS on the floor, with an improvement of his BP to 98 systolic and persistent tachycardia to 120's. He was then transferred to the MICU for monitoring. In the MICU, his abx were broadened to po Vanc (to cover for cdiff), Aztreonam, Linezolid (given h/o MRSA PNA), and levo/flagyl. He received 5.5 L total of NS in the MICU with his BP now stable in the 110's systolic. He continues to have asymptomatic sinus tachycardia into the 110's-120's. . Currently patient is unable to answer any questions as he is lethargic, though arousable. Past Medical History: PMH: -primary progressive MS, dx 99 with oligoclonal bands, white matter changes, followed by Dr. [**Last Name (STitle) **] (neuro) -hx of ? viral encephalitis in '[**05**] Social History: Social Hx: Single, lives alone. Smoked 1.5 packs per day. Used to work as a phototechnician. Now on disability. Wheelchair-bound at baseline but able to transfer Family History: Unremarkable for neurologic disease. Physical Exam: Physical Examination: Tc: 97.2 BP: 134/60 HR: 89 RR: 18 O2Sat.: 94%/RA Gen: WD/WN, sleeping and needed to be physically roused to awaken, dozed off repeatedly during exam but NAD. HEENT: NC/AT. Anicteric. Mucosa extremely dry. Throat erythematous. Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No carotid bruits. Lungs: Coarse anterolaterally. No R/R/W. Cardiac: RRR. S1/S2. No M/R/G. Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Warm and well-perfused. Left leg externally rotated. Abrasion over left forearm. Neuro: Mental status: Sleeping and difficult to arouse. Dozed off if not stimulated or prompted repeatedly. Oriented to person, place, and [**2117-2-14**]. Gave [**Hospital1 1806**] as President but quickly self corrected to [**Last Name (un) 2450**]. Able to recite days of week forwards but only gets to Thursday when going backwards. Speech fluent with fair comprehension and repetition. Naming impaired for low frequency items. Marked dysarthria. No paraphasic errors. No apraxia, no neglect. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. No RAPD. Blinked to threat bilaterally. Unable to see fundi. III, IV, VI: Downward vertical skew of right eye. Did not fully abduct right eye. V, VII: Marked right upper motor neuron facial weakness. VIII: Hearing intact grossly. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk. Spastic tone in lower extremities. Left leg externally rotated at rest. In the upper extremities, strength full with exception of right finger extensors 4+/5. Right pronator drift. In the lower extremities, there is flicker of muscle contraction at IPs but patient unable to overcome gravity. Moves legs laterally on bed but easily overcome by examiner on adduction testing, more so on right. Unable to flex or extend voluntarily at knee joint and legs fall immediately back to bed on quad or ham testing. Bilateral foot drop. [**5-19**] plantar flexion bilaterally. Sensation: Intact to light touch, cold. Limited by somnolence, but impaired JPS and VBS at toes and ankles. Reflexes: Hyperreflexic with LUE>RUE. More symmetric in legs with crossed adductors, 1-2 beats of clonus. Toes up at baseline. Coordination: Slow but accurate finger-nose-finger. Hypometric and kinetic fine finger movements on right compared to left. Clumsy RAMs on right compared to left. Gait: Did not assess. Pertinent Results: [**2117-4-15**] 04:45PM SED RATE-58* [**2117-4-15**] 04:45PM PT-12.6 PTT-23.0 INR(PT)-1.1 [**2117-4-15**] 04:45PM PLT COUNT-330 [**2117-4-15**] 04:45PM POIKILOCY-1+ [**2117-4-15**] 04:45PM NEUTS-80.8* LYMPHS-11.9* MONOS-7.2 EOS-0.1 BASOS-0.1 [**2117-4-15**] 04:45PM WBC-13.2*# RBC-4.40* HGB-14.2 HCT-38.5*# MCV-88 MCH-32.2* MCHC-36.8* RDW-13.4 [**2117-4-15**] 04:45PM ALBUMIN-4.4 CALCIUM-10.5* PHOSPHATE-3.3 MAGNESIUM-2.2 [**2117-4-15**] 04:45PM CK-MB-10 MB INDX-0.4 cTropnT-<0.01 [**2117-4-15**] 04:45PM LIPASE-25 [**2117-4-15**] 04:45PM ALT(SGPT)-28 AST(SGOT)-74* CK(CPK)-2592* ALK PHOS-88 AMYLASE-32 [**2117-4-15**] 04:45PM CK(CPK)-2496* [**2117-4-15**] 04:45PM GLUCOSE-106* UREA N-42* CREAT-1.3* SODIUM-142 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-24 ANION GAP-17 CHEST, UPRIGHT AP VIEW: Comparison is made to [**2113-10-24**]. The heart size is normal. The aortic contour is unchanged. The lungs are clear. There are no pleural effusions or pneumothorax. There is prominence of the soft tissues of the lower neck. IMPRESSION: No radiographic evidence of acute cardiopulmonary process. NON-CONTRAST CT HEAD: There is a small oval hyperdensity seen within the left putamen with surrounding lucency likely indicating intraparenchymal hemorrhage with surrounding edema. There is no shift of normally midline structures. [**Doctor Last Name **]-white matter differentiation is preserved. There is no evidence of blood within the ventricles or elsewhere within the parenchyma. The paranasal sinuses are well aerated. No fractures are seen. IMPRESSION: Small ovoid hyperdensity in the left putamen with surrounding lucency, likely representing intraparenchymal hemorrhage with surrounding edema. No mass effect or other areas of hemorrhage. No hydrocephalus. Recent outside films with similar findings were reviewed with neurology team. [**6-9**] - CT PELVIS WITH IV CONTRAST: Again demonstrated are bilateral fluid collections tracking beneath the fascia of the obturator internus muscles bilaterally. Allowing for slight differences in contrast phase from the prior CT, these appear unchanged in size and in overall appearance. The medial width of the right collection is 1 cm, and the posterior width of the collections are approximately 1 cm respectively. There is no gas within the collections and no destruction of the adjacent osseous structures to suggest osteomyelitis. Mildly prominent prostate again noted. Foley catheter in a nondistended bladder. The rectum and visualized distal large bowel is normal. IMPRESSION: Stable size and appearance of fluid collections, likely abscesses, tracking under the obturator internus muscles bilaterally. [**6-2**] - CT OF THE PELVIS: A Foley catheter is again seen within the bladder lumen. Prostate, seminal vesicles appear unremarkable. The descending sigmoid colon and the rectum are again seen to be distended with air and stool. No pathologic pelvic or inguinal lymphadenopathy is identified. There is no free fluid within the pelvis. Again seen are the fluid collections tracking beneath the fascia of the obturator internus muscle bilaterally. These do not appear significantly changed since the prior study. The largest posterior to the right acetabulum appears to measure approximately 3.4 x 1.2 cm. No foci of air are seen within these collections. There is no evidence of adjacent bone destruction to suggest osteomyelitis. IMPRESSION: Stable appearance to the bilateral fluid collections adjacent to the obturator internus muscles. [**5-25**] - CT OF THE PELVIS: IMPRESSION: 1) Bilateral peripherally enhancing fluid collections, likely abscesses, tracking beneath the fascia of the obturator internus muscles as described above. The left-sided collection was previously present but is slightly more prominent. The right-sided collection is new. 2) Small hypodense lesion in the left lobe of the liver likely a simple cyst but too small to characterize. 3) Bibasilar atelectasis and small bullae at the right lung base. 4) Extensive stool throughout the rectum and colon. Brief Hospital Course: This is a 59 y/o male with history of multiple sclerosis, initially admitted to the neurology service when found to have bilateral basal gangila hemorrhages, and then transferred to the medicine service when found to have persistent fevers and subsequently bilateral obturator abscesses of unknown etiology. . # ID - While in-house developed fever and leukocytosis; CT torso oddly demonstrated collection at L obturator internus muscle; attempt at US-guided aspiration of this area was unsuccessful on [**5-14**]. Empiric therapy with cipro/flagyl helped WBC and fevers somewhat; interval reimaging 5 days later demonstrated collection that was a few mm smaller. Antibiotics were held in an attempt to obtain optimal cultures—at which time he developed hypotension and spent a few days in ICU though did not require pressors. Empiric therapy was reinitiated with linezolid/zosyn (vanc allergic). T remained 98-99s but he had persistent WBC 18-21, with eosinophilia as high as 20%, so was placed on levo/flagyl in case beta-lactam sensitivity was contributing. He developed marked skin erythema of the lower extremities with skin peeling and large, tense blisters of the feet. Derm followed and felt this was due to antibiotics (more specifically, the Zosyn already discontinued). It wasn't certain that this OI collection is the source of his fever/WBC, though other w/u had been otherwise unrevealing. There are a few little chest lesions though not enough to explain leukocytosis. PPD in-house was negative. On [**5-25**], pt underwent repeat CT scn of the Pelvis which revealed bilateral peripherally enhancing fluid collections tracking beneath the fascia of the obturator internus muscle bilaterally, tracking from its origin anteriorly along the surface of the obturator membrane to its insertion posteriorly along the medial surface of the greater trochanter of the femur. Both collections were thin in width and difficult to accurately measure but are approximately 1 cm in maximum diameter, though thinner in majority of the other portions. On [**5-26**], he underwent CT guided drainage of the right abscess which yielded 10cc of blood and pus sent to the lab for cultures. The abscess culture grew out Bacteroides fragilis. The patient was continued on levo/flagyl with improvement in fevers and leukocytosis. However, on [**6-3**], the patient suddenly developed hypotension and leukocytosis (10 to 24), requiring transfer to ICU for goal-directed therapy, including fluids and broad spectrum antibiotcs of levo/flagyl/linezolid/po vanc (tolerated well)/aztreonam. He did not require pressors and stayed in the ICU only for a night. Cx at that time demonstrated a dirty u/a, with pseudomonas in the urine only sensitive to Tobramycin. The patient was started on Tobramycin and all abx except levo/flagyl were peeled off. He responded to the antibiotics with stable vital signs, defervescene, and resolution of the leukocytosis. Repeat CT scans on [**6-2**] and [**6-9**] show decreased size of the bilateral abscesses. The patient finished his course of Tobramycin for the UTI on [**2117-6-11**] (7-day course). He continues to be on IV levo/flagyl for the OI abscesses with an open-end duration at this time, as etiology is unclear and it is uncertain how these abscesses will respond over time to abx. The patient is scheduled to have repeat imaging on [**6-25**] of the OI abscesses and scheduled to see Dr. [**First Name4 (NamePattern1) 4333**] [**Last Name (NamePattern1) 4334**] in [**Hospital **] clinic on [**7-8**], who at that time will determine the duration of the antibiotics. He needs weekly CBC, Chem 10, LFTs, ESR, and CRP checked while at rehab and results to be faxed to Dr. [**Last Name (STitle) 4334**] at [**Telephone/Fax (1) 1419**]. . # Intracranial hemorrhage - Head CT performed at [**Hospital1 18**] was consistent with a left basal ganglia bleed. On initial neurological exam, mental status exam was notable for inattention. Cranial nerve exam notable for right sided skew, abduction paresis, and facial palsy. Lower extremity exam with paraparesis, worsened from last reported exam by Dr. [**Last Name (STitle) **]. The etiology of the bleed was initially unknown. MRI was performed and although limited by motion artifact, revealed no evidence of underlying mass. After transfer to the MICU (see below), he was called back out to the floor on the internal medicine service. There, he initially did well, but had an episode of decreased responsiveness which prompted a repeat CT of the head. This revealed a new right basal ganglia hemorrhage. He was subsequently transferred to the neurology service. After this event, it was noted that the patient's blood pressures were in the 170-180's systolic. This was felt to be the most likely etiology behind the bilateral basal ganglia intracranial hemorrhages. Just to be sure, a stroke consult was called. They agreed that the bleeds were most likely hypertensive. However, a transesophageal echocardiogram was performed and ruled out cardiac valvular vegetations as a source of embolus. In addition, a CT venogram of the head was performed and ruled out venous sinus thrombosis as a cause. The pt's blood pressure was subsequently well-controlled with metoprolol. The patient's mental status has remained stable during his course, notable for intermittent delirium. His neurologic exam also has remained stable. His blood pressures have remained stable off of antihypertensives, which were discontinued due to his hypotension during sepsis episodes. If his pressures increase again, he should be restarted on an antihypertensive to keep SBP<140. He is scheduled to his neurologist, Dr. [**Last Name (STitle) **], for follow-up on [**2117-6-25**]. . # Hypercalcemia - Patient was noted to have hypercalcemia while in-house with serum Ca in the high 10's-low 11's. Patient was asymptomatic. PTH, vitamin D levels, and 24-hour urine were all consistent with primary hyperparathyroidism - elevated PTH, elevated serum Ca, normal vitamin D levels, and urine Ca>300. Endocrine was consulted in-house for recommendations for management. They recommended IVF and increasing free H20 boluses in TF, which was done. The patient, as he is asymptomatic and stable serum calcium for over a month, should follow with an outpatient endocrinologist by calling the number included in the paperwork in the next 1-2 weeks. He needs to have a PTH and calcium checked on [**2117-6-14**]. . #. Encephalopathy/MRSA pneumonia - On the floor, he remained agitated and encephalopathic, with poor attention that worsened at night and improved substantially during the day. He often required restraints at night. The initial workup was negative for toxic-metabolic or infectious etiologies. UA and CXR as well as blood cultures failed to demonstrate any infection that could have precipitated encephalopathy. At admission, he had an elevated CPK as well as BUN/Creatinine - for this early rhabdomyolysis, he was treated with IVF and this improved. The patient was transferred to MICU, however, after found to have hypoxemic respiratory failure secondary to aspiration pneumonia and possible mucus plugging. He was intubated temporarily and a couple of days after intubation, he was extubated without difficulty. For presumed aspiration pneumonia, he was treated with 10 day course of flagyl and levofloxacin. His sputum returned positive for MRSA for which vancomycin was started on [**4-23**]. However, due to papulomacular, blanching rash which developed after vancomycin, vancomycin was discontinued on [**4-28**] and started on linezolid, which was continued for a 10 day course. For left basal ganglial hemorrhage and mental status changes, the patient underwent IR guided LP which was negative for HSV and negative CSF cx for meningitis. The patient was briefly on acyclovir and ampicillin to empirically cover HSV and listeria until cx and HSV pcr came back negative. The patient failed speech and swallow on [**4-26**] and NGT was placed for nutritional support. The patient was intermittently hypotensive in the unit thought to be secondary to infection and responded well to IVF boluses. Adrenal insufficiency was ruled out with a negative cosyntropin stimulation test. He continued to remain encephalopathic. Abdominal CT demonstrated possible left obturator internus muscle abscess, but attempted drainage by IR could not aspirate fluid. Nevertheless, he was empirically treated with broad-spectrum antibiotics. The pt's mental status gradually but slowly improved over the course of the hospital stay, though he continues to remain delirious intermittently and requiring wrist restraints. He has failed repeat speech/swallow studies and needs to be NPO. He can get a video swallow for further evaluation at rehab if needed. . #. Anemia/Guaiac positive stool: The patient does have guaiac postive stools and Hct dropped to 19 at one point in the MICU thought to be secondary to fluids, requiring 2 units of PRBCs, however, no urgent scope was felt necessary and CT of abdomen did not reveal any hematoma. Iron studies were consistent with anemia of chronic disease. His hematocrit eventually stabilized once on the floor. . #. Hypertension: As above, the pt was found to be hypertensive after his second intracranial hemorrhage. His blood pressure was eventually well-controlled with metoprolol. As above, his anti-hypertensives were d/c'd when his sepsis occured with hypotension. His pressures have stabilized off the anti-hypertensives, and he does not require them currently. If he becomes hypertensive again, these meds can be restarted for a goal of SBP<140. . # Sinus tachycardia - patient has been in sinus tachycardia into the 110's for the last few weeks of his course, of unclear etiology. A CT was negative for PE, EKG negative for ischemic changes. Patient was rehydrated with IVF and treated appropriately for his infections. Unlikely this is secondary to infection as he is afebrile and on antibiotics. . #. PPX: PPI, SC hep, RISS, MVI, albuterol prn . #. F/E/N: On tube feeds, has persistently failed speech/swallow evals for PO clearance (most recent [**2117-6-11**]). Recommend video swallow eval in the near future for further evaluation if needed. Continue tube feeds. . #. Access: PICC line placed [**2117-6-11**] . #. Communication: sister [**Name (NI) 26196**] [**Name (NI) 43482**] (HCP) [**Telephone/Fax (1) 43483**]. . #. Code: DNR/DNI - discussed [**6-2**] with patient and health care proxy . Medications on Admission: None. Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4-6H (every 4 to 6 hours) as needed. 4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itchiness. 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 8. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 11. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 12. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane TID (3 times a day) as needed. 13. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 14. Levofloxacin 500 mg IV Q24H 15. Metronidazole 500 mg IV Q8H 16. Outpatient Lab Work Weekly CBC, Chem 10, LFTS, CRP, ESR to be drawn and faxed to Dr. [**First Name4 (NamePattern1) 4333**] [**Last Name (NamePattern1) 4334**] at [**Telephone/Fax (1) 1419**]. First set of labs need to be drawn on [**2117-6-14**], please also check PTH with the above labs on Monday. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Principal: Bilateral obturator abscesses of uncertain etiology Bilateral Basal Ganglia Hemorrhages Hypoxic Respiratory Failure Acute Renal Failure, resolved Aspiration MRSA Pneumonia Multidrug Resistant Pseudomonal UTI Candiduria Primary Hyperparathyroidism Encephalopathy Sacral Pressure Ulcer Vancomycin Hypersensitivity Erythrodermic Rash Zosyn Hypersensitivity Desquamative/Bullous Drug Rash Eosinophilia Cholestasis Secondary Multiple Sclerosis - Primary Progressive Viral Encephalitis Discharge Condition: Stable, afebrile Discharge Instructions: Please continue all mediations as prescribed. Please attend all follow-up appointments. If you experience fevers, shortness of breath, weakness, or other concerning symptoms, please call your primary care doctor, your neurologist, or come to the emergency department for evaluation. - you will need weekly labs (CBC, Chem 10, LFTs, ESR, CRP) to be drawn and faxed to [**First Name4 (NamePattern1) 4333**] [**Last Name (NamePattern1) 4334**], M.D. at [**Telephone/Fax (1) 1419**] - NPO except tube feeds, as patient has failed multiple speech/swallow evals -> he needs a video swallow evaluation while at rehab for re-evaluation Followup Instructions: Neurology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD Phone:[**Telephone/Fax (1) 5434**] Date/Time:[**2117-6-25**] 11:00 ID: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2117-7-8**] PCP: [**Name10 (NameIs) **] up in [**3-19**] weeks Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2117-6-28**] 3:30 - please arrive at 2:30 pm at [**Location (un) **] [**Hospital Ward Name **] - do not EAT OR DRINK 3 HOURS PRIOR (STOP TUBE FEEDS 3 HOURS PRIOR) Endocrine: please schedule an appt for follow-up in [**2-15**] weeks by calling # [**Telephone/Fax (1) 9941**] Completed by:[**2117-6-13**]

[ "482.41", "E930.8", "V09.0", "584.9", "707.03", "305.1", "518.81", "695.1", "728.89", "995.92", "252.01", "V15.88", "401.9", "507.0", "427.89", "792.1", "349.82", "431", "599.0", "038.9", "340" ]

icd9cm

[ [ [] ] ]

[ "96.6", "00.14", "88.72", "96.04", "83.95", "99.04", "96.72", "46.32", "38.93", "03.31" ]

icd9pcs

[ [ [] ] ]

22094, 22191

9840, 20364

380, 427

22727, 22746

5751, 6877

23424, 24141

3129, 3167

20420, 22071

22212, 22706

20390, 20397

830, 2737

22770, 23401

3182, 3182

3204, 3732

244, 342

455, 813

4239, 5732

6886, 9817

3747, 4223

2759, 2934

2950, 3113

62,464

103,163

9566

Discharge summary

report

[** **] Date: [**2171-2-16**] Discharge Date: [**2171-2-21**] Date of Birth: [**2093-5-31**] Sex: F Service: MEDICINE Allergies: Oxycodone / Codeine / morphine / OxyContin Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypotensive, concern for cholangitis Major Surgical or Invasive Procedure: ERCP History of Present Illness: 77F history of CAD, hypertension, atrial fibrillation on coumadin, IBS, epilepsy, diabetes, and dementia presents with ? cholangitis. She is being transferred from [**Location (un) 620**] with fever, elevated LFTs/bili. Her nursing home was concerned about increased abdominal pain, increased LFTs, and hypoxemia. There was also a concern about ? CHF. Labs signifcant for AST 195, ALP 293, ALT 223, Tbili 3.1 (mostly direct - 2.5). She was sent to the ER at [**Location (un) 620**]. VS on transfer were BP 180/80, HR 81, RR 20, T 97.2. At [**Location (un) 620**], initial VS in ER were 100.8 HR: 89 BP: 133/67 Resp: 22 Sat: 98 Normal. Her chief compliant was chest pain intermittent for weeks. She was noted to be lethargic appearing and unable to given an adequate history. Patient also would desat to 85 % depending on position. Exam was significant for skin mottling of lower extremity, cyanotic finger tips, and significant swelling of left leg. Labs performed showed WBC 8.2, Hgb 11.2 (unknown baseline), Hct 34.9, Plt 125 with Diff N 93.6. Lactate was 2.2. Coags significant for INR was 7.6. Chemistry panel showed Na 138 K 4.1 Cl 101 Glu 319 BUN 39 Cr 1.6 (unknown baseline, last Cr 1.1 in [**2167**] and 1.3 in [**2168**]), Ca [**69**].2 (H). LFTs were albumin 3.4, Tbili 3.79, ALP 369, ALT 236, ALT 177. Lipase was wnl. Initial troponin T was < 0.01. ECG showing atrial fibrillation at rate of 96, NA, NI (except QTc 463 ms). No ST/T changes. Compared to prior dated [**2164-1-10**], atrial fibrillation is new. UA showed many bacteria, 0 epi, negative LE/nitrate. Blood cultures were drawn and per prelim report are [**4-24**] for GNR. CXR, Abdominal US, CT Abd and pelvis without contrast were performed. CXR showed minimal opacity in left lung base likely representing atelectasis/scar as there is no obscuration of the hemidiaphgragm. There are low lung volumes, which may represent COPD. Cardiomegaly persists. RUQ US was "negative" per reports. CT abdomen/pelvis showed "no acute abnormality." Patient appeared ill with fever. Impression was sepsis. She was covered with flagyl/levaquin/vancomycin for ? cholangitis. She had gradual worsening of hemodynamics with BP trending down from 130s to 90s for which she received 4 L NS. She was transferred to [**Hospital1 18**] for ICU [**Hospital1 **] and ERCP. In the main [**Hospital1 18**] ED inital vitals were, 0 99.0 80 110/58 22 94% 2L Upon arrival to [**Hospital1 18**] ER, she was complaining of lower abdominal pain and nausea. She was alert and oriented x 2. ERCP was consulted and recommended [**Hospital1 **] to [**Hospital Unit Name 153**] with ? ERCP. She had no further episodes of hypotension in the [**Hospital1 18**] ER. Labs in [**Hospital1 18**] ER were performed. Chemistry panel was within normal limits except BUN 33, Cr 1.4, glucose 227 with no anion gap. LFTs were abnormal with ALT 167, AST 86, AP 257, Tbili 3.2. CBC showed WBC 5.9, Hgb 10, plt 118 with neutrophilia. Coags were significant for INR 8.7, PTT 55.5. She was given zofran and morphine for the aforementioned symptoms. She was also given flagyl 500 mg IV x 1. VS on transfer: HR 83 BP 127/58 RR 22 pOx 100 on 2L . On arrival to the ICU, patient was AAOx3 (unable to name year exactly). She was able to say the days of the weeks backwards. She complained primarily of RUQ abdominal pain. She denied any history of chest pain. Past Medical History: - DM2 (last A1c 7.2 on [**2170-3-2**]) - CAD - atrial fibrillation on coumadin - IBS - epilepsy - meningioma - urinary retention with prior history of UTI - gait abnormality - osteoarthritis - GERD - hypertension - hyperlipidemia - hypercalcemia - bronchitis - Hyperparathyroidism - History of stroke - glaucoma - Depression/personality disorder - Cerebral aneurysm - Pancreatitis mass (?cyst) - ? Recent left lower extremity DVT SURGICAL HISTORY: 1. Total abdominal hysterectomy, [**2119**]. 2. Colectomy for colon cancer, [**2148**]. 3. Meningioma of the right frontal lobe, [**2152**] Social History: Patient denies current alcohol, tobacco, or illicit drug usage Family History: Patient denies family history of hepatic disease Physical Exam: [**Year (4 digits) **] Exam: General Appearance: No acute distress, Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL, Right EJ Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : , Diminished: bases) Abdominal: Soft, Bowel sounds present, Tender: RUQ, - [**Doctor Last Name **] sign Extremities: Right lower extremity edema: Absent, Left lower extremity edema: 3+, ? lymphedema with some patches of erythema with ? cellulitis vs. stasis changes Skin: Warm Neurologic: Attentive, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed, right sided UE and LE weakness, [**4-25**] Pertinent Results: [**Month/Day (1) **] Labs: [**2171-2-16**] 05:46AM BLOOD WBC-5.9 RBC-3.33* Hgb-10.0* Hct-30.2* MCV-91 MCH-29.9 MCHC-33.0 RDW-13.2 Plt Ct-118*# [**2171-2-16**] 05:46AM BLOOD Neuts-89.3* Lymphs-6.0* Monos-3.9 Eos-0.5 Baso-0.3 [**2171-2-16**] 05:46AM BLOOD PT-85.1* PTT-55.5* INR(PT)-8.7* [**2171-2-16**] 05:46AM BLOOD Fibrino-742* [**2171-2-16**] 05:46AM BLOOD Glucose-227* UreaN-33* Creat-1.4* Na-138 K-3.7 Cl-108 HCO3-23 AnGap-11 [**2171-2-16**] 05:46AM BLOOD ALT-167* AST-86* CK(CPK)-23* AlkPhos-257* TotBili-3.2* DirBili-2.7* IndBili-0.5 [**2171-2-16**] 05:46AM BLOOD Lipase-12 [**2171-2-16**] 05:46AM BLOOD CK-MB-1 cTropnT-<0.01 [**2171-2-16**] 05:46AM BLOOD Albumin-3.5 [**2171-2-16**] 09:59AM BLOOD Lactate-1.4 Brief Hospital Course: 77F history of CAD, hypertension, atrial fibrillation on coumadin, prior stroke, epilepsy, diabetes mellitus type II, and dementia presents with cholangitis, sepsis, GNR bacteremia. # Sepsis/cholangitis: Patient meets sepsis criteria on presentation with fever, tachpynea with blood cultures suggestive of high grade bacteremia from GNR (in OSH cultures). Patient was placed on vancomycin and zosyn initially. UA with bacteria, but negative nitrate/LE. CXR not suggestive of pulmonic process initially. Her sacral decubitus ulcer, present on [**Month/Day/Year **], does not appear infected. Hypotension responded to 4 L fluid resuscitation. Intra-abdominal imaging and US at OSH not suggestive of gallstone or other acute intraabdominal process however given RUQ pain, elevated LFTs/Tbili, and fever, ERCP was performed with sphincterotomy, decompression with extraction of pus and stone. Patient remained hemodynamically stable with LFTs improving, on broad spectrum antibiotics, ultimately tailored to ceftriaxone for bacteremia and with flagyl given ? of aspiration pneumonia (see below). # Hypoxemia: Per nursing home notes, there was some concern about a heart failure exacerbation (although do not have formal documentation of such history) with home medications including lasix and spironolactone. She was given lasix for ? tachypnea at nursing home. CXR was without pulmonary edema or other pulmonic process but did have cardiomegaly. Per nursing home notes, concern about CHF given weight increased 9 lbs from [**2170-12-5**]. She has been on lasix 80 mg PO qD since [**Month (only) 359**] in addition to spironolactone. Patient has also been on systemic anticoagulation making PE less likely. Respiratory thought to be secondary to sepsis. Patient given several doses of lasix IV (80mg) after FFP administration, with moderate UOP and stable oxygenation saturation in the mid90s. Trop neg x1. Echo showed preserved function. Patient is at aspiration risk, and though she's been given nectar thick liquids, she may have aspirated contributing to her oxygen sats in the low 90s at times, and repeat chest xray suggested possible aspiration pneumonia in the mid left and lower lung zones. Treated with ceftriaxone and with flagyl (latter for 8 day course total). # Supratherapeutic INR: Reversed for ERCP. Heparin bridge to therapeutic warfarin initiated. Heparin d/c'd once INR over two. At time of discharge INR was 2.8. # ARF: Patient appears to have CKD III-IV at baseline. Baseline Cr around 1.3, but was up to 1.5 during [**Month (only) **]. Likely pre-renal etiology on [**Month (only) **] given insensible losses with fevers with Cr trending down with fluid resuscitation. # Left leg swelling: Patient has reported history of both LLE DVT and ? lymphedema. Per nursing home staff, her leg has been swollen for some time - but unclear history overall. No evidence of DVT on LENI U/S performed at [**Hospital1 18**] this [**Hospital1 **]. # Skin impairments: Stage 3 decubitus ulcer and multiple skin breakdowns on left lower extremities was managed by wound care, and with frequent turnings. # Atrial fibrillation: Patient with atrial fibrillation on [**Hospital1 **], high CHADS2 score given ?CHF, HTN, age, diabetes mellitus type II, prior stroke. High risk for cardioembolic issues. INR was temporarily reversed for ERCP and warfarin was restarted within 36hrs of procedure. Beta blocker was held in the setting of sepsis, but restarted soon after. # Hypertension: Held atenolol given sepsis, discharged on metoprolol given eGFR. # Epilepsy: continued keppra. # Diabetes mellitus type II: Managed on HISS and lantus. # Dementia: Patient appeared to be AAOx3 on [**Hospital1 **]. Per nursing home documents, she cannot make medical decisions due to underlying dementia # Aspiration risk: Patient with known aspiration risk per nursing home records. Patient was given thickened nectar liquids. # QTc prolongation: QTc was 463 ms [**First Name (Titles) **] [**Last Name (Titles) **]. Qtc prolonging drugs were avoided. Repeat EKG showed QTc of 422. # Mood disorder: continued home psychiatric medications. Medications on [**Last Name (Titles) **]: - acetaminophen 650 mg PO q 4 hr prn pain, fever - hydrocodone/APAP 5-500 mg PO q 4 hr prn pain - nitrostat 0.4 mg SL prn - coumadin 4.5 mg PO every Tues, Thurs, Sat - coumadin 5 mg PO every Monday, Wed, [**Last Name (LF) 2974**], [**First Name3 (LF) **] - SSI - lantus 17 units qhS - abilify 5 mg PO qD - atenolol 50 mg PO qD - cranberry 425 mg PO BID - vitamin B12 1000 mcg INH qmonth - docusate/senna - furosemide 80 mg PO qD - [**First Name9 (NamePattern2) 32469**] [**Male First Name (un) **] 0.005 % 1 drop each eye qHS - levetiracetam 1000 mg PO qAM - levetiracetam 500 mg PO qHS - melatonin 6 mg PO qHS - omeprazole 20 mg PO qD - spironolactone 25 mg PO qD - vitamin C tab 500 mg PO qD - vitamin D 1000 units PO qD - sertraline 200 mg PO qD - tylenol 650 mg PO qD Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever > 100.5. 2. aripiprazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. petrolatum Ointment Sig: One (1) Appl Topical DAILY (Daily). 8. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: inr goal is 2.5-3.5. 9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 10 days. 16. metronidazole 500 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. Tablet(s) 17. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units, insulin Subcutaneous at bedtime. 18. insulin lispro 100 unit/mL Solution Sig: per sliding scale units, insulin Subcutaneous QIDACHS: see attached sliding scale. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at [**Location (un) 620**] Discharge Diagnosis: 1. choledocholithiasis s/p ercp and sphincterotomy with stone extraction 2. probable aspiration pneumonia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: see below Followup Instructions: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2171-2-21**]

[ "584.9", "038.9", "715.90", "427.31", "V45.72", "574.51", "296.90", "V58.67", "576.1", "252.00", "995.91", "345.90", "294.20", "426.82", "507.0", "707.23", "272.4", "V58.61", "564.1", "707.03", "250.00", "V10.05", "799.02", "530.81", "414.01", "401.9" ]

icd9cm

[ [ [] ] ]

[ "38.97", "51.85", "51.88" ]

icd9pcs

[ [ [] ] ]

12748, 12825

6177, 11134

337, 344

12975, 12975

5436, 6154

13218, 13339

4472, 4523

11157, 12725

12846, 12954

13153, 13164

4538, 5417

261, 299

372, 3761

12990, 13129

3783, 4376

4392, 4456

17,933

177,268

29756

Discharge summary

report

Admission Date: [**2140-1-16**] Discharge Date: [**2140-1-23**] Date of Birth: [**2088-2-14**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: Jaundice, fever Major Surgical or Invasive Procedure: ERCP and sphincterotomy Percutaneous drainage of subhepatic biloma History of Present Illness: 51-year-old man who underwent laparoscopic cholecystectomy on [**2140-1-10**] presented to the office on [**2140-1-16**] with jaundice and fever. He was admitted placed on antibiotics and sent for ERCP in [**Location (un) 86**] and admitted after the procedure for further treatment Past Medical History: Mitral valve prolapse Social History: Noncontributory Family History: Noncontributory Physical Exam: Discharge exam: Afebrile, vital signs stable NAD, A&Ox3 RRR CTAB Abd soft, NT, ND, +BS. Drain site c/d/i, yellow/green fluid in gravity bag. Pertinent Results: Admission Labs [**2140-1-16**] 01:16PM BLOOD WBC-14.5* RBC-3.60* Hgb-11.0* Hct-32.2* MCV-89 MCH-30.6 MCHC-34.3 RDW-13.9 Plt Ct-166 [**2140-1-16**] 01:16PM BLOOD Glucose-136* UreaN-13 Creat-0.6 Na-136 K-4.5 Cl-102 HCO3-20* AnGap-19 [**2140-1-16**] 01:16PM BLOOD ALT-389* AST-94* LD(LDH)-228 AlkPhos-122* Amylase-14 TotBili-1.7* [**2140-1-16**] 01:16PM BLOOD Lipase-10 [**2140-1-16**] 01:16PM BLOOD Albumin-2.4* Calcium-7.5* Phos-1.4* Mg-1.6 Discharge Labs [**2140-1-23**] 07:15AM BLOOD WBC-8.1 RBC-3.97* Hgb-11.9* Hct-34.6* MCV-87 MCH-30.0 MCHC-34.4 RDW-13.7 Plt Ct-391 [**2140-1-22**] 06:15AM BLOOD Glucose-111* UreaN-12 Creat-0.7 Na-136 K-4.3 Cl-102 HCO3-24 AnGap-14 [**2140-1-22**] 06:15AM BLOOD ALT-67* AlkPhos-115 Amylase-101* TotBili-0.9 [**2140-1-22**] 06:15AM BLOOD Lipase-105* Brief Hospital Course: HD1: Admitted to ICU for observation, made NPO, Foley placed, started on Vancomycin, Levaquin, Flagyl. Placed on IV Lopressor for blood pressure control. ERCP Findings: The CBD was not dilated and there was one questionable filling defect within. After filling the CBD with contrast a leak from the duct of luschka was identified. HD2: Was stable overnight, fevers resolved, was transferred to floor. Gallbladder fossa fluid collection assessed as too small for drainage. HD3: Foley d/c'd. Vancomycin stopped. HD4: RUQ US: Within the gallbladder fossa, a 2.7 x 3.1 x 2.5 cm, ovoid, anechoic fluid collection is present. This collection is unchanged in size from the previous CT examination from four days previously. Levaquin and flagyl changed to PO. HD5: Biloma aspirated by interventional radiology; 10cc bile returned and sent for gram stain and culture. Gram stain: no microorganisms. Culture: no growth. HD6: WBC and LFTs failed to decrease as expected. Abd CT: large L-sided peri-hepatic fluid collection. HD7: Interventional radiology placed a drainage catheter in a different fluid collection with return of bile, no signs of infection/abscess. Fluid sent for gram stain (no microorganisms) and culture (no growth). Postprocedure was advanced to clears. HD8: Uneventful course overnight. Diet advanced to regular. WBC count decreased from 15.6 to 8.1. Discharged home with VNA and drain care teaching. Medications on Admission: None Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 1 weeks. Disp:*21 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Duct of Luschka Biliary leak E. Coli Bacteremia Biloma requiring percutaneous drainage Discharge Condition: Good Discharge Instructions: -Call if you have any questions or concerns. -Call if you have any of the following symptoms: -Fever >101.4 or chills -Intractable nausea or vomiting -Increasing abdominal discomfort/pain -Intolerance to tube feeding regimen -Dizziness or increasing weakness -Your drain output suddenly changes color or the amount of drainage significantly increases or decreases Followup Instructions: Please call Dr. [**First Name (STitle) 2819**] for a follow-up appointment in 1 week. Completed by:[**2140-1-25**]

[ "995.93", "576.8", "E878.6", "038.42", "424.0", "998.59", "997.4" ]

icd9cm

[ [ [] ] ]

[ "54.91", "51.85" ]

icd9pcs

[ [ [] ] ]

3673, 3731

1809, 3240

330, 398

3861, 3867

999, 1786

4279, 4395

806, 823

3295, 3650

3752, 3840

3266, 3272

3891, 4256

838, 838

854, 980

275, 292

426, 712

734, 757

773, 790

28,294

128,479

31181

Discharge summary

report

Admission Date: [**2123-9-4**] Discharge Date: [**2123-9-21**] Date of Birth: [**2050-4-5**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: CP/NSTEMI Major Surgical or Invasive Procedure: [**2123-9-4**] - Emergency off-pump coronary artery bypass grafting x3 (left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal and obtuse marginal arteries). History of Present Illness: This 73-year-old patient, who was transferred from outside hospital in cardiogenic shock with a large inferior MI, was taken emergently for coronary artery bypass grafting. At the outside hospital he had bare metal stent inserted to the occluded right coronary artery. Other lesions he had was a significant critical left mainstem lesion and further lesions in the diagonal. Past Medical History: HTN CRI Dementia CRI AAA Lung Mass GI Bleed Social History: Lives with wife. [**Name (NI) **] [**Name2 (NI) 1818**] and drinks alcohol occassionally. Family History: None noted Physical Exam: 90 paced 80/50 18 GEN: WDWN intubated and sedated SKIN: Warm, dry, no clubbing or cyanosis. Multiple solar/actinic kertosis and nevi. Well healed Left knee scar HEENT: PERRL, Anicteric sclera, OP Benign NECK: Supple, no JVD, FROM. LUNGS: bilateral rales. HEART: RRR, No M/R/G ABD: Soft, ND/NT/NABS EXT:warm, well perfused, no bruits, no varicosities, mild peripheral edema Pertinent Results: [**2123-9-4**] ECHO Patient is on high dose norepinepherine, epinepherine,and phenylepherine infusions with ventricular pacing. The left atrium is mildly dilated. The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mild to moderate inferior basal hypokineiss. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are complex (>4mm) atheroma in the ascending aorta. There are complex (mobile) atheroma in the aortic arch. There are complex (mobile) atheroma in the descending 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 ([**2-16**]+) mitral regurgitation is seen. There is no pericardial effusion. Post off pump bypass, patient is still on high dose epinenpherine, norepinepherine, now with vasopressin and pacing. No change in LV function EF 50%. MR is now mild. Aortic contours are intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [**2123-9-12**] CT Scan ABD/PEL 1. Extensive right retroperitoneal hematoma . 2. Mildly aneurysmal abdominal aorta measuring 3.5 cm in maximum diameter. 3. Fatty infiltration in the wall of the transverse colon suggestive of chronic inflammatory changes. Though this is seen most commonly in the setting of Crohn disease, ulcerative colitis, and cytoreductive therapy, it can occassionaly be seen as a normal variant--correlation with clinical history would be most useful. [**2123-9-12**] Femoral U/S 1. No evidence of pseudoaneurysm or arteriovenous fistula. 2. Right pelvic hematoma. [**2123-9-20**] 01:00PM BLOOD WBC-12.8* RBC-4.50* Hgb-14.0 Hct-41.8 MCV-93 MCH-31.2 MCHC-33.6 RDW-14.9 Plt Ct-601* [**2123-9-20**] 01:00PM BLOOD Plt Ct-601* [**2123-9-21**] 06:10AM BLOOD Glucose-115* UreaN-29* Creat-1.6* Na-147* K-4.6 Cl-110* HCO3-24 AnGap-18 [**2123-9-20**] 01:00PM BLOOD Glucose-147* UreaN-31* Creat-1.6* Na-145 K-4.4 Cl-109* HCO3-27 AnGap-13 [**2123-9-18**] 05:10AM BLOOD UreaN-34* Creat-1.7* K-4.1 Brief Hospital Course: Mr. [**Name13 (STitle) 9464**] was admitte dto the [**Hospital1 18**] on [**2123-9-4**] via transfer from an outside hospital for emergent surgical management of his coronary artery disease. He was take to the operating room where he underwent off pump coronary artery bypass grafting to three vessels. Postoperatively he was taken to the intensive care unit for monitoring. he was noted to have blood in his NG tube. An EGD was performed which showed a ulcer in the cardia which was injected with epinephrine with hemostasis acheived. The general surgery service was consulted who recommended close observation at this time. His GI bleeding subsequently improved, and he was weaned from his vasoactive drips. He was cardioverted on [**9-7**] for atrial fibrillation and hypotension and converted to NSR. He underwent bronchoscopy on [**9-7**] for bloody secretions and BAL. He was started on tube feeds. He remained hypoxic but improved with diuresis and slow vent wean, and was extubated on [**9-12**]. He was seen by vascular surgery on [**9-12**] on drop in HCT and retroperitoneal bleed. He was transfused, and his heparin was dc'd. Bedside swallow on [**9-14**] allowed his diet to be advanced to regular with thin liquids. He was transferred to the floor on POD [**9-16**]. He was initially confused and required a 1:1 sitter and haldol, but improved and the sitter was dc'd and the haldol was weaned. He was put on keflex for forearm phlebitis. He continued to improve and was ready for discharge to rehab on [**9-21**]. He was seen by thoracic surgery prior to discharge for lung mass seen on chest xray and subsequent chest CT, and will follow up witht him in 3 weeks. Medications on Admission: Doxazosin Lisinopril Amlodpine HCTZ Norvasc Aspirin Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for stent. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO at bedtime. 13. Cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 2 days: to finish 7 day course. Discharge Disposition: Extended Care Facility: Life Care of [**Hospital1 **] Discharge Diagnosis: CAD Hyperlipidemia HTN COPD PAF Sleep Apnea Diverticulitis CRI TIA CHF Depression 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. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Follow-up with cardiologist Dr. [**Last Name (STitle) **] with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 66694**] in 2 weeks. [**Telephone/Fax (1) 66697**] Please call all providers for appointments. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2123-9-21**]

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icd9cm

[ [ [] ] ]

[ "99.07", "96.56", "99.61", "36.15", "96.6", "45.13", "99.05", "36.12", "96.04", "96.71", "99.04", "89.60", "33.23" ]

icd9pcs

[ [ [] ] ]

6753, 6809

3878, 5558

328, 535

6935, 6943

1553, 3855

7658, 8085

1130, 1142

5660, 6730

6830, 6914

5584, 5637

6967, 7635

1157, 1534

279, 290

563, 940

962, 1007

1023, 1114

29,780

150,913

8147

Discharge summary

report

Admission Date: [**2180-6-24**] Discharge Date: [**2180-6-27**] Date of Birth: [**2102-10-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 77 yo male with h/o systolic heart failure with EF 20%, HTN, and asymptomatic fib s/p recent cardioversion now admitted after syncopal episode, found to be bradycardic. He was anticoagulated for 4 weeks and cardioverted at [**Hospital1 18**] yesterday for A fib with RVR and started newly on amiodarone. This morning he was feeling weak and took Lasix 120mg and was walking up the stairs on his way to use the bathroom when he had a near syncopal event. He was caught by his family member, sustained no head trauma, though he was + for LOC. . EMS arrived and he had a junctional rhythm at 50. He was externally paced in the field and he received a total of 1 amp of atropine for a bradycardia in the 30s and his SBP was in the 70s. He was brought to [**Location (un) 745**] [**Location (un) 3678**] and found to have a HR in the 50s. He was started on a dopamine drip at 6mg. He desated to 90% on 4L and he needed to be started on a non rebreather with sats at 98%. He was given Lasix 20mg IV x1. The pt voided a total of 100cc at [**Location (un) 745**]-Wellesey. In transport the pt voided an additional 240cc. Pt refuses foley catheter and demands to stand to urinate. A CT scan was done at OSH to look for a bleed. . + 2 pillow orthopnea winded after climbing one flight of stairs . 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, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, ankle edema, or palpitations. Past Medical History: CHF with EF 20% (acute systolic and diastolic heart failure decompensation in setting of new A fib with RVR) HTN AFib/Flutter with rapid ventricular response- Dx sometime after [**2179-11-13**] s/p radiation for prostate CA in [**2177**]--Dr.[**Name (NI) 14072**] at [**Hospital1 112**] s/p tonsillectomy ALLERGIES: NKDA OUTPATIENT CARDIOLOGIST: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29026**] Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: His father died of an MI at 57. Physical Exam: VS: T 96.2, BP 119/80 , HR 86 , RR 22 , 96% on non rebreather Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented, Mood, Argumentative HEENT: PERRL, EOMI, mmm, no LAD Neck: Supple with elevated JVD. CV: regular rate and rhythm normal S1, S2. No S4, no S3. Chest: + diffuse crackles throughout lung, + accessory muscle use, no chest wall deformities, scoliosis or kyphosis. Abd: distended, mild tense, + tympany in RLQ, no shifting dullness Ext: pitting edema +1 to knees R>L, +2 DP pulses in both extremities. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: radial +2 bilaterally, DP +2 bilaterally Left: radial +2 bilaterally, DP +2 bilaterally Pertinent Results: LABORATORY DATA on admission: Creatinine 3.9 Mg 2.9 Ph 6 INR 2.3 WBC 13.4 . EKG demonstrated NSR with left anterior hemiblock; EKG showed conduction of P waves. T wave inversion in I and AVL and question of Q waves in III and AVF and v1-v4 which have been stable since prior EKG. 12-leads from NW show junctional escape rhythm at rate ~40. EKG [**2180-6-12**]: Atrial flutter with variable block. Left axis deviation. Left anterior fascicular block. Intraventricular conduction delay. Late R wave progression. . TELEMETRY demonstrated: NSR in 70s. . 2D-ECHOCARDIOGRAM performed on demonstrated: [**2180-6-20**] -EF of 20% with severe global hypokinesis -left atrium is markedly dilated, right atrium is moderately dilated. -right ventricular cavity is mildly dilated with severe global free wall hypokinesis -trace aortic regurgitation -moderate (2+) mitral regurgitation -moderate pulmonary artery systolic hypertension . Portable CXR [**2180-6-24**]: Cardiac silhouette is enlarged but unchanged. There is again noted prominence of the interstitial markings consistent with pulmonary edema. This is slightly increased since the previous study. No pleural effusions are seen. . Renal u/s [**2180-6-25**]: FINDINGS: The right kidney measures 11.2 cm, and the left kidney measures 11.9 cm. There is mild right and moderate left hydronephrosis. Multiple bilateral cysts are seen, the largest measuring 4.8 cm in the superior pole of the right kidney. The cortical thickness is preserved. Urinary bladder is distended, measuring 15.5 x 11.6 x 16.5 cm. The prostate is enlarged, measuring 7 x 6.5 x 6.3 cm. IMPRESSION: Mild bilateral hydronephrosis most likely due to prostate hypertrophy, chronicity indeterminate. Brief Hospital Course: A/P: 77 yo male with h/o HTN, CHF and EF of 20%, and recent cardioversion for A fib who is s/p syncopal event with EKG showing junctional bradycardia. Now hemodynamically stable in sinus rhythm. . # Syncope/bradycardia: Pt had junctional bradycardia with underlying sinus node dysfunction leading to hemodynamic instability initially requiring dopamine gtt. He had normal AV node conduction. Of note he was on amiodarone, digoxin, and carvedilol, the levels of which may have been increased in the setting of ARF. He meets criteria for pacemaker/ICD placement but patient emphatically refused despite being told that he could have recurrence of his syncope without intervention. He was monitored on telemetry during his admission. He was discontinued on digoxin and amiodarone. He was discharged on lower dose of carvedilol. He has a follow up appointment with Dr. [**Last Name (STitle) **]. . # Pump: He had acute on chronic diastolic and systolic HF. The patient has a history of diastolic and systolic CHF with an EF of 20%. Prior to admission his home dose of lasix was 80qAm and 40qPM although the morning prior to admission to the OSH he took Lasix 120mg and received 20mg IV at the OSH. On presentation to the CCU he desaturated and required a non rebreather mask in order to maintain an oxygen saturation of 94%. On arrival to the CCU he was volume overloaded on exam with diffuse crackles and 1+ pitting edema to the knee R>L. He was continued on low dose coreg but his lasix and ACE I were held given his acute renal failure. He was discharged on lasix 120mg daily. . # Rhythm: The pt was in A fib until being cardioverted the day prior to his admission. On admission he had conducting P waves and a long PR interval. He was originally on a heparin drip in case the decision was made to put in a pacer. . # Acute Renal Failure on Chronic Renal Insufficiency: he patient has a baseline creatinine of 1.6 to 2.2. On admission his creatinine was 3.9 and it improved to 2.4 by the time of discharge. His renal failure was likely secondary to obstruction from enlarged prostate which was seen on ultrasound. His urinary retention was likely exacerbated by the atropine dose received on day of admission. The patient adamantly refused a foley despite our recommendation. His ACE, lasix, and digoxin were held given his acute renal failure. He was discharged on lasix 120mg daily. . # Abdominal distention: The patient had significant abdominal distention during his admission. He was having normal bowel movements and no abdominal pain. His LFTs were normal with the exception of an isolated conjugated hyperbilirubinemia. He should follow up this abnormal lab value as an outpatient with his PCP. . # Elevated WBC: The patient had an increased white cell count to 13. 4 on admission but was afebrile and asymptomatic. His UA/Ucx, blood cx, and CXR were all negative. He developed no other signs of infection during his hospitalizations. His white count was 11.5 on the day of discharge. . # CAD: He was continued on ASA, statin, and a low-dose beta blocker. His ACE inhibitor was held given his acute renal failure. . # HTN: He originally required a dopamine gtt which was successfully weaned. He was then restarted on a lower dose of carvedilol. He was discharged on lasix 120mg daily. His quinapril was held in the setting of his acute renal failure and was not restarted prior to discharge. . # FEN: He was on a cardiac/low salt diet and his lytes were maintained K>4 and Mg>2. Medications on Admission: Carvedilol 12.5 mg [**Hospital1 **] Digoxin 0.125 mg daily Lasix 40 mg 2 tabs in the am and 1 tab in the pm (he states he took another ?????? tab last night) Quinapril 80mg daily Coumadin 5 mg 1 tab daily Simvastatin 20 mg 1 tab daily ASA 81 mg 1 tab daily Calcium supplement 1 tsp daily MVI 1 tab daily Discharge Medications: 1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Calcium Oral 4. Multivitamin Oral 5. Outpatient Lab Work Please draw BUN, creatinine, potassium, ALT, AST, Alk Phos, T. bili, D. bili and forward results to Dr. [**Last Name (STitle) **] Fax: [**Telephone/Fax (1) 29027**] 6. Lasix 40 mg Tablet Sig: Three (3) Tablet PO once a day. Tablet(s) 7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 8. Standard Walker Discharge Disposition: Home Discharge Diagnosis: Primary 1. Syncope 2. Junctional bradycardia sinus node dysfunction 3. Atrial Fibrillation with RVR 4. Acute systolic heart failure . Secondary Cardiomyopathy with EF of 20% HTN S/p radiation for prostate CA ([**2177**]) S/p tonsillectomy Discharge Condition: Stable Discharge Instructions: You were admitted for syncope due to an abnormal, slow heart rhythm which resulted from your heart's impaired intrinsic pacing. You were treated medically for your symptoms since you did not want a pacemaker placed. You were also treated for acute congestive heart failure. . We have made the following changes to your medications. You should NOT be taking: Coumadin Quinapril Digoxin Amiodarone . We have decreased the Carvedilol to 3.125mg twice daily. We have increased to a full dose Aspirin 325mg daily. We have changed the lasix to 120mg daily. . You had some abnormalities in your liver function tests and your kidney function, these appear to be improving. You will need to get follow up labs drawn on Friday, [**6-30**] and these will be forward to Dr. [**Last Name (STitle) **] office in [**Location (un) **] where you will be seeing him next week. . You will need to discuss with Dr. [**Last Name (STitle) **] regarding the best time to restart the Quinapril and he may want to increase the dose of Carvedilol at your next appointment. . If you develop any new chest pain, shortness of breath, weakness or any other general worsening of condition please call your PCP or come directly to the ED. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Followup Instructions: Cardiology: Dr. [**Last Name (STitle) **] Wednesday [**7-5**] at 2:30pm. [**Location (un) **] office Phone: [**Telephone/Fax (1) 8645**]. Completed by:[**2181-1-31**]

[ "425.4", "V58.61", "428.43", "782.4", "585.9", "428.0", "427.81", "403.90", "424.0", "185", "591", "584.9", "427.31" ]

icd9cm

[ [ [] ] ]

[ "99.62" ]

icd9pcs

[ [ [] ] ]

9763, 9769

5308, 8814

323, 329

10052, 10061

3572, 3588

11422, 11591

2823, 2856

9168, 9740

9790, 10031

8840, 9145

10085, 11399

2871, 3553

276, 285

357, 2129

3602, 5285

2151, 2681

2697, 2807

19,839

111,434

30172

Discharge summary

report

Admission Date: [**2167-4-26**] Discharge Date: [**2167-5-2**] Date of Birth: [**2095-9-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: septic shock Major Surgical or Invasive Procedure: ERCP History of Present Illness: 71 y/o male with PMH of HTN, Afib, CVA, MVR, Seizure Disorder presented to [**Hospital3 13313**] on [**2167-4-5**] with weakness, abdominal discomfort, mild jaundice, and constipation, found to have icterus and distended abdomen, with bilirubin of 3.1, WBC count of 14 with 82% polys, lactate of 5.8, AST 83, ALT 100, AP 387, INR 12.2, KUB showing ileus, given levo and flagyl, and had a laparoscopy showing 3 sections of nectrotic jejunum which were resected and a large hematoma in the mesentary which had ruptured into the abdomen. Post surgical course complicated by respiratory distress and intubation on [**2167-4-13**], fevers despite antibiotics without positive cultures. All antibiotics stopped on [**2167-4-24**]. Transferred for continued ileus, rising Tbili and rising AP and LFT's for ERCP. Past Medical History: HTN Hyperlipidemia Atrial Fibrillation h/o CVA at age 62 with left hemiparesis s/p MVR 29 mm St Jude Valve (Dr. [**Last Name (STitle) **] s/p TV annuloplasty with [**Doctor Last Name **] life sciences MC-3 band (Dr. [**Last Name (STitle) **] Seizure Disorder GERD Depression Diverticulosis s/p tonsillectomy Social History: Per records- Lives at home with wife. [**Name (NI) **] very involved family. Does not smoke. No alcohol use since stroke. Family History: Per [**Name (NI) 71902**] Father died at 82 y/o from MI. Brother with Diabetes. Grandfather with CAD. Mother died of [**Name (NI) **] Disease. Physical Exam: Severely jaundiced male, intubated, sedated, with NG tube and foley catheter in place. T 99.6 HR 74 BP 125/50 (Cuff- on Dopamine) RR 29 SAT 100% SKIN: Jaundiced. No rashes HEENT: PERRL, icteric sclera, NG tube in place, ET tube in place. NECK: Normal carotids, no LAD. RIJ in place. CHEST: No axillary LAD. Lungs rhoncherous. HEART: Irregular. 2/6 Systolic murmur over precordium. ABD: Distended, tympanic, midline healing scar, no palpable masses, no audible bowel sounds. Rectal without stool. EXT: Pitting edema of legs to calf bilaterally. Good peripheral pulses. NEURO: Awakens to noxious stimuli. Moves right hand and leg spontaneously. Left sided decreased tone. Reflexes increased left patellar compared to right, and right bicepts compared to left. Pertinent Results: [**2167-5-1**] 06:06AM BLOOD WBC-46.6* RBC-2.55* Hgb-8.1* Hct-22.4* MCV-88 MCH-31.9 MCHC-36.3* RDW-25.8* Plt Ct-392 [**2167-4-26**] 07:44PM BLOOD Neuts-85* Bands-4 Lymphs-4* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1* Promyel-1* NRBC-9* [**2167-4-30**] 04:50AM BLOOD PT-13.8* PTT-71.2* INR(PT)-1.2* [**2167-5-1**] 06:06AM BLOOD Glucose-71 UreaN-63* Creat-1.4* Na-138 K-3.7 Cl-106 HCO3-21* AnGap-15 [**2167-5-1**] 06:06AM BLOOD ALT-127* AST-157* LD(LDH)-380* AlkPhos-817* TotBili-27.1* [**2167-4-27**] 02:11AM BLOOD Lipase-131* GGT-2492* [**2167-5-1**] 06:06AM BLOOD Albumin-2.0* Calcium-7.8* Phos-3.2 Mg-2.1 Head CT: Intraventricular blood within the occipital horns of the lateral ventricles bilaterally as well as blood within a large area of encephalomalacia involving the right middle cerebral artery territory. Above findings were discussed with Dr. [**Last Name (STitle) 18721**] immediately after the completion of the study. Echo: No thrombus/mass is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. There is symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are mildly thickened. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. A bileaflet mitral valve prosthesis is present. The motion of the mitral valve prosthetic leaflets appears normal. The transmitral gradient is normal for this prosthesis. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The degree of mitral regurgitation seen is normal for this prosthesis. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. CT abd: 1. Findings strongly suggest high-grade distal small bowel obstruction, with likely transition point in the left lower abdomen, likely adhesive. Continued observation recommended. 2. Bibasilar opacities most likely pneumonic, less likely atelectasis. 3. Mild periportal and peri-cholecystic edema for which hepatitis or other intrinsic liver disease remains likely etiology. Small ascites. 4. Biliary stent in situ. COMMENT: Dr. [**Last Name (STitle) **] and I have discussed the case tonight on the telephone. Brief Hospital Course: A/P: 71 y/o male s/p recent resection of necrotic jejunum at OSH, transferred for suspected biliary obstruction as well as hypotension and respiratory failure. Went into MOD and overwhelming MRSA septic shock. . ## Septic shock secondary to MRSA bacteremia: We contimuied him on pressors thoughout his stay. His sputum ended up growing MRSA which was thought to be the source of his bacteremia and septic shock. TTE/TEE showed no evidence of vegetations. Nonetheless, his leukocytosis persisted in spite of continuous broad spectrum antibiotics . ## Hyperbilirubinemia: His bilirubinemia persisted throughout his stay, in spite of having a biliary stent placed during ERCP. . ## ARDS: He became progressively more difficult to oxygenate and his CXR and ventilator numbers were consistent with ARDS. . ## Small bowel obstruction seen on CT scan: Surgery consult was involved. Felt that he was not an op candidate at the time due to his multisystem organ failure. When he finally did have a small BM, the stool was positive for C. Diff toxin and he was started on metronidazole. . ## Acute blood loss anemia: No longer seems to be significantly GI bleeding. Very likely to be bleeding into subcutaneous tissue over left chest/arm - hand surgery consult appreciated; no compartment syndrome; A-line re-sited - decrease goal PTT level for heparin gtt to 50-70 sec - q6h Hct; active T&S - continue IV pantoprazole q12h for any residual GI bleeding . ## Pupillary changes: now larger and sluggish whereas they had been fixed and constricted before; R toe upgoing (L nonreactive) - Head CT showed hemorrhage into the site of his old CVA. . ## Acute Renal Failure: Postualted to be ATN at [**Hospital 71903**] Hospital because of muddy brown casts. Worsening again - IVFs for hypotension should improve renal perfusion; follow UOP - renally-dose meds . ## Hyperglycemia:- cont insulin drip for tight glycemic control . ## Atrial Fibrillation: currently bradycardic off meds - digoxin level no longer elevated; cont to hold - EP recs appreciated; [**Hospital1 1516**] pads on, atropine at bedside - cont anticoagualtion with Heparin drip . ## s/p MVR St Jude Valve: - anticoagulation with IV heparin, though he developed intracranial bleeding at the site of his old CVA - TEE and TTE without evidence of vegetations . ## HOCM: Dicsovered on echo on [**4-29**]. Severe resting LOVT gradient. Pressors likely not helping, but are necessary given his sepsis . ## Seizure Disorder: - continue dilantin; total phenytoin level low, but albumin also low so corrected level likely wnl . ## h/o HTN: currently hypotensive on pressors; no antihypertensive meds at this time. . ## Hyperlipidemia: holding statin given elevated LFT's . ## GERD: continue IV protonix ## Depression: holding zoloft ## Access: LIJ placed on [**2167-4-27**] ## Diet: cont TPN ## Prophylaxis: Heparin Drip for MVR, Afib, and DVT prophylaxis, IV protonix for stress ulcer prophylaxis ## Due to his progressively worsening ARDS and multisystem organ failure in the setting of an acute intracranial hemorrhage, the patient's family (including HCP [**Name (NI) **] [**Name (NI) **]) chose to pursue comfort measures only on [**2167-5-2**]. Antibiotics, fluids, and pressors were stopped, and the patient expired shortly thereafter. Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: septic shock, ARDS, intracranial hemorrhage, small bowel obstruction, C. Difficile colitis Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a

[ "008.45", "584.5", "038.11", "427.31", "785.52", "425.1", "345.90", "518.5", "560.9", "311", "530.81", "272.4", "276.1", "285.1", "401.9", "576.1", "431", "458.9", "V43.3", "995.92" ]

icd9cm

[ [ [] ] ]

[ "96.72", "51.87", "88.72", "99.15", "38.91" ]

icd9pcs

[ [ [] ] ]

8396, 8405

5051, 8345

327, 333

8539, 8549

2591, 3204

8601, 8607

1654, 1798

8368, 8373

8426, 8518

8573, 8578

1813, 2572

275, 289

361, 1167

3213, 5028

1189, 1498

1514, 1638

30,580

138,563

34348

Discharge summary

report

Admission Date: [**2164-9-5**] Discharge Date: [**2164-9-7**] Date of Birth: [**2082-7-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1171**] Chief Complaint: newly diagnosied pericardial effusion Major Surgical or Invasive Procedure: Pericardialcentesis with drain placement and subsequent removal History of Present Illness: The patient is an 82 y/o russian spekaing female w/ hx of breast CA and prancreatic CA who is directly admitted for evaluation of newly diagnosied pericardial effusion w/ tamponade physiology. The patinet was diagnosed with pancreatic CA in [**3-24**] after presentive w/ jaundice. Over the last month the patient has noted new onselt leg edema, which as progressively worsened with each day. The leg swelling does not limit the ADLs in this self-described active women. Additionally, over this time period, the normally hypertensive patient has been normo to hypotensive, and her BP medication was discontinued. The patient was recently at NYP hoslpital in NY 2d prior to presentation as part of a preoperative evaltion for a Whipple. An echocardiogram obtained on [**9-4**] showed a moderate to large pericardial effusion causing both right atrial and right ventricular diastolic collapse. She was recommended to have a cardiology consultation but surprisingly, she was not offered an admission to the hospital. The patient returned to [**State **], and was seen by Dr. [**Last Name (STitle) **] in clinic on the day of admission. The patinet returned home after her clinic visit, and was called at home this evening and told to come to the hospital. In discussion with the patient, she had any episodes of chest pain, shortness of breath, palpitations, presyncope or syncope. Her breathing has been comfortable without any PND or orthopnea. She has no prior cardiac history. She densies any recent illnesses, fever, or chills. She has no hx of renal dysfunction, CTD, or TB exposure. She is currently comfortable. Past Medical History: -hepatitis B 20 years ago, -status post total abdominal hysterectomy for uterine prolapse 20 years ago in [**Location (un) 4551**] and then re-do in [**Country **], - status post parathyroidectomy for parathyroid adenoma nine years ago in [**Country **], -status post basal cell resection at [**Hospital3 2358**] -status post left breast lumpectomy for breast cancer in [**2159**] in [**Location (un) 24402**], ME but not followed by XRT or chemotherapy Social History: Patient is a survivor of the holocaust, originally from [**Country 532**]. Worked as an economist. No hx of tobacco or alcohol. Has 2 children. Family History: Unknown as holocaust survior. Physical Exam: VS: T 95.9 BP 134/74 P 76 RR 100 % RA Pulsus: 6 GEN: Elderly russian female, sitting in bed, alert and comfortable HEENT: NCAT, oropharynx clear and without erythema or exudate, poor dentition. NECK: Supple, no LAD, no appreciable JVD CV: RRR, normal S1S2, no murmurs, rubs or gallops. Heart sounds not muffled. Pulsus of 6. PULM: Scoliosis. CTAB, no w/r/r, good air movement bilaterally ABD: Soft, NTND, normoactive bowel sounds, no organomegaly, no abdominal bruit appreciated EXT: Warm and well perfused, full and symmetric distal pulses, has 3+ pitting edema to knees. NEURO: AAOx3, responds appropriately to questions, CN 2-12 grossly intact Pertinent Results: [**2164-9-7**] 05:57AM BLOOD WBC-5.4 RBC-3.71* Hgb-10.4* Hct-33.2* MCV-90 MCH-28.0 MCHC-31.3 RDW-19.2* Plt Ct-360 [**2164-9-6**] 09:10AM BLOOD Neuts-49.1* Lymphs-43.8* Monos-5.9 Eos-1.1 Baso-0.1 [**2164-9-6**] 09:10AM BLOOD PT-14.3* PTT-29.0 INR(PT)-1.2* [**2164-9-7**] 05:57AM BLOOD Plt Ct-360 [**2164-9-7**] 05:57AM BLOOD Glucose-97 UreaN-7 Creat-0.7 Na-142 K-3.1* Cl-107 HCO3-26 AnGap-12 [**2164-9-6**] 09:10AM BLOOD ALT-76* AST-104* LD(LDH)-224 AlkPhos-694* TotBili-1.6* [**2164-9-6**] 09:10AM BLOOD Albumin-2.1* Calcium-8.0* Phos-3.2 Mg-1.7 [**2164-9-6**] 09:10AM BLOOD TSH-4.5* [**2164-9-6**] 09:10AM BLOOD T3-62* Free T4-0.83* Echo [**9-6**] pre pericardiocentesis: The left atrium is moderately dilated. The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a moderate sized pericardial effusion. The effusion appears circumferential. No right atrial or right ventricular diastolic collapse is seen. IMPRESSION: Moderate-sized pericardial effusion without echocardiographic signs of tamponade. Preserved global biventricular systolic function. Mild aortic regurgitation. Pericadiocentesis: 1- Diagnostic pericardiocentesis with limited removal of 7 CC of markedly viscous fluid. 2- The patient developed a brief vagal episode with heart rate down from 90 bpm to 55-65 bpm and SBP down to 60-70 mmHg (down from 140-160 mmHg). Administration of Atropine (0.5 mg iv) and intravenous fluids lead to rapid restoration of baseline vital signs. FINAL DIAGNOSIS: 1. Limited removal of 7 CC of markedly viscous pericardial fluid. Specimen was sent for laboratory analysis. Echo [**9-6**] post pericardiocentesis: Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small pericardial effusion. The effusion may be loculated. There are no echocardiographic signs of tamponade. IMPRESSION: Small pericardial effusion. No tamponade. Compared with the prior study (images reviewed) of [**2164-9-6**], the effusion appears slightly smaller. [**2164-9-6**] pericardial fluid cell count [**Pager number **] RBC 650 WBC 91 polys 1 band [**2164-9-6**] 6:10 pm FLUID,OTHER Site: PERICARDIUM culture. GRAM STAIN (Final [**2164-9-6**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI . IN PAIRS AND CHAINS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO K. COMEN ON [**2164-9-6**] @ 10:35 PM. FLUID CULTURE (Final [**2164-9-10**]): 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.. VIRIDANS STREPTOCOCCI. HEAVY GROWTH OF TWO COLONIAL MORPHOLOGIES. GRAM NEGATIVE ROD(S). MODERATE GROWTH OF TWO COLONIAL MORPHOLOGIES. VIRIDANS STREPTOCOCCI. MODERATE GROWTH STRAIN 3. NEISSERIA SPECIES. MODERATE GROWTH. NON-PATHOGENIC. ANAEROBIC CULTURE (Final [**2164-9-10**]): NO ANAEROBES ISOLATED. ACID FAST CULTURE (Preliminary): ACID FAST SMEAR (Final [**2164-9-7**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**9-7**] Blood cultures pending. Brief Hospital Course: A+P: 82 y/o with h/o breast CA, Pancreatic CA, presents with pericardial effusion originally worrisome for tamponade based on OSH echo. Pt only complains of LE edema, repeat echo without signs of tamponade. . # Pericardial Effusion: Evidence of tamponade physiology On NYP echo. No evidence of hemodynamic instability, with adequate BP and no symptomatic effects. Low voltage on EKG c/w effusion. Pulsus of 15 in clinic prior to admission, 6 on admission. Given the size of the effusion w/ absence of a greater deal of hemodynamic compromise, likely more of a chronic, slow growing effusion. Large differential, but given pancreatic CA and hx of breat CA, malignant pericardial effusion most likely. Effusion [**2-18**] to thyroid dysfunction in this patient w/ hx of hypothyroidism also a possibility. No viral illness to suggest post viral etiology, nor MI, uremia, TB, or CKD. A repeat echo on [**9-6**] was without evidence of tamponade. Consulted thoracic surgery for eval of pericardial window given likely malignant source of effusion which will likely reaccumulate. They defered on a window until definite diagnosis of effusion. Suggested pericardialcentesis with drain which was performed. 7cc of viscous pericardial effusion was removed. However drain did not function well since effusion apears to be loculated and the drain was later pulled. Cell count and culture results of pericardial effusion as detailed in results section. The effusion is felt to most likely be [**2-18**] malignancy altough cytology is pendin,. The mixed flora in the fluid culture is concerning and blood cultures were obtained to r/o systemic infection. The pt was without fever or white count to suggest infection but is considered at risk [**2-18**] her fairly recent pallative procedure for pancreatic CA which may have been a nitus for bacterial seeding. The pt refused to stay in house for further monitoring and agreed to close f/u in case the blood cultures were to positive. The results will need to be f/u by the PCP. [**Name10 (NameIs) **] understands that a postitive culture would need to be treated with IV antibiotics. Blood cultures from [**9-7**] remain pending as of [**9-11**]. Pt has a f/u echo scheduled as below. Pt will also f/u with CT [**Doctor First Name **], Dr [**Last Name (STitle) **] as detailed below for further discussion of a pericardial window pending the final cytology results. . # Lower Extremity Swelling: [**2-18**] to diastolic heart failure in the setting of tamponade vs. low oncotic pressure in the setting of hypoalbunemia. No role for diuresis w/ potential tamponade. LENIs ruled out DVT. Should monitor to see if resolves with resolution of the pericardial effusion. . # Hypothyroidism: TSH 4.5, Free T4 0.83 in house. [**Month (only) 116**] need continued alteration to home synthroid dose as outpt. Etiology of pericaridial effusion less likely 2.2 Thyroid given viscous loculated nature of fluid. . # Hx of Breast Ca: Had lumpectomy w/o XRT - cont home aromatase inhibitor . # CODE: Full confirmed with pt and family. . #Comm:[**Name (NI) 79038**] care proxy and power of attorney: daughter [**Name (NI) 79039**] [**Telephone/Fax (1) 79040**]. PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 79041**] in [**Location (un) 583**] / [**Location (un) **] Medications on Admission: Levothyroxine 0.05-mg/day, Femara 2.5-mg/day since the breast cancer operation, and omeprazole 20-mg/day Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO daily (). 3. Omeprazole 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: ABP Discharge Diagnosis: Pericardial Effusion Pancreatic cancer Discharge Condition: good Discharge Instructions: You were admitted to the hospital because you have a pericardial effusion (fluid around the heart). This is very worrisome because it can impair heart function. You had an attempt to drain the fluid around the heart however it was not able to be drained. It is likely that the fluid is there because of the cancer but we have studies of the fluid that are not yet resulted which will give us more definate information. You had ultrasound of your legs which did not show any blood clots. You were followed by the Cardio-thoracic surgery team who will see you in clinic and decide if a surgery is indicated to remove the fluid around the heart. The culture of the fluid around your heart had bacteria in it which is concerning that you could have an infection, although you do not have any symptoms compatible with this. We checked blood cultures to be sure that you don't have a blood stream infection but you did not want to wait for those cultures to be resulted. It is very important that you are able to be reached by phone in case these cultures come back positive. In that case you will need immediate intravenous antibiotics. Please follow up as below. Please call your doctor or return to the hospital if you have any concerning symptoms including chest pain, difficulty breathing, fever, light headedness or fainting or any other worrisome symptoms. Followup Instructions: 1) You have an appointment for an echocardiogram on Friday [**9-14**] at 2:00. Please go to the [**Location (un) 436**] of the [**Hospital Ward Name 23**] building. Please call [**Telephone/Fax (1) 62**] if you need to reschedule. (Please try to keep this appointment as we would like you to have this echocardiogram before your appointment with the surgeon) 2) Please follow up with Dr. [**First Name (STitle) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 2348**] Date/Time:[**2164-9-18**] 10:30. 3) You have an appointment scheduled to follow up with your primary care doctor, Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 5308**]. 4) Please call [**Telephone/Fax (1) 62**] and schedule an appointment to follow up with Dr. [**Last Name (STitle) **]. Completed by:[**2164-9-11**]

[ "041.09", "157.8", "423.9", "428.0", "244.9", "V10.3", "428.30", "041.85" ]

icd9cm

[ [ [] ] ]

[ "37.0" ]

icd9pcs

[ [ [] ] ]

11069, 11103

7338, 10649

358, 423

11186, 11193

3439, 5359

12610, 13433

2725, 2756

10805, 11046

11124, 11165

10675, 10782

5376, 7089

11217, 12587

2771, 3420

7126, 7225

7258, 7315

281, 320

451, 2070

2092, 2548

2564, 2709

2,784

112,512

26724

Discharge summary

report

Admission Date: [**2173-4-9**] Discharge Date: [**2173-5-5**] Date of Birth: [**2104-4-12**] Sex: F Service: [**Last Name (un) 7081**] HISTORY OF PRESENT ILLNESS: This is a 68-year-old Cambodian female who has no significant past medical history. She was found unresponsive at home on [**2173-4-6**]. She was found to be hypertensive and intubated at the scene and resuscitated with IV fluid boluses. Prior to this, the patient had neck swelling for 2 days which occurred in conjunction with administration of Actos for newly diagnosed diabetes. Laryngoscopy was performed revealing airway edema. A CT scan of the chest and neck revealed a goiter with airway compression. TSH was elevated at 7.13. Neurology workup including EEG and CT was negative. She was transferred here for a planned sternotomy with mass resection. HOSPITAL COURSE: On admission, the patient was stable and intubated. Endocrine was consulted given the patient's diabetes and hypothyroid state. It was recommended that total thyroidectomy be performed as well as thyroid hormone replacement initiated. She was preopped for surgery on [**2173-4-12**]. On [**2173-4-12**], the patient underwent bronchoscopy and partial sternotomy with right total and left subtotal thyroidectomy. See operative report for details. The patient tolerated the procedure well from a hemodynamic standpoint. However, attempts to re-intubate her at the end with assistance of tube changer were unsuccessful using 8.0, 7.5, 7.0 and even a 6.5 endotracheal tube and it was presumed that the patient had an extrinsic mass or perhaps extrinsic pathology to the trachea. She was returned to the OR on [**2173-4-14**] for rigid bronchoscopy and tumor debridement as well as dilation of tracheal stenosis. At this time, it was noted that she had diffusely abnormal mucosa of her subglottic space and significantly narrow tracheal lumen down to the distal trachea. Biopsies and therapeutic aspiration were performed. At this time, a 6.5 ET tube was placed without difficulty. She was transferred back to the ICU for further management. The pathology showed the patient to have papillary carcinoma of the thyroid with extrathyroidal invasion and nodal involvement. At this time, the patient was found to have nosocomial pneumonia with sputum cultures positive for Acinetobacter, pan-resistant, as well as Enterobacter cloacae, pansensitive. ID was consulted and the patient was started on imipenem and tobramycin at this time. The patient remained stable and on [**2173-4-16**], returned to the OR for bronchoscopy with tracheal dilation (balloon and rigid) with tracheostomy. Postoperatively, chest x-ray showed that the patient had developed a right pneumothorax, displacing the right hemidiaphragm and the mediastinum, collapsing the right lung secondary to barotrauma versus the tracheal dilation procedure. A right chest tube was placed as well as her central line was changed over wire and post chest tube chest x-ray showed marked improvement of the large right pneumothorax. At this time, it was also noted that the patient had gram negative rods, specifically Acinetobacter in her blood cultures, and she was also placed on amikacin. On [**4-17**], chest x-ray showed near resolution of her right pneumothorax. Unfortunately, the patient went into atrial flutter which responded to IV Lopressor. Given her high grade of bacteremia, a CT sinus was recommended by Infectious Disease. This showed mucosal thickening of both maxillary sinuses and opacification of the ethmoid and sphenoid air cells. No fluid levels were noted. Additionally, there is opacification of the mastoid air cells bilaterally. At this time, given her stable, resolved pneumothorax, the chest tube was placed to water seal. On [**2173-4-18**], her vent was weaned to CPAP and pressure support which the patient tolerated well. Her A line sites were changed as well. Over the following day, the patient was diuresed and tolerated tracheostomy mask trials for 2-3 hour periods per day. Endocrine was following and corrected the patient's hypocalcemia with Calcitriol as well as calcium carbonate. Her blood sugars were stable and the patient was off the insulin drip at this point. She was started on NPH and sliding scale insulin. On [**2173-4-20**], a chest CT was performed to evaluate for consolidation. Multifocal opacities in the left lower lobe, right lower lobe and right upper lobe were concerning for pneumonia. A small right-sided pneumothorax persisted with the right chest tube in place. On [**2173-4-22**], the patient remained stable. Her chest tube was removed and post pull chest x-ray showed no evidence of pneumothorax. At this point, the patient had been receiving tube feeds at goal via NG tube. On [**2173-4-23**], a PICC line was placed and the central line was removed. She was tolerating tracheostomy mask for 6 hours. Over the next few days, the [**Hospital 228**] hospital course was uneventful save for a fever spike in which blood cultures were negative, sputum cultures showed persistent Acinetobacter infection and urine cultures showed yeast. The Foley was changed. On [**2173-4-27**], a bedside swallow was performed to evaluate for the patient's ability to tolerate p.o. intake. Unfortunately, she aspirated at this time and failed the swallow exam. ENT was consulted for evaluation of possible vocal cord paralysis. On fiberoptic exam, it was noted that the patient had significant edema and pooling of secretions above her vocal cords. ENT felt that her ET tube was too big/long to phonate and cognitive issues were also preventing her from fully cooperating with the exam. They recommended downsizing her tracheostomy. Discussions with interventional pulmonology were initiated regarding having a custom-made T tube made. On [**2173-4-28**], a Dobhoff tube was placed and plans were made for a PEG to be placed the following week given the patient's failure to pass the swallow exam. Over the next few days, the patient was stable and remained afebrile on Unasyn and amikacin. She completed her antibiotic course on [**2173-5-1**]. She continued to tolerate her Dobhoff tube feeds. On [**2173-5-3**], the patient returned to the OR for a flexible bronchoscopy for tracheal measurements as well as flexible EGD with insertion of a percutaneous endoscopic gastrostomy tube. The patient tolerated the procedure well and returned to the recovery room in stable condition. On [**5-4**], her tube feeds were resumed and increased to a goal of 50 cc per hour with fiber at full strength. She tolerated her tube feeds well. On [**2173-5-5**], a rehab facility accepted the patient and she was discharged to rehab in stable condition. Of note, I had no interaction with this patient's care. This hospital course was dictated from the patient's records only. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: Papillary cancer with positive nodes status post sternotomy and partial right and total left thyroidectomy on [**2173-4-12**], status post rigid bronchoscopy and tumor debridement on [**2173-4-14**], status post open tracheostomy on [**2173-4-16**], status post bronchoscopy and percutaneous endoscopic gastrostomy tube placement on [**2173-5-3**]. DISCHARGE MEDICATIONS: Heparin subcutaneously 5,000 units/ml, 1 injection b.i.d., albuterol sulfate 0.083% solution, 1 puff q.6h. as needed, ipratropium bromide 0.02% solution, 1 puff q.6h. as needed, Percocet 5/325 mg per 5 ml solution, [**6-16**] ml p.o. q.4-6h. p.r.n., metoprolol 37.5 mg p.o. t.i.d., lansoprazole 30 mg suspension, delayed release, 1 p.o. daily, liothyronine 25 mcg 0.5 tablets p.o. b.i.d., calcium carbonate 500 mg per 5 ml suspension, 5 ml p.o. t.i.d., Heparin Lock Flush 100 units per ml, 2 ml IV daily as needed, followed by 10 cc of normal saline, insulin NPH human recombinant 100 units per ml suspension, 20 units subcutaneously 3 times a day, adjust to achieve euglycemia. FOLLOW-UP PLANS: Interventional Pulmonology has ordered a custom T tube for the patient. Later, she will be contact[**Name (NI) **] to arrange for overnight admission for placement. She has an appointment with Dr. [**Last Name (STitle) 10759**] from Endocrine, [**Telephone/Fax (1) 62877**] on [**2173-6-1**] at 2:30 p.m. in the [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]. [**Name6 (MD) 4667**] [**Name8 (MD) **], M.D. [**MD Number(2) 39921**] Dictated By:[**Name8 (MD) 37607**] MEDQUIST36 D: [**2173-5-5**] 11:27:34 T: [**2173-5-5**] 12:59:02 Job#: [**Job Number 65843**] cc:[**Name8 (MD) 65844**]

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icd9cm

[ [ [] ] ]

[ "93.90", "96.72", "33.22", "96.04", "38.93", "31.99", "34.04", "06.51", "96.6", "43.11", "31.44", "31.1", "99.04" ]

icd9pcs

[ [ [] ] ]

6884, 7234

7258, 7938

862, 6828

7956, 8592

185, 844

6853, 6862

76,878

175,538

18458

Discharge summary

report

Admission Date: [**2186-3-27**] Discharge Date: [**2186-4-13**] Date of Birth: [**2137-5-24**] Sex: F Service: ORTHOPAEDICS Allergies: Prochlorperazine / Decongestant Sinus Attending:[**First Name3 (LF) 3190**] Chief Complaint: Back pain due top scoliosis Major Surgical or Invasive Procedure: Removal previous [**Location (un) 931**] Rod Instrumentation Total laminectomy of L5, L4, L3 and L2 Fusion T3-S1 Instrumentation L4-S1 History of Present Illness: Ms. [**Known lastname **] returns for her posterior thoracolumbar fusion. Past Medical History: Gout Social History: Lives with husband. Family History: Non-contributory Physical Exam: A&O X 3; NAD RRR CTA B Abd soft NT/ND BUE- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes symmetric at biceps, triceps and brachioradialis BLE- good strength at hip flexion/extension, knee flexion/extension, ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes symmetric at quads and Achilles Pertinent Results: [**2186-4-12**] 09:47AM BLOOD WBC-7.5 RBC-4.11* Hgb-11.5* Hct-35.1* MCV-85 MCH-28.0 MCHC-32.8 RDW-14.3 Plt Ct-653* [**2186-4-9**] 02:14PM BLOOD WBC-6.1# RBC-3.92* Hgb-11.7* Hct-34.2* MCV-87 MCH-29.7 MCHC-34.1 RDW-14.7 Plt Ct-439# [**2186-4-7**] 07:06AM BLOOD WBC-14.0* RBC-3.29* Hgb-9.6* Hct-27.5* MCV-83 MCH-29.1 MCHC-34.9 RDW-15.2 Plt Ct-260 [**2186-4-6**] 02:07AM BLOOD WBC-10.4# RBC-3.11* Hgb-8.9* Hct-26.5* MCV-85 MCH-28.7 MCHC-33.6 RDW-14.9 Plt Ct-419 [**2186-4-4**] 08:55AM BLOOD WBC-4.3 RBC-3.72* Hgb-10.5* Hct-31.7* MCV-85 MCH-28.1 MCHC-33.0 RDW-14.9 Plt Ct-400# [**2186-4-9**] 02:14PM BLOOD Glucose-105* UreaN-4* Creat-0.4 Na-140 K-3.4 Cl-101 HCO3-31 AnGap-11 [**2186-4-6**] 02:07AM BLOOD Glucose-146* UreaN-9 Creat-0.5 Na-138 K-4.4 Cl-103 HCO3-29 AnGap-10 [**2186-4-4**] 08:55AM BLOOD Glucose-102* UreaN-15 Creat-0.4 Na-139 K-3.7 Cl-102 HCO3-28 AnGap-13 [**2186-3-29**] 01:04AM BLOOD Glucose-121* UreaN-11 Creat-0.5 Na-139 K-3.8 Cl-106 HCO3-26 AnGap-11 Brief Hospital Course: Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on [**3-27**] and taken to the Operating Room for a posterior thoracolumbar fusion for scoliosis. Please refer to the dictated operative note for further details. The patient was transferred to the PACU in a stable condition. A lumbar drain was placed intraoperatively due to a dural tear and was left in place for one week. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were given per standard protocol. Initial postop pain was controlled with a PCA. Postoperative HCT was low and she was transfused PRBCs. She remained flat for 48 hours and the head of her bed was slowly elevated. She was kept NPO until bowel function returned then diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. She was fitted with a TLSO to be worn when ambulating or sitting in a chair. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: See previous list. Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 2. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Estroven Maximum Strength 400 mcg Tablet Sig: One (1) Tablet PO Daily (). 5. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 6. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 10. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 11. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). 12. Ciprofloxacin 500 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12 hours) for 5 days. 13. Diazepam 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for spasm. Discharge Disposition: Extended Care Facility: apple rehab Discharge Diagnosis: Scoliosis Post-op acute blood loss anemia Dural tear Discharge Condition: Good Discharge Instructions: You have undergone the following operation: ANTERIOR/POSTERIOR Thoracolumbar Decompression With Fusion Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a brace. This brace is to be worn for comfort when you are walking. You may take it off when sitting in a chair or while lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Activity: Activity as tolerated Thoracic lumbar spine: when OOB TLSO when OOB- Apply brace when sitting at bedside Treatments Frequency: Please change the dressing daily. Followup Instructions: With Dr. [**Last Name (STitle) 363**] in 2 weeks Completed by:[**2186-4-13**]

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Discharge summary

report

Admission Date: [**2148-2-6**] Discharge Date: [**2148-2-9**] Date of Birth: [**2077-5-3**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 5973**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: none History of Present Illness: 70M with [**First Name3 (LF) **] with LAD 50% (s/p stent to pLAD '[**34**]), LCX 50%, RCA s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] in '[**42**], hypertension, DMII, prior stroke residual right sided weakness, OSA, Morbid Obesity, COPD, CHF EF 45-55% (diastolic and systolic), pulmonary hypertension, hyperlipidemia, h/o substance abuse who was found down in apartment today by apartment staff. Tried to wake him up but he was combative. Checked his blood sugar and it was 50. He was given D50 and glu improved, although still with persistent AMS so he was brought to the ED. The patient is somewhat unclear on what happened but he does report poor PO intake for 1 week with diarrhea and nausea but no notable weight loss. . Of note the patient has had 2 visits to the Ed for hypoglycemia since [**Month (only) **], both times it improved with juice and crackers and he was d/c'd home. He had a similar presentation [**2-13**] for lethargy and AMS that was improved after hypoglycemia resolved. . In the ED, initial vs were: 96.0 70 115/58 10 98 . On exam, pinpoint pupils, CN fine, strength good. Not oriented, falling asleep initially. Labs notable for WBC count of 5.1, Creatinine 1.4, BNP 1075, AST 58, Albumin 3.1, CK 483, Tn:0.02. U/A and urine tox sent but still pending.CT head was negative for bleed. CXR showed possible vascular congestion. EKG shows multiple PVCs, appears to have bigemeny? on the monitor. Patient was given 1 amp d50, then FSG up to 140s, then back down to 50s received 2nd amp. It was noted that patient was on glyburide so started on octreotide. Blood sugar at 10pm was 78 so patient started on a d5 gtt. Likely VBG, 02. Current vitals are 58 128/74 98% on 2L, RR 19. . On the floor, the patient's FSG is 86, he is alert and oriented x3, appropriate. Complains of pain in his legs, several small cuts related to being combative in the apartment and of back pain which is chronic. He admits to some cocaine use at a party over the weekend. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. . Past Medical History: # PCIs: s/p cath in [**11-10**] with 2 vessel dz. - LAD proximal stenosis involving the origin of D1 (50%). - RCA was diffusely diseased with a mid 70% stenosis after AM and 80% stenosis, s/p 2 Cypher stents overlapping in the RCA. [**12/2134**] stent to pLAD, [**11-10**] [**Month/Year (2) **] to RCA # Mitral regurgitation # CHF: EF 45-50%, diastolic and systolic failure # Severe Hypertension # Pulmonary Hypertension # +PPD (15mm) CXR Negative # Impotence # Narcotics Contract: For pain from hip fracture # Hip fracture [**12-10**] # Back pain: several MRIs in the past. # HTN # DMII: Followed at [**Last Name (un) **] # COPD # OSA # PUD # Gastric Mass- noted [**12-14**] # GERD- H. Pylori +, s/p four drug tx. # Glaucoma # Prostate Disease # Elevated D-Dimer: (Received 5 CTAs over 2-3 years) Social History: He has blister packs that are prepared by [**Location (un) **]. He gets around on a scooter. Lives alone in senior housing in a handicapped apartment. Wife passed away [**2144-10-5**]. Retired [**Hospital Ward Name **] and chef at [**University/College **] and previously in the Navy. Has 9 children (5 sons, 4 daughters),who help him out with his finances and groceries as well as VNA services. - Tobacco: 80 pack year smoking history, still about 1PPD. - Alcohol: A beer or less a day - Illicits:history of cocaine abuse, last positive U/A for cocaine was 12/[**2145**]. Patient admits cocaine use this past weekend. Family History: Father [**Year (4 digits) **] - [**Name2 (NI) **] in his 50s Mother died last [**2147-10-8**] at [**Age over 90 **] years old Physical Exam: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . On transfer to medicine floor: Vitals: T: BP:138/94 P:74 R:24 O2:88% on RA -> 92% on 2L General: obese, alert, communicative, " I feel good" HEENT: Sclera anicteric, dry membranes Neck: thick Lungs: Limited due to habitus. Decreased at bases. No crackles or wheezes CV: Distant. Regular Abdomen: Obese, mildly distended but soft with positive bowel sounds. Non-tender GU: no foley Ext: several superficial skin tears over pre-tibial area bilaterally. Excoriation on right toe. Pertinent Results: LABS ON ADMISSION: [**2148-2-6**] 05:20PM BLOOD WBC-5.1 RBC-5.13 Hgb-16.1 Hct-48.7 MCV-95 MCH-31.4 MCHC-33.1 RDW-14.3 Plt Ct-273 [**2148-2-6**] 05:20PM BLOOD Neuts-79.7* Lymphs-11.9* Monos-7.0 Eos-0.7 Baso-0.7 [**2148-2-6**] 05:20PM BLOOD Plt Ct-273 [**2148-2-6**] 05:20PM BLOOD Glucose-105* UreaN-18 Creat-1.4* Na-142 K-4.0 Cl-104 HCO3-31 AnGap-11 [**2148-2-6**] 05:20PM BLOOD ALT-22 AST-58* CK(CPK)-483* AlkPhos-78 TotBili-0.4 [**2148-2-6**] 05:20PM BLOOD Lipase-24 [**2148-2-6**] 05:20PM BLOOD CK-MB-7 proBNP-1075* [**2148-2-6**] 05:20PM BLOOD Albumin-3.1* Calcium-9.0 Phos-3.3 Mg-2.2 [**2148-2-6**] 05:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2148-2-6**] 08:38PM BLOOD FiO2-21 pO2-54* pCO2-54* pH-7.39 calTCO2-34* Base XS-5 Intubat-NOT INTUBA [**2148-2-6**] 08:38PM BLOOD Glucose-56* Lactate-1.0 [**2148-2-6**] 05:24PM BLOOD Glucose-106* Lactate-1.7 Na-146 K-3.3* Cl-99* calHCO3-30 LABS ON DISCHARGE: [**2148-2-7**] 02:10AM BLOOD Glucose-125* UreaN-20 Creat-1.4* Na-142 K-3.6 Cl-106 HCO3-29 AnGap-11 [**2148-2-7**] 02:10AM BLOOD ALT-22 AST-50* LD(LDH)-411* CK(CPK)-511* AlkPhos-69 TotBili-0.3 [**2148-2-7**] 02:10AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1 CARDIAC ENZYMES: [**2148-2-7**] 02:10AM BLOOD CK-MB-7 cTropnT-0.02* [**2148-2-7**] 12:45AM BLOOD CK-MB-8 cTropnT-0.01 [**2148-2-6**] 05:20PM BLOOD cTropnT-0.02* CXR: The cardiac silhouette remains moderately enlarged. The thoracic aorta is tortuous but unchanged. There is upper zone vascular redistribution with pulmonary vascular indistinctness, compatible with mild pulmonary vascular congestion. Additionally, there are hazy ill-defined opacities within both lung bases, likely atelectasis. No sizable pleural effusion is seen. There is no pneumothorax. There are no acute skeletal abnormalities. IMPRESSION: Findings compatible with mild pulmonary vascular congestion with bibasilar ill-defined opacities, likely atelectasis. CT HEAD W/O CONTRAST Study Date of [**2148-2-6**] 5:36 PM FINDINGS: Exam is slightly limited due to motion artifact. Within this limitation, there is no evidence of acute intracranial hemorrhage or shift of normally midline structures. The ventricles and sulci are prominent consistent with age-related atrophy. There is extensive periventricular and subcortical white matter hypodensity consistent with chronic small vessel ischemic changes. The basilar cisterns are preserved. Intracranial vascular calcifications are again noted. The visualized paranasal sinuses are clear. There is no evidence of acute fracture. IMPRESSION: No acute intracranial hemorrhage. Chronic small vessel ischemic changes. . HGBa1c [**2147-11-24**] 08:15AM 6.4 [**2147-8-25**] 08:30AM 7.4 [**2147-5-5**] 08:25AM 8.8 [**2146-11-19**] 06:10AM 7.6 [**2146-7-1**] 08:15AM 9.8 [**2145-6-22**] 12:30PM 8.9 [**2145-2-19**] 08:30AM 9.9 [**2144-12-21**] 09:37AM 11.3 . EKG: Old TWI in I/III/aVF and V2-4 . Hip films: Four total views are obtained. There are plates and screws transfixing a prior acetabular fracture with sclerosis at the fracture site. In addition, there is mild sclerosis about the right femoral neck. It is unclear as to whether this represents a healing subacute fracture. There are mild degenerative changes at the left femoral acetabular joint. The femoral neck is obscured by overlying soft tissues. Further assessment with MR [**First Name (Titles) 151**] [**Last Name (Titles) 102501**] artifact reduction protocol may be helpful. There are severe degenerative changes of the lumbar spine and mild degenerative changes of the sacroiliac joints. . MRI: No proximal right femoral fracture, as questioned. Prominent osteophytes at the right femoral head-neck junction likely account for the sclerosis on the recently performed radiograph. Brief Hospital Course: 70 year old male with DM2, OSA, COPD, found down in his house with glucose 50, brought to ED for altered mental status and admitted to ICU for hypoglycemia and close glucose monitoring. Positive cocaine toxicology. # Hypoglycemia: Likely due to poor PO intake, rising creatinine in the setting of continued high doses of insulin and glipizide as well as to recent cocaine (prolonged use of sympathomimetics can result in hypoglycemia). LFTs normal, unlikely cardiac event. Recently had his lantus decreased due to improvement in his HgbA1c from 8.8 in [**2147-4-7**] to 6.4 in [**2147-11-7**]. Unclear if this is from improved diet, increased adherence to medications or another organic cause. On previous admissions for hypoglycemia the patient's glyburide was held and he remained without hypoglycemic episodes in the hospital. As the patient's hgba1c has improved and he has bubble packs for his meds with improved adherence, it was felt by the primary medicine team and [**Last Name (un) **] consultants that patient should not be restarted on glyburide. In house patient was treated with single dose of octreotide for glyburide intoxication which was then held as his sugars resolved. The patient's blood sugars remained in the 80-130 range NPO and then rose to 180-200 after eating breakfast. Lantus and insulin sliding scale were restarted and adjusted accordingly by [**Last Name (un) **]. # Altered Mental Status: Most likely [**1-9**] hypoglycemia vs cocaine use. No evidence of bleed on head CT. TIA possible given patient's h/o CVA and rapid improvement but less likely in setting of more possible hypoglycemic etiology. No WBC count, no fever, rapid improvement making meningitis unlikely. # Cocaine Use: Patient reporting recent cocaine use one time at his nephew's party on Friday night. Patient noting that his life has been empty since his wife died 2 years ago. Social work consulted for assistance with substance abuse and patient agreed to abstain from cocaine going forward. Beta blocker held in setting of possible continued cocaine use. . # Right Hip Pain: Patient complained of right hip pain, felt likely due to trauma from the fall prior to his being found down on admission. Given previous surgeries in the area, xray films were ordered. These showed ?subacute fracture and recommended MRI imaging with [**Month/Day (2) 102501**] artifact signal reduction which was performed and showed no fractures, some sclerosis and osetophyte collections which are nonspecific. # CHF: Lasix held in setting of [**Last Name (un) **] felt likely pre-renal in etiology. Stopped carvedilol in the setting of cocaine use initially but was resumed upon discharge given the risk-benefit of CHF protection and cocaine interactions. # [**Last Name (un) **]: Creatinine 1.4 on admission then rose to 1.6 shortly after likely in the setting of pre-renal physiology. Baseline 1.1. Trended down with IVF and PO intake back to normal by day of discharge. # [**Last Name (un) **]: TWI in v2 and v3 in MICU that persisted in repeat EKGs on the Medicine floor. In comparison to previous EKGs, these TWI also seen in I, III and aVF were not felt to be different/new but made more prominent by hypoglycemia and recent cocaine use. [**Last Name (un) 5937**] also found to be prolonged to 480, likely in setting of cocaine use that gradually normalized to 430s. Ruled out by cardiac enzymes. Continued on plavix and aspirin. # Increased CK: CK in 600s on admission, likely [**1-9**] immobilization (patient found down) vs recent cocaine use. Cardiac enzymes flat. CK trended down with IVF. # s/p MCA CVA: Per PCP notes, has residual right sided weakness, primarily in his leg and with writing, but this has been improving over time and it was decided not to add coumadin. # Back/hip pain: On percocet at home, as patient's mental status back to baseline, and complaining of [**8-16**] pain he was restarted on home regimen. # COPD: followed by Dr. [**Last Name (STitle) **]. Continued on home advair and spiriva. # Glaucoma: Continued latanoprost after confirming dose with pt's pharmacy. # GERD: continue omeprazole but will contact patient's PCP and cardiologist about plavix/omeprazole interaction. Medications on Admission: AMLODIPINE [NORVASC] - 5 mg by mouth once a day ATORVASTATIN [LIPITOR] - 80 mg Tablet - by mouth once a day CARVEDILOL - 25 mg Tablet - 1 Tablet(s) by mouth twice a day CLOPIDOGREL [PLAVIX] - 75 mg Tablet - by mouth once a day FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose Disk with Device - 1 inhaled puff twice a day FUROSEMIDE - 80 mg Tablet - one Tablet(s) by mouth once a day GLYBURIDE - 5 mg Tablet - 2 Tablet(s) by mouth twice a day INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 35 units per INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - use as directed before meals four times a day per sliding scale IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90 mcg)/Actuation Aerosol - 2 puffs inhaled four times a day as needed for shortness of breath LATANOPROST [XALATAN] - Dosage uncertain LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth daily NITROGLYCERIN - 0.4 mg Tablet, Sublingual - prn OMEPRAZOLE - 20 mg Capsule, Delayed Release by mouth once a day OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for pain POLYETHYLENE GLYCOL 3350 - 17 gram (100 %) Powder in Packet - 1 Powder(s) by mouth once a day as needed for constipation TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - 1 capsule inhaled once a day ASPIRIN, BUFFERED - 325 mg Tablet - by mouth once a day DOCUSATE SODIUM - 100 mg Capsule - by mouth twice a day FERROUS SULFATE - 325 mg (65 mg Iron) Tablet - 1 Tablet(s) by mouth DAILY (Daily) SENNA - 8.6 mg Tablet - 1 Tablet(s) by mouth twice a day Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: 1-2 puffs Disk with Devices Inhalation [**Hospital1 **] (2 times a day). 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB. 12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 13. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 15. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day as needed for constipation. 16. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 5 minutes as needed for chest pain: Not to exceed three doses with an episode of chest pain. If does not resolve after three doses, go to Emergency Room. 17. Insulin Glargine 100 unit/mL Solution Sig: Forty Five (45) units Subcutaneous with breakfast. 18. Humalog 100 unit/mL Solution Sig: Per NEW sliding scale Subcutaneous four times a day. 19. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 20. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Primary: Hypoglycemia, altered mental status, acute renal failure, cocaine abuse Secondary: Type II Diabetes, coronary artery disease, congestive heart failure, hypertension, back/hip pain, peptic ulcer disease/GERD Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Out of Bed independently to chair, motorized scooter or wheelchair Discharge Instructions: -You were admitted with low blood sugars that caused you to be confused. You were treated with intravenous dextrose (sugar) and your glyburide was stopped with good effect. The [**Hospital **] Clinic saw you in the hospital and made changes to your insulin regimen. Your kidneys were also found to not be functioning as well, likely due to dehydration. They normalized after some intravenous and oral fluids. -It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission: --> STOP Glyburide --> START new insulin regimen with Lantus (Glargine) 45 units with breakfast and Humalog sliding scale. . You complained of some hip pain while you were here, you had a hip MRI, preliminary results of this do not show hip fracture . It is likely that cocaine use contributed to injuring your kidneys and your low blood sugar. Using cocaine is dangerous and could be deadly. We recommend never using cocaine again. . -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. For your heart, weigh yourself every Followup Instructions: Appointment #1 Department: PULMONARY FUNCTION LAB When: WEDNESDAY [**2148-2-14**] at 3:10 PM 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: WEDNESDAY [**2148-2-14**] at 3:30 PM With: DR [**Last Name (STitle) **] & DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . APPOINTMENT #2 Please follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. You have an appointment for Thursday, [**2-16**] at 7:40 am. You can reach his office at [**Telephone/Fax (1) 250**]. It is important that you make this appointment. . APPOINTMENT #3 Please follow-up in the [**Hospital **] [**Hospital 982**] Clinic. You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14116**] on [**2-22**] at 1:30pm. You can reach their office at: [**Telephone/Fax (1) 2378**].

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

16989, 17044

9218, 10628

291, 297

17304, 17304

5428, 5433

18761, 19917

4292, 4419

15072, 16966

17065, 17283

13454, 15049

17494, 18738

4434, 5409

2368, 2818

6643, 9195

230, 253

6376, 6626

325, 2349

5448, 6357

17319, 17470

2840, 3639

3655, 4276

41,634

142,636

36297

Discharge summary

report

Admission Date: [**2157-3-23**] Discharge Date: [**2157-3-31**] Date of Birth: [**2104-5-2**] Sex: F Service: NEUROSURGERY Allergies: Penicillins / Tetracycline / Neomycin / Erythromycin Attending:[**First Name3 (LF) 2724**] Chief Complaint: Syncope, fever, hypotension. Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 52 year old female with h/o HTN, DM, hypothyroidism, RA, Sjogren's, vasculitis, recent lumbar surgery, presents from an OSH after a fall with hypotension and fever. The patient recently underwent L3-S1 laminectomy/foraminotomy on [**3-2**] at [**Hospital 23925**] [**Hospital **] hospital. Following surgery, she developed hypotension and renal failure and was found to have adrenal insufficiency. She was discharged on a prednisone taper which was scheduled for completion on [**3-16**]. Per report, today the patient had an unwitnessed syncopal event, however there is no documentation of this. She was brought to [**Location (un) **] ED. At [**Location (un) **], the patient was febrile to 104, hypotensive. Received vanco 1500mg IV, fentanyl, and IVF prior to transfer. CT head and CT chest were reportedly negative. WBC was 5.6, Hct 32.8, plt 280, cr 1.1. Transferred here out of concern for sepsis. In the [**Hospital1 18**] ED, vitals T 101.6, HR 100, BP 101/53, 20, SaO2 100% on 4L. Was on levophed upon transfer, but this was discontinued on arrival. SBP 120-130s--> 100s. Appeared pale and ashen. Confused with garbled speech. Pt unable to give history. Tender along lower abdomen. When she was rolled over, large amount of frank pus from spinal surgical incision--mild amount of erythema with 1cm opening draining pus. Labs notable for lactate 3.0, WBC 6.7 (91.4%N), Cr 1.4 (from 1.1 at OSH, unknown baseline). Received 10mg IV dexamethasone, cefepime, flagyl, tylenol, 5L NS. Ordered for CT abd/pelvis to evaluate abdominal tenderness en route to MICU. Admitted to MICU for close monitoring and further work-up. On arrival to the floor, the patient is very somnolent and unable to answer most questions. She does admit to having some pain in her back and feeling fatigued. Also feels lightheaded/dizzy. On ROS, she denies HA, chest pain, SOB, abdominal pain, nausea, vomiting, diarrhea, joint pain. Past Medical History: Past Medical History: -Diabetes Mellitus (DMII)- diet controlled, however has been on levemir and novolog sliding scale since hospital discharge given hyperglycemia on steroids -HTN -OA -Hypothyroidism [**1-3**] hashimoto's thyroiditis -RA -Autoimmune vasculitis -fibromyalgia -sjogren's -Post-herpetic neuropathy -h/o chronic back pain s/p multiple back surgeries Past Surgical History: -s/p tonsillectomy -TMJ surgery -Wisdom teeth extraction -Mediastinoscopy -Thyroid lobectomy -lumbar laminectomy with fusion Social History: Positive for alcohol and tobacco use. Married with no children. Works as a computer manager. Family History: Non-contributory. Physical Exam: On admission: PE: T 97.6, BP 108/69, HR 100, RR 20, SaO2 100% RA General: somnolent obese female, opens eyes to voice and attempts to answer questions but can only give few word responses and then closes her eyes again. HEENT: PERRL, EOMI, dry MM. Neck: thick, difficult to assess JVP. Heart: tachy, regular, no murmur appreciated. Lungs: CTAB, no wheezes, rales, rhonchi. Abdomen: obese, soft, +BS, tender to palpation diffusely, most severe with voluntary guarding in the RLQ. Extrem/Skin: warm and well-perfused, 2+ pedal pulses, no LE edema Back: 7cm lower spinal incision with staples in place, 2in patch of erythema surrounding incision for the length of the wound with approximately 1in of induration along the left edge of the incision, ~3cm area of fluctuance near the superior edge of the incision, tiny amount of thin purulent fluid could be expressed from incision Neuro: A+O to name, moving all four extremities but unable to cooperate with full neuro exam On discharge: Tmax 100.1 Vital signs stable. A&O x 3 Motor strenght intact throughout Wound Vac 10 inch linear dressing at midline and 4 inch dressing to the left of the midline incision. Pertinent Results: Labs on admission: [**2157-3-23**] 09:07PM BLOOD WBC-6.7 RBC-3.17* Hgb-9.4* Hct-28.2* MCV-89 MCH-29.7 MCHC-33.3 RDW-15.1 Plt Ct-216 [**2157-3-23**] 09:07PM BLOOD Neuts-91.4* Lymphs-3.4* Monos-5.0 Eos-0.1 Baso-0.1 [**2157-3-23**] 09:07PM BLOOD PT-17.6* PTT-35.7* INR(PT)-1.6* [**2157-3-23**] 09:07PM BLOOD Fibrino-694* [**2157-3-23**] 09:07PM BLOOD Glucose-172* UreaN-24* Creat-1.4* Na-128* K-5.5* Cl-98 HCO3-19* AnGap-17 [**2157-3-23**] 09:07PM BLOOD ALT-14 AST-17 TotBili-0.5 [**2157-3-23**] 09:07PM BLOOD Lipase-19 [**2157-3-23**] 09:07PM BLOOD Calcium-7.8* Phos-2.6* Mg-1.3* [**2157-3-24**] 02:02AM BLOOD Cortsol-43.8* [**2157-3-23**] 09:15PM BLOOD Glucose-151* Lactate-3.0* Na-127* K-5.5* Cl-95* calHCO3-24 CT abd/pelvis, [**2157-3-23**]: 1. Two subcutaneous collections, the largest to the left and posterior to the surgical site measuring up to 11.4 cm. The second is more midline and to the right beginning superiorly to the surgical site and extending inferiorly and connecting to the skin. 2. No evidence of hardware failure at the L3-S1 spinal fusion. 3. No intra-abdominal abscess. 4. 5-mm nodule in the right lower lobe. Followup CT at 6-12 months is suggested. CT head [**2157-3-23**]: No acute intracranial pathology. MRI L-spine [**2157-3-24**]: 1. Artifacts obscure details from L3 to S1 level. No abscess or abnormal enhancement seen from T12 to L2. 2. Large left-sided fluid collection within the subcutaneous fat at L3 and L4 level extending to the left side of the iliac crest which by the MRI appearances alone does not appear like an abscess, but clinical correlation is recommended to exclude superimposed infection. Cardiac Echo: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. SWAB [**3-23**] - MSSA Blood culture [**3-23**] - MSSA x2 Blood culture [**3-24**], [**3-25**], [**3-26**] ngtd CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2157-3-29**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Brief Hospital Course: This is a 52 year old female with history of HTN, DM, hypothyroidism, RA, Sjogren's, vasculitis, recent L3-S1 laminectomy/foraminotomy admitted from OSH after fall with fever and hypotension. . ## Sepsis/Wound infection: Initial presentation consistent with septic shock, but now off pressors, HD stable and lactate down trending. Likely source is infection at spine wound seeding blood stream since both are growing Coagulase positive Staph. UA negative. CXR unremarkable. TTE negative for vegetations and no peripheral manifestations of endocarditis, including Osler nodes, [**Doctor Last Name **] spots or Janeways. Patient went to the OR [**3-29**] for wound washout. MRI with artifact obscuring the imaging of the spinal canal at L3 to S1 level by MRI. No spinal abscess or abnormal enhancement from T12 to L2. Patient initially managed on vancomycin and cefepime, but later transitioned to nafcillin as this is the ideal drug for MSSA bacteremia. Patient will require a 8 week course of antibiotics Per ID recommendations. PICC Line was placed on [**3-28**] and ID recommended: 1. Repeat Stool culture for C. diff if diarrhea/loose stools persist loose stools. 2. Check Blood cultures x2 if fever spikes ( 101.5) 3. Check CBC, LFTs, Chem 7 once weekly while on Nafcillin. # Delirium: Resolved over the night following admission. Was likely related to bacteremia. . # Lung nodule: An incidental finding of a 5-mm nodule in the right lower lobe of the lung was noted on CT scan of the abdomen and pelvis. Followup CT at 6-12 months is suggested. . # Rheum: The patient has a history of RA, Sjogren's, and autoimmune vasculitis per records. She is currently taking plaquenil, which was held on admission. # Fibromyalgia/Chronic pain: On admission, her pain meds, elavil, and neurontin were initially held for altered mental status. Elavil and neurotin restarted on the medicine floor. . ## Anemia: Anemia: Hct in mid 20s with unknown baseline. guaiac negative x1. Iron studies consistent with AOCD. . ## Adrenal insufficiency: Now off prednisone taper. Random cortisol 49, so clearly no longer insufficient. . ## DM: Diet controlled. Continue ISS while inhouse. . ## HTN: Holding antihypertensives in the setting of sepsis. Restarted atenolol on the medicine floor. On lisinopril, atenolol and HCTZ at baseline. . ## Prophylaxis: Heparin SC 5000 tid, PPI, bowel regimen . ## Code status: FULL CODE confirmed with patient . ## Communication: Husband [**Name (NI) **] [**Telephone/Fax (1) 82240**] Medications on Admission: Elavil 100mg PO QHS Atenolol 50mg PO BID Lisinopril 40mg PO daily Klonopin 1-2mg PO QHS Colace 100mg PO BID Ferrous sulfate 325mg PO TID Flonase Neurontin 600mg PO TID HCTZ 25mg PO daily Prednisone taper (scheduled to complete on [**3-16**]) Plaquenil 200mg PO BID Synthroid 125 mcg PO daily Protonix 40mg PO BID MS contin 45mg PO TID MSIR 15-45mg q3 prn Niacin 500mg PO qHS Salagen 5mg PO TID Tylenol prn Flexeril 10mg PO q8 prn Benadryl 50mg PO qHS prn Milk of magnesia prn Miralax prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Tablet(s) 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 5. Amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. 7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 13. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 15. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1) Intravenous Q4H (every 4 hours). 16. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 17. Heparin Flush 10 unit/mL Kit Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [**Hospital 8641**] Healthcare, NH Discharge Diagnosis: Lumbar wound infection Discharge Condition: Neurologically stable Discharge Instructions: ?????? Do not smoke. . Keep your wound dry while you have a wound Vac in place, you may not shower and get the area wet, but may sponge bath the area ?????? ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? 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. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine. ?????? Any weakness, numbness, tingling in your extremities. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? Fever greater than or equal to 101?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Follow Up Instructions/Appointments All of your follow up care should be arranged with Dr. [**Last Name (STitle) 82241**], ask to speak to [**Doctor First Name **] for your appointment: [**Telephone/Fax (1) 82242**] Ext: 123 Please See your primary care provider upon discharge from Rehab. An appointment has been made for you on [**5-25**] at 11:30 AM with Dr. [**First Name (STitle) **]. Please take a copy of your discharge summary with you to this appointment. Completed by:[**2157-3-30**]

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icd9cm

[ [ [] ] ]

[ "03.02", "93.56", "77.69", "78.69", "38.93" ]

icd9pcs

[ [ [] ] ]

11383, 11444

6862, 9365

345, 352

11511, 11535

4182, 4187

13045, 13544

2968, 2987

9903, 11360

11465, 11490

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3002, 3002

3987, 4163

277, 307

380, 2305

4201, 6839

2349, 2693

2858, 2952

16,454

114,069

26402

Discharge summary

report

Admission Date: [**2171-1-19**] Discharge Date: [**2171-1-26**] Date of Birth: [**2120-2-22**] Sex: M Service: SURGERY Allergies: Penicillins / Percocet / Oxycodone / Morphine Attending:[**First Name3 (LF) 371**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: s/p ex lap, LOA History of Present Illness: 50M s/p multiple abdominal surgeries presents with acute onset of abdominal pain associated with nausea and vomiting x 12 hours. Past Medical History: - Recurrent MRSA infections, four of right elbow - IPMN s/p distal pancreatectomy/splenectomy/CCY [**8-24**] c/b wound infection [**12-24**] - IDDM post-distal pancreatectomy - Recurrent pancreatitis [**2167**] - Steroid-dependent chronic tophaceous gout x 20+ years - Hypertension - Hypercholesterolemia - NSAID-induced colonic ulcer c/b LGIB [**12-22**] - Fatty liver [**12-22**] - Chronic lower back pain - Basal cell CA - lower back - Nephrotic syndrome on steroids >30 years (started age 19) - MRSA bacteremia and osteomyelitis s/p partial vertebrectomy of C4, C5 and C6, Fusion C3-C7, Vertebral body replacement application, Right iliac crest bone graft, Autograft and allograft [**10/2170**] - UE DVT from PICC line during admission [**10/2170**] Social History: Transferred from rehab following recent admission for osteomyelitis and epidural abscess. Separated from his wife, has 2 grown children. On disability. Smoked occasional cigars but quit 18 years ago, no cigarette use. No current ETOH. No illicit or IVDU. Family History: No h/o cancer, DM, CAD Mother has gout (not tophaceous) in her 60s, no other family h/o rheumatic diseases Physical Exam: afebrile, vitals in normal range NAD, gouty tophi on hands/arms/legs chest clear RRR, no MRG abdomen soft and appropriately tender for postoperative course s/p Ex lap, LOA; no erythema or induration; wound healing without complications extremities with tophi as above, moderate tenderness to the touch but improving per pt, otherwise minimal peripheral edema and strength returning to baseline Pertinent Results: [**2171-1-23**] 07:20AM BLOOD WBC-16.7* RBC-3.70* Hgb-9.1* Hct-30.8* MCV-83 MCH-24.5* MCHC-29.5* RDW-18.8* Plt Ct-509* [**2171-1-22**] 11:20AM BLOOD WBC-19.0* RBC-3.91* Hgb-9.5* Hct-33.3* MCV-85 MCH-24.3* MCHC-28.4* RDW-18.8* Plt Ct-425 [**2171-1-19**] 01:05PM BLOOD WBC-24.3*# RBC-4.72# Hgb-11.9*# Hct-39.2*# MCV-83 MCH-25.3* MCHC-30.5* RDW-19.2* Plt Ct-532* [**2171-1-22**] 11:20AM BLOOD Neuts-75.9* Lymphs-16.3* Monos-4.4 Eos-2.8 Baso-0.5 [**2171-1-22**] 11:20AM BLOOD Glucose-73 UreaN-23* Creat-0.9 Na-144 K-4.0 Cl-108 HCO3-24 AnGap-16 [**2171-1-22**] 07:00AM BLOOD Glucose-57* UreaN-23* Creat-0.9 Na-144 K-4.4 Cl-109* HCO3-21* AnGap-18 [**2171-1-19**] 01:05PM BLOOD ALT-15 AST-18 AlkPhos-89 TotBili-0.2 [**2171-1-22**] 11:20AM BLOOD Calcium-9.1 Phos-2.7 Mg-1.7 [**2171-1-19**] 06:45PM BLOOD %HbA1c-6.1* Brief Hospital Course: Admitted to ICU postoperatively for resuscitation after ex-lap, lysis of adhesions for SBO. On POD2, intensive care was not required and the pt was transferred to the floor. GI: By POD2, the NGT was discontinued; by evening the pt was passing minimal flatus and sips were started. By POD4, flatus was routine and diet was advanced to clears as the pt was hesistant about restarting a regular diet at this time. On POD5, diet was fully advanced and pt tolerated this without nausea or vomiting. The abdominal incision was healing without complication throughout the hospitalization. Rheum: The pt's gout flared postoperatively and made movement painful from POD2-4. During this time, PT and OT were consulted for evaluation and management strategies. After 3 days of PT, the pt was cleared for discharge home with home/outpatient PT follow up. By discharge, the pt was taking his home dose of prednisone and his arthritic symptoms were improved so that he could independently perform all daily activities. ID: Pt was continued on all home medications and remained on bactrim throughout this hospitalization. His white count remained stable around 15-20 on prednisone. He did not spike any fevers during this hospitalization. Endo: Pt was maintained on RISS during this hospitalization and should resume his home routine upon discharge. Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Year/Month/Day **]: One (1) Tablet PO BID (2 times a day). 2. Amlodipine 5 mg Tablet [**Year/Month/Day **]: Two (2) Tablet PO DAILY (Daily). 3. Allopurinol 300 mg Tablet [**Year/Month/Day **]: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Year/Month/Day **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Carisoprodol 350 mg Tablet [**Year/Month/Day **]: One (1) Tablet PO QHS (once a day (at bedtime)). 6. Metoprolol Tartrate 50 mg Tablet [**Year/Month/Day **]: Two (2) Tablet PO BID (2 times a day). 7. Insulin Regular Human 100 unit/mL Solution [**Year/Month/Day **]: One (1) Injection ASDIR (AS DIRECTED). 8. Pregabalin 75 mg Capsule [**Year/Month/Day **]: One (1) Capsule PO daily (). 9. Prednisone 20 mg Tablet [**Year/Month/Day **]: One (1) Tablet PO DAILY (Daily). 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Year/Month/Day **]: One (1) Tablet PO DAILY (Daily). 11. Fentanyl 100 mcg/hr Patch 72 hr [**Year/Month/Day **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 12. Fentanyl 75 mcg/hr Patch 72 hr Transdermal Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: small bowel obstruction Discharge Condition: good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Call to arrange follow up with Dr. [**Last Name (STitle) **] in [**10-1**] days. You should call to arrange an appointment with your PCP next week for your gout flare. Call to arrange an appointment with your PCP in the next week.

[ "274.0", "251.3", "557.0", "552.3", "401.9", "560.81", "272.0" ]

icd9cm

[ [ [] ] ]

[ "54.4", "54.59" ]

icd9pcs

[ [ [] ] ]

5488, 5539

2933, 4282

319, 337

5607, 5614

2101, 2910

7063, 7297

1563, 1672

4305, 5465

5560, 5586

5638, 6702

6717, 7040

1687, 2082

265, 281

365, 495

517, 1274

1290, 1547

13,491

133,713

23743

Discharge summary

report

Admission Date: [**2113-4-6**] Discharge Date: [**2113-4-19**] Date of Birth: [**2051-8-26**] Sex: M Service: [**Last Name (un) **] This is a 61-year-old with anemia and weight loss. He was seen by his PCP in [**Month (only) 956**] and had a CT of his abdomen in [**Month (only) 956**] which demonstrated liver metastases. Colonoscopy on [**4-6**], at the time of admission, showed a nearly obstructing lesion in the sigmoid colon. The patient had reported a 25 pound weight loss over the past 3 years, and was incontinent with stool for over 6 months. He did not seek medical treatment, had no ETOH and was guaiac positive. The patient attributed the guaiac positive to a history of steroids. His past medical history was not significant for anything else. His surgical history was only significant for a tonsillectomy as a youth. He had no known drug allergies. His medications at home included aspirin and Actifed. At the time of admission he was cachectic appearing, alert and oriented, was not in any acute distress. His chest was clear. His heart was regular. His liver edge was felt about 6 cm below the costal margin. It was soft, nondistended, nontender, but suspicion on physical exam demonstrated ascites. Rectal was guaiac positive with a mass 4 to 5 cm from the anal verge. Hematocrit on admission was 28.9. His white count was 9.7. Total bilirubin was 1.8. For the EGD report from [**2113-4-6**] (please see the EGD report), but esophageal candidiasis was noted, otherwise a normal EGD to the second part the duodenum. Also the colonoscopy was noted grade II internal hemorrhoids and a mass in the sigmoid colon. Colonoscopy demonstrated a mass in the sigmoid and colonoscopist, upon visualizing the mass, [**Name (NI) 653**] Dr. [**Last Name (STitle) **], and that is how he was admitted to our service. He was afebrile at 97.0 on admission, had a heart rate of 103, blood pressure 127/65, rate of 16 with 100% on 2 liters nasal cannula. On hospital day #2 the patient had no events overnight. He was afebrile at 98.3, heart rate of 90, 120/64. He was prepped with a plan for operation. Foley catheter was started and the patient was started on clears. An extensive discussion was undertaken with Dr. [**Last Name (STitle) **] in regards to his care. Also, the patient had been evaluated by Dr. [**Last Name (STitle) **] and discussion was held with the family and Dr. [**Last Name (STitle) **] in regards to potential chemotherapy agents and courses had been discussed as well. On [**2113-4-8**], (please see operative dictation) the patient underwent an LAR for an obstructing rectosigmoid cancer. Dr. [**Last Name (STitle) **] was assisted by Dr. [**Last Name (STitle) **] with general anesthesia. There were no complications. They found an obstructing cancer that was massive with multiple hepatic metastasis. Specimen was sent to pathology. The EBL was listed at about 150 cc and the patient made about approximately 30 cc of urine during the case. Right IJ was placed during the case. Chest x-ray was checked. There was no pneumothorax, and the patient was taken to the PACU in stable condition. On his postop check the patient was afebrile at 98.1, had a blood pressure of 101/50, heart rate of 75, saturating 100%. Urine output was approximately between 33 and 70 cc an hour. His white count was normal. His hematocrit was 24.6 after time of operation and his electrolytes were normal. He was given a bolus and a repeat hematocrit was drawn. On postoperative day #1 the patient had an uneventful day. He had a little bit of ectopy on the monitor strip. His repeat labs were taken and his magnesium was repleted, as was his potassium. The PVCs that the patient had on the monitor stopped after repletion of electrolytes and the patient's pain was well controlled by acute pain service; says he had an epidural. The patient was started on postoperative day #2 on TPN and the patient still had not had GI function. He was afebrile at 99.0 and 97.7, heart rate 95, 120/60, and had made 736 in urine overnight and 250 in urine since midnight. On postoperative day #3 the patient remained afebrile, had some low urine output earlier in the day and was given a 500 cc bolus. His urine output responded appropriately and the patient picked up and made 1090 of urine that day. On postoperative day #4 the patient remained afebrile, was on full TPN. He had a chest x-ray checked that was negative for any pathology. The patient was consented by Dr.[**Name (NI) 2829**] team and taken to the OR for single lumen port placement in preparation for chemotherapy. The patient was doing quite well at this point and time. He was seen by physical therapy. He denied pain at rest, ambulated with them, moved all extremities. He was noted to have impaired functional mobility but was doing well from a physical therapy perspective. On [**2113-4-12**] the patient underwent a Port-A-Cath placement by Dr. [**Last Name (STitle) **]. There were no complications. The patient did well. There was no hematoma or any complications. Postop check was well. On postoperative day number 5 and postoperative day number 1 from the port placement the patient was afebrile, did have a T-max to 99.4 but his vital signs were stable. His heart rate was 98. Blood pressure was 140/80. He made 1500 cc of urine overnight and was doing well. His pain was well controlled with PCA and discharge planning was begun about discharging the patient to a rehab facility. Patient's family and social work were actively involved in the patient's care. On postoperative day #6 the patient continued to well. Did note on his abdominal exam some minor distension. His abdomen was soft, nontender. His wound was clean, dry and intact. The patient had no pain and the patient had arranged for an appointment with Dr. [**Last Name (STitle) **] for [**4-26**]. He was out of bed, using incentive spirometry. Discharge planning was begun to rehab. On postoperative days #7 and 3 the patient was receiving TPN. He was comfortable. He was out of bed. His temperature was 99.0 and 97.9, heart rate 86, 130/80, 20, and 94% on room air. He was in no acute distress. His respiratory rate was regular. His lungs were clear to auscultation. His port site was clean, dry, and intact. He was minimally distended. His abdomen was soft and nontender. His wound was clean, dry and intact. He was doing well. His strength was improving and he was still doing well. He was stable despite the slight abdominal distension. The patient had received on [**2113-4-15**] 1 unit of packed red blood cells for a hematocrit of 22.4. He was complaining of some pain with scrotal edema and was a little bit uncomfortable when awake, and was answering questions appropriately throughout the early morning on [**2113-4-16**]. On [**4-16**] the venous access team came to evaluate him for a PICC. On [**4-16**], postoperative day #8, he had some sinus tachycardia to the 120s. An EKG was performed to rule out ischemia and there was no atrial fibrillation. His magnesium was low at 1.6 and his calcium was low at 7.7. His electrolytes were repleted. His blood pressure had dropped to 90/50 with the sinus tachycardia, but after a liter of bolus it improved to 120/70. Temperature was 99.9. T-max current was 97.6, heart rate was 104, 120/90, 93% on room air. Blood sugar was 88 to 130. The patient made 1500 cc of urine overnight. The abdomen was described as a little bit distended with a minimal fluid wave, concerning for ascites. White count was 10.1, hematocrit was 25.5. An ultrasound was performed at that point and time which showed right upper quadrant intrahepatic ductal dilatation. His LFTs had increased, therefore, the ultrasound had been performed. There was concern whether he was developing biliary obstruction. There was consideration about ERCP. On [**4-17**], postoperative day #9, the patient appeared jaundiced. He was afebrile at 97.4, heart rate 104, blood pressure 110/60, and was saturating 98% on room air. He had made 800 of urine overnight. The patient was jaundiced and had a direct bilirubin that increased in a 24-hour period from 5 to approximately 11. The patient was NPO for ERCP. There was suspicion of biliary obstruction, but there was also concern for sequela related to the metastatic disease of the liver. The patient was being evaluated very carefully and repeatedly during this time frame. On [**2113-4-17**] patient's 7:00 p.m. total bilirubin was 9.8. Ammonia level was 239. Patient's blood pressure was a little bit lower at 7:00 p.m. in the 80s to 90s systolic. The patient was confused on exam and he was diffusely tender in the abdomen. He had some guarding, especially in the right lower quadrant. Discussion was taken to Dr. [**Last Name (STitle) **] of GI in order to evaluate the patient for ERCP, as we thought this was potentially one of his concerning issues. At that point in time we transferred him to the ICU. We went for aggressive resuscitation including IV fluids and possible pressors. We continued the antibiotics and we placed an NG tube. The patient was transferred to the SICU in an expeditious fashion. Urine output was minimal at that point and time and he was deemed too unstable to move to the [**Hospital Ward Name **] for possible ERCP with Dr. [**Last Name (STitle) **]. The patient was bolused appropriately. His white count at the time of transfer on [**4-17**] at 7:15 p.m. was 13.2, hematocrit was 29. His lactate was discovered to be 4.5. His LFTs demonstrated AST of 132, ALT of 59, alkaline phosphatase of 340 and total bilirubin of 8.7. The patient was given aggressive fluid resuscitation, NG tube and rectal tube. The patient had a prerenal picture and transfusions were done to keep hematocrit above 30. We added vancomycin and fluconazole to the levofloxacin and Flagyl that were already going. The patient on arrival to the SICU was described as alert and in no acute distress, jaundiced, increased respiratory rate, and lungs had clear breath sounds. He was tender and had a distended abdomen with 2+ pitting edema to the mid calf. His DPs and PTs were intact. His FENa demonstrated the patient to be prerenal. He was resuscitated. Placement of a radial A- line was done. The patient was eventually, at 1:00 in the morning, intubated for respiratory acidosis. On [**2113-4-18**] the patient was again evaluated by the chief resident of surgery service. A Swan was placed and the patient was aggressively resuscitated. On postoperative day #12, unit day #2, the patient was on Levophed, Pitressin and propofol. A CT scan was performed early in the morning, which was a non-contrast CT. It did demonstrate a touch of pneumoperitoneum. At this point the patient was deemed critically ill with a potential biliary source, but also with a potential other source such as an anastomotic leak, therefore, the patient was taken back to CAT scan subsequently early that morning and performed rectal contrast. Rectal contrast demonstrated a significant leak. Extensive discussion was undertaken with the family, the attending, and all teams involved. Social work was involved. After extensive discussion with the family and the patient's prognosis with liver replaced by metastatic disease from his original cancer, a decision was made to make the patient comfort measures only. The patient was made comfort measures only, as per discussion with the family, and the patient died on CMO. FINAL DIAGNOSIS: Obstructing colon cancer, resection with subsequent anastomotic leak, and sepsis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1286**], MD [**MD Number(1) 11126**] Dictated By:[**Last Name (NamePattern1) 7823**] MEDQUIST36 D: [**2113-4-18**] 19:15:45 T: [**2113-4-20**] 11:55:08 Job#: [**Job Number 60643**]

[ "995.92", "997.4", "518.81", "584.9", "401.9", "197.7", "568.89", "578.1", "570", "198.89", "280.0", "154.0", "112.84", "038.9", "560.1" ]

icd9cm

[ [ [] ] ]

[ "45.16", "99.04", "86.07", "48.63", "89.64", "38.91", "96.04", "00.17", "99.15", "96.71", "48.24" ]

icd9pcs

[ [ [] ] ]

11476, 11834

3,956

198,895

23933

Discharge summary

report

Admission Date: [**2126-5-10**] Discharge Date: [**2126-5-12**] Date of Birth: [**2064-7-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7055**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with cypher stent placement History of Present Illness: 62yo M former tobacco smoker with family history of early CAD presents with episode of chest pain. The chest pain is described as crushing chest pain located across the chest. The pain occurred while asleep at 2AM and woke him up. There was no radiation and was not associated with any sob, diaphoresis, n/v. The patient took one maalox without any improvement. He subsequently took one adult ASA and went to the local hospital. There he was diagnosed with STEMI with 0.5mm elevation of ST segment in III and aVF. He was started on heparin gtt and transferred directly to the catheterization lab. In hindsight, he reports an episode of shortness of breath while shoveling dirt in his driveway the day prior to admission. Past Medical History: 1. Low back pain. Social History: Pt admits to smoking 1 to 1.5ppd x 20+year but reports he quit in [**2094**]. He also admits to drinking 1-2 beers/day for many years. He denies any illicit drug use. Family History: Father: 1st MI at age 66. Mother: deceased from brain tumor Brother: 1st MI at age 50 Sister: [**Name (NI) 8751**] Physical Exam: VS: BP: 110/70 P: 60 RR: 12 SaO2: 99% on 2L NC Gen: well nutritioned caucasian male lying in bed in NAD. Unable to move as he is post cath, but conversing fluently in full sentences. HEENT: PERRL, EOMI, anicteric, op clear, mmm CV: RRR, S1, S2 Chest: CTA bilaterally Abd: soft, NT, ND, BS+ Ext: wwp, no c/c/e, DP+2 Neuro: CN II-XII grossly intact. Pertinent Results: [**2126-5-10**] 05:51AM HGB-13.8* calcHCT-41 O2 SAT-97 [**2126-5-10**] 05:51AM TYPE-ART O2 FLOW-3 PO2-135* PCO2-44 PH-7.35 TOTAL CO2-25 BASE XS--1 [**2126-5-10**] 07:42AM WBC-7.6 RBC-4.53* HGB-14.2 HCT-40.2 MCV-89 MCH-31.3 MCHC-35.4* RDW-12.7 [**2126-5-10**] 07:42AM PLT COUNT-136* [**2126-5-10**] 07:42AM TRIGLYCER-97 HDL CHOL-46 CHOL/HDL-3.8 LDL(CALC)-108 [**2126-5-10**] 07:42AM ALBUMIN-3.7 CALCIUM-8.7 PHOSPHATE-2.9 MAGNESIUM-1.9 CHOLEST-173 [**2126-5-10**] 07:42AM CK-MB-263* MB INDX-11.7* cTropnT-4.21* [**2126-5-10**] 07:42AM LIPASE-21 [**2126-5-10**] 07:42AM GLUCOSE-114* UREA N-22* CREAT-0.9 SODIUM-139 POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-25 ANION GAP-12 [**2126-5-10**] 07:42AM ALT(SGPT)-49* AST(SGOT)-191* LD(LDH)-402* CK(CPK)-2240* ALK PHOS-60 AMYLASE-62 TOT BILI-0.5 [**2126-5-10**] 12:32PM CK-MB-280* MB INDX-12.7* cTropnT-5.13* [**2126-5-10**] 12:32PM CK(CPK)-2209* . . CARDIAC CATHETERIZATION [**2126-5-10**]: COMMENTS: 1. Selective coronary angiography revealed a right dominant system. The RCA had a long 60% mid vessel lesion and was totally occluded in the mid to distal vesel with left to right collaterals to the distal vessel. The LMCA had a 60% distal lesion. The LAD had a 70% mid vessel lesion. The D1 had a 70% lesion. The LCX had a 70% ostial lesion. The first major OM had a 80% lesion. 2. Hemodynamics post PCI showed normal central pressure, mildly elevated left sided filling pressures, and a normal cardiac index. 3. After the export catheter was used during the procedure, the patient had a bradycardic episode to HR 32 with decreased blood pressure - which required atropine. Pacer was introduced, but patient did not require pacing. 4. Successful Primary PCI of the RCA with two overlapping Cypher DES (3.5 x 33 mm, post-dilated with a 4.0 mm balloon, and 3.0 x 33 mm, post-dilated with a 3.5 mm balloon). FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Mildly elevated left sided filling pressure. 3. Acute inferior myocardial infarction, managed by acute PCI of the RCA. . . TTE [**2126-5-10**]: MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.2 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *6.1 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *6.1 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.2 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 35% (nl >=55%) Aorta - Valve Level: 3.5 cm (nl <= 3.6 cm) Aorta - Ascending: 3.0 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.4 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 0.57 Mitral Valve - E Wave Deceleration Time: 255 msec TR Gradient (+ RA = PASP): *29 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Moderate regional LV systolic dysfunction. No LV mass/thrombus. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. Mild to moderate ([**2-10**]+) MR. LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline PA systolic hypertension. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with akinesis of the inferior wall and hypokinesis of the infero-septum and infero-lateral walls. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild to moderate ([**2-10**]+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate regional LV systolic dysfunction c/w CAD. Brief Hospital Course: A/P: 61yo M former tob smoker with family history of early CAD who presents with STEMI s/p cath with 3VD and PCI of RCA. . 1. CV: A). Coronaries: Pt presented to OSH with chest pain and was found to have an STEMI. He was transferred to [**Hospital1 18**], where he underwent urgent cardiac catheterization. The cath demonstrated left main and 3v CAD and the patient underwent a PCI of RCA which was thought to be the culprit lesion based on angiographic findings. After his cardiac catheterization, he was monitored on telemetry and managed medically. He was initially ordered for metoprolol 12.5mg [**Hospital1 **] which was subsequently held and then d/c'd due to bradycardia. He was started on ACEI which he tolerated as well as ASA and Plavix. He was also given lipitor 80mg QHS initially, but this was also stopped due to elevated LFT. The patient requires a repeat LFT and Cholesterol panel as outpatient to be re-evaluated for statin therapy. Pt was successfully rate and pressure controlled with goal of: HR <70 and SBP <120. The patient received a surgical evaluation for possible CABG on [**2126-5-23**], he was already evaluated by anesthesia while in house as well. Pt is to call Dr. [**Last Name (STitle) **] for an outpatient appointment as he still requires a carotid US prior to undergoing CABG. . B). Pump: Pt with STEMI, and unknown pre-MI cardiac function. TTE demonstrates a reduced EF of 35%. Given lack of clinical findings of CHF, he was not actively diuresed. He was however counseled on fluid and salt balance and given some education on dietary control. . C). Rhythm: The patient was monitored on telemtry during the duration of his stay and he was in NSR to sinus bradycardia during his admission. His bradycardia limitted use of beta blocker. This should be re-addressed as an outpatient. . D). Primary risk reduction: The patient was initially started on lipitor 80mg QHS given his ACS. However due to slightly elevated LFT, the statins were held. We recommend outpatient follow up of his LFT and cholesterol. If LFTs are normal, the patient will benefit from statins. The patient was counsel on lifestyle, diet, and exercise and their impact on his cardiovascular as well as generalized health. Even though his FS and glucose on chemistries were wnl, his A1c was 6.4 suggesting some degree of glucose intolerance. We recommend an outpatient follow up of his glucose and A1c levels as uncontrolled blood sugars have been shown to have an effect on mortality. . . 2. LBP: pt with hx of LBP. He was given percocet PRN after cath with good control. . . 3. Elevated LFT: AST:ALT of 2.5 to 1 ratio suggestive of possibly Alc liver disease. Currently no sign of cirrhosis with intact synthetic function. Although he was initially started on lipitor, this was stopped once his LFT were returned. Suggest outpatient LFT check and re-administration of lipitor if possible. . . 4. PPx: Pt was initially on integrillin after cath and then subsequently on Heparin subQ TID for DVT prophylaxis. Colace, senna for bowel regimen, and PPI for ICU stress were also given during his stay. . Medications on Admission: Aspirin Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: ACS - 3 vessel coronary artery disease with stenting of RCA with overlapping cypher stents. Secondary: Hyperlipidemia Discharge Condition: Good. Discharge Instructions: Please take all of your medication. Please follow up with your doctors. If you notice any episode of chest pain, palpitations, shortness of breath, please call your PCP or come directly to the ED. Followup Instructions: Please follow up with your PCP [**Name9 (PRE) 60995**] one to two weeks of discharge. Please call Dr. [**Last Name (STitle) 26225**] for a follow up appointment as well. At the time, please have your physician [**Name9 (PRE) 32385**] [**Name Initial (PRE) **] cholesterol level and liver panel and if necessary, have a cholesterol medication (statin) started. In addition, please arrange to have a carotid US series performed in anticipation of cardiac bypass graft surgery. Provider: [**Name10 (NameIs) **],[**Name Initial (NameIs) **] [**Name12 (NameIs) **] to schedule appointment: [**Telephone/Fax (1) 170**] Completed by:[**2126-5-18**]

[ "426.6", "428.0", "458.29", "427.89", "410.41", "724.2" ]

icd9cm

[ [ [] ] ]

[ "36.07", "39.64", "99.20", "88.56", "36.01", "37.22" ]

icd9pcs

[ [ [] ] ]

10275, 10281

6532, 9669

326, 379

10453, 10460

1888, 3764

10708, 11357

1383, 1499

9727, 10252

10302, 10432

9695, 9704

3781, 6509

10484, 10685

1514, 1869

276, 288

410, 1139

1161, 1181

1197, 1367

1,173

177,265

1859+55328

Discharge summary

report+addendum

Admission Date: [**2135-7-16**] Discharge Date: Date of Birth: [**2059-9-25**] Sex: M Service: HISTORY OF PRESENT ILLNESS: (per Medical Intensive Care Unit admission note) The patient is a 75 year old male with alcoholic cirrhosis, ascites, edema, multiple gastrointestinal bleeds from Grade I varices, and lower gastrointestinal bleed from diverticula and hemorrhoids. Today, he noted explosive diarrhea, dark and melanotic per patient, about every two hours, and he came to the Emergency Department. He was started on Motrin four times a day times four days for gouty flare. He complained of lightheadedness but denied fever or chills, nausea or vomiting, chest pain, shortness of breath, hematemesis, bright red blood per rectum. He had a colonoscopy on [**2135-7-7**], for bleeding, with polyps. He had a resection at that time and was also noted to have diverticula with internal hemorrhoids. He is quasi-transfusion dependent for packed red blood cells in two days. Nasogastric lavage was negative in the Emergency Department. PAST MEDICAL HISTORY: 1. Cirrhosis secondary to alcohol. 2. Atrial flutter status post cardioversion and arteriovenous node ablation. 3. Coronary artery disease status post coronary artery bypass graft, left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal stent [**38**]/[**2132**]. 4. History of multiple gastrointestinal bleeds. 5. Diverticulosis. 6. Multiple colonic polypectomies. 7. Esophageal varices [**4-18**], Grade I. 8. History of telangiectasias stomach. 9. Chronic renal insufficiency with baseline creatinine 1.5 to 1.8. 10. History of urosepsis. 11. Right esotropia. 12. Hemorrhoids. 13. Gout. 14. History of peptic ulcer disease in [**2132**]. 15. History of cellulitis of left leg. MEDICATIONS ON ADMISSION: 1. Nitroglycerin patch. 2. Protonix 40 p.o. q. day. 3. Lactulose 30 mg p.o. q. day. 4. Lopressor 50 mg p.o. twice a day. 5. Lasix 40 mg p.o. twice a day. 6. Aldactone 35 mg p.o. twice a day. 7. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mg p.o. q. day. SOCIAL HISTORY: Married; quit alcohol. Thirty pack year smoking history. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Temperature 97.1 F.; blood pressure 126/44; heart rate 70. In general, an elderly male in no apparent distress. HEENT: Mucous membranes were moist. Lungs clear to auscultation bilaterally. Cardiovascular is regular rate and rhythm, Grade III/VI systolic murmur at left upper sternal border. Abdomen soft, obese, nontender, nondistended, positive bowel sounds. Extremities with no pedal edema. Neurological: Alert, pleasant conversant. LABORATORY ON ADMISSION: White blood cell count 3.8, hematocrit 25.5, platelets 106, 72% neutrophils, 18% lymphocytes, 6% monocytes, 2% eosinophils. Sodium 135, potassium 4.4, chloride 99, carbon dioxide 26, BUN 40, creatinine 3.0 from baseline of 1.5 to 1.8. Glucose 122, INR 1.1. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit for gastrointestinal bleed and multiple bleeding sources. Gastroenterology was consulted who recommended beginning Octreotide, taking a right upper quadrant ultrasound and transfusing as needed. The patient had an esophagogastroduodenoscopy performed on [**2135-7-17**], which revealed Grade I esophageal varices without evidence of recent bleed. Small fundic polyp; biopsy was not performed as he is currently undergoing evaluation for gastrointestinal bleed and this can be re-evaluated at the time of next esophagogastroduodenoscopy. The patient then underwent colonoscopy on [**7-18**], which revealed diverticulosis of the sigmoid colon. There were large nonbleeding rectal veins and varices noted; otherwise normal colonoscopy to the cecum. There was no source clearly obtained from study. The patient was transfused to maintain hematocrit greater than 30. The plan was discussed regarding the possibility of performing capsule endoscopy, however, given the patient's reluctance for surgery, the decision was made to not pursue further work-up and to transfuse only as needed. The patient remained hemodynamically stable with a normal hematocrit. 2. HEMATOLOGY: The patient with a long standing pancytopenia seen evidenced one year ago. He also had acute blood loss anemia as described above. Reticulocyte count was performed which revealed an appropriate bone marrow response to ongoing anemia with a reticulocyte index of only 1.5. His platelets remained low but as he had stopped bleeding, he did not require any platelet transfusions. He was not on any heparin products. Pt really is against invasive aproach and it was felt that even if aggressive w/u including bone marrow bx, the likelyhood of finding a reversible cause was very unlikely so no further w/u will be pursue. 3. INFECTIOUS DISEASE: On [**2135-7-19**], the patient spiked a fever to 103.3 F. Urinalysis was positive for trace leukocytes, 11 to 20 white blood cells, moderate bacteria with zero to two white blood cell casts, so he was started on Levofloxacin 250 mg p.o. q. day times seven day course. He was not on a Foley catheter. Chest x-ray, blood cultures and urine cultures were obtained prior to initiating antibiotics. Blood cultures ultimately revealed Staphylococcus aureus. The patient was initially started on Vancomycin until the sensitivities returned showing Methicillin sensitive Staphylococcus aureus and he was changed to oxacillin to complete a two week course. He had a transesophageal echocardiogram which showed no evidence of endocarditis and the decision was made not to pursue a transesophageal echocardiogram given that he is clinically stable. His urine culture initially came showing fecal contamination. A repeat urine culture sent after initiation of Levofloxacin ultimately showed no growth. He was given a PICC line and sent to rehabilitation for intravenous Oxacillin times a two week course. 4. CARDIOVASCULAR SYSTEM: The patient has a history of coronary artery disease with coronary artery bypass graft, diastolic dysfunction. His aspirin was held given the bleed. His beta blocker was also held given the bleed, however, it was restarted on discharge to rehabilitation. 5. RENAL: The patient was admitted with a creatinine of 3.0, however, with intravenous fluids, creatinine improved and ultimately he was discharged with a creatinine of 1.1, below baseline. DISCHARGE DIAGNOSES: 1. Melena. 2. Anemia secondary to blood loss. 3. Acute renal failure, prerenal. 4. Cirrhosis of liver, alcoholic. 5. Esophageal varices, Grade I. 6. Methicillin sensitive Staphylococcus aureus bacteremia. 7. Pancytopenia. 8. Leukopenia. 9. Thrombocytopenia. 10. Chronic obstructive pulmonary disease. 11. Gout. 12. Diastolic congestive heart failure. DISCHARGE MEDICATIONS: 1. Acetaminophen p.r.n. 2. Pantoprazole 40 mg p.o. q. 12 hours. 3. Maalox p.r.n. 4. Ambien p.r.n. 5. Oxycodone p.r.n. gout pain. 6. Albuterol inhaler q. six hours. 7. Levofloxacin 250 mg p.o. q. 24 hours, last dose 06/09, for a seven day course. 8. Lactulose 30 mg p.o. q. day. 9. Lasix 20 mg p.o. twice a day. 10. Spironolactone 25 mg p.o. twice a day. 11. Colchicine 0.6 mg p.o. q. day. 12. Oxacillin two grams intravenously q. six hours times 14 days, with last dose [**2135-8-1**]. 13. Metoprolol 50 mg p.o. twice a day. 14. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. q. day. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8829**], M.D. [**MD Number(1) 8830**] Dictated By:[**Last Name (NamePattern1) 2918**] MEDQUIST36 D: [**2135-7-23**] 17:44 T: [**2135-7-23**] 20:44 JOB#: [**Job Number 10386**] Name: [**Known lastname 1048**], [**Known firstname **] Unit No: [**Numeric Identifier 1461**] Admission Date: [**2135-7-18**] Discharge Date: [**2135-7-22**] Date of Birth: [**2059-9-25**] Sex: M Service: MEDICATIONS ON DISCHARGE: Addendum metoprolol to 25 mg po bid which is his dose on admission, otherwise no other hospital events. The patient was discharged to [**Hospital3 643**]. DR.[**Last Name (STitle) 1462**],[**First Name3 (LF) 1463**] 12-751 Dictated By:[**Last Name (NamePattern1) 1464**] MEDQUIST36 D: [**2135-7-25**] 15:21 T: [**2135-7-29**] 06:51 JOB#: [**Job Number 1465**]

[ "578.1", "284.8", "280.0", "571.2", "428.30", "585", "584.9", "790.7", "496" ]

icd9cm

[ [ [] ] ]

[ "99.21", "45.23", "45.13", "38.93", "96.34" ]

icd9pcs

[ [ [] ] ]

2230, 2248

6513, 6874

6897, 8052

8079, 8476

1841, 2135

3021, 6492

2272, 2727

143, 1061

2742, 3002

1083, 1815

2153, 2212

27,455

133,225

34059

Discharge summary

report

Admission Date: [**2143-7-22**] Discharge Date: [**2143-7-30**] Date of Birth: [**2075-4-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Endotracheal intubation; right IJ central venous catheterization; right radial arterial catheterization; R thoracentesis; bronchoscopy History of Present Illness: Patient is a 68 yo male with h/o DM who has not seen a doctor in 2 years and has been off meds presenting with SOB x 1 week per his family. His family reports that he was in his usual state of health until 1 week ago when he noted increasing SOB. His family urged him to go to the hospital, but he refused. Over the past 3 days he has been persistently SOB with orthopnea, and became confused the evening prior to admission at which time his family finally convinced him to come to the ED. He denied fevers, chills, cough, abdominal pain, HA or CP. . In the ED, initially T 98.2 BP 157/93 HR 113 RR 36 O2 sats 84% on 5 L, 100% on Bipap with 100% FiO2. CXR revealed large right sided pleural effusion. Elevated LFTs prompted an abdominal CT scan which did not reveal any hepatobiliary or other intraabdominal pathology, but confirmed the pleural effusion. He became progressively more tachypneic and required intubation. He became hypotensive to 80s/60s after intubation and was started on pressors and vanco/levoflox/ceftriaxone prior to transfer to the ICU for further management. Past Medical History: DM Chronic lower extremity ulcers Social History: Lives alone. Does his own shopping, pays bills, drives. No ETOH, quit smoking 20 years ago after smoking 1.5 ppd for many years, no drugs. Retired airport worker. His family lives around the corner but says that he is "very private. Family History: Father died at 92, mother died at 76 from ? bowel perforation. GF with lung cancer. No other family h/o malignancy or cardiac disease. Physical Exam: GEN: obese, intubated, sedated; does not respond to command but responds to pain HEENT: scleral icteris, pinpoint sluggish pupils bilat; edentulous, ET tube in place; excoriation over bridge of nose, right eye hematoma NECK: R IJ. dressing c/d/i, no erythema CV: RRR, nl S1 & S2 no m/r/g PULM: diminished breath sounds at right base, bibasilar crackles R>L, no wheeze ABD: +BS, soft obese abdomen, NTND, no hepatomegaly EXT: multiple discrete tibial ulcerations with central necrosis bilat; ext warm, dry, good cap refill, 1+ symmetrical LE edema. R radial A-line NEURO: Moving all extremeties equally in response to agitating stimulus. Brief Hospital Course: Shock - Cardiogenic or septic, or both, in origin. Patient was given massive amounts of IVF for blood pressure support which compounded poor cardiopulmonary substrate. CVP was monitored via a right IJ CVC. proBNP was markedly elevated. TTE revealed severely diminished LV function with an EF ~20% and an LV thrombus. It was thought that this may represent profound ischemic CMP from past silent ischemia in the setting of DM neuropathy. He did not tolerate inotropic therapy due to tachycardia, nor did his blood pressure tolerate substantial diuresis. He continued to have a significant pressor requirement throughout the first six days of his hospital course. He was treated with stress-dose steroids, ABX coverage for CAP and anaerobic coverage for possible aspiration PNA. Blood, sputum, and pleural fluid cultures have not grown to date. . Hypercapneic and hypoxic respiratory failure - Large right layering pleural effusion seen on initial chest imaging was noted to have underlying compression atelectasis vs. pneumonia. ABX started given fever, leukocytosis, and possible parapneumonic effusion. Underwent ultrasound-guided right-sided thoracentesis and bronchoscopy, which revealed sanguinous lung tissue but no evidence of an underlying malignancy. Continued to require significant ventilator support due to substantial fluid overload and poor cardiac function. . Transaminitis - Thought to respresent shock liver vs. hepatic congestion, although could not rule out ETOH. CT Abdomen did not reveal any evidence of cirrhosis, NASH, or liver mass. Viral and autoimmune serologies, and serum and urine tox screens, were negative. He was given a banana bag, and his LFT's were monitored as they trended down. . Coagulopathy/thrombocytopenia - Likely secondary to hepatic insult. Reversed with FFP prior to thoracentesis. Considered DIC, but fibrinogen WNL (as were platelets initially on admission). Did not display any S/Sx of bleeding. . Head wound - Concern for an unreported fall, particularly in the setting of a coagulopathy, prompted a noncontrast head CT to rule out hemorrhage or skull fracture. The exam was negative for both. . LE ulcerations - Derm was consulted and recommended biopsy of skin lesions, which revealed a neutrophilic dermatosis such as Sweet's syndrome or pyoderma gangrenosum. He did not receive high-dose steroids in light of more critical comorbid issues. . DM - Started on RISS, but poor glycemic control required eventual insulin gtt. . . After reviewing prognosis during a family meeting with physicians and nurses in attendance, it was decided to make the patient CMO. At the family's request, the ETT was removed and the patient died at 2:35 pm on [**2143-7-30**]. Examination confirmed death and the family was notified. Consent for autopsy was obtained from the patient's brother, [**Name (NI) 2174**] [**Name (NI) **]. Medications on Admission: None reported. Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: 1) Cardiopulmonary collapse 2) Acute CHF 3) Pneumonia Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2143-7-31**]

[ "790.4", "518.81", "584.9", "427.5", "038.9", "276.50", "427.1", "V66.7", "250.00", "287.5", "428.0", "425.4", "486", "707.19", "459.81", "790.92", "782.1", "785.52", "995.92" ]

icd9cm

[ [ [] ] ]

[ "96.6", "33.22", "38.91", "86.11", "96.04", "96.72", "34.91" ]

icd9pcs

[ [ [] ] ]

5689, 5698

2729, 5596

343, 479

5795, 5804

5856, 6026

1915, 2051

5661, 5666

5719, 5774

5622, 5638

5828, 5833

2066, 2706

283, 305

507, 1592

1614, 1649

1665, 1899

23,304

112,646

1831

Discharge summary

report

Admission Date: [**2137-5-9**] Discharge Date: [**2137-5-16**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: colon CA Major Surgical or Invasive Procedure: s/p right colectomy History of Present Illness: : Mr. [**Known lastname 10239**] is an 83 year-old gentleman who presented with some anemia and underwent a colonoscopy which demonstrated a fungating lesion in the right ascending colon. Biopsy of the colon was consistent with carcinoma. The patient was then booked for elective right colectomy. Past Medical History: CAD s/p STEMI [**2126**], RCA stent, LAD stent failed->CABGx3 [**3-/2128**], L CEA for infarct, basal cell ca with resection, seborrheic dermatitis, actinic keratosis, CHF (class I-II [**4-21**]) with LV dysfunction, hyperlipidemia, CCY in [**2077**] Family History: mother died in [**2110**] of "old age", father died when pt was 6 yo (unclear cause) Physical Exam: NAD, AAOx3 Card: RRR, no m/r/g Pulm: CTAB Abd: soft, mildy tender, ND, incision c/d/i with staples Ext: no LE edema Pertinent Results: [**2137-5-13**] 10:45AM BLOOD CK(CPK)-135 [**2137-5-13**] 02:15AM BLOOD CK(CPK)-130 [**2137-5-12**] 03:12PM BLOOD CK(CPK)-173 [**2137-5-10**] 07:43PM BLOOD CK(CPK)-211* [**2137-5-10**] 04:04PM BLOOD CK(CPK)-188* [**2137-5-10**] 08:31AM BLOOD CK(CPK)-146 [**2137-5-10**] 02:30AM BLOOD CK(CPK)-113 [**2137-5-13**] 10:45AM BLOOD CK-MB-4 [**2137-5-13**] 02:15AM BLOOD CK-MB-4 [**2137-5-12**] 03:12PM BLOOD CK-MB-4 cTropnT-<0.01 [**2137-5-10**] 07:43PM BLOOD CK-MB-3 [**2137-5-10**] 04:04PM BLOOD CK-MB-3 [**2137-5-10**] 08:31AM BLOOD CK-MB-2 cTropnT-<0.01 [**2137-5-10**] 02:30AM BLOOD CK-MB-2 cTropnT-<0.01 [**2137-5-15**] 11:02AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.9 Brief Hospital Course: Pt was admitted to the floor on telemetry s/p his colectomy where he went a normal postoperative course until POD #2 in which it was noted that he had a few beats of ventricular tachycardia during the night. The patient was asymptomatic and was cleard by both an EKG and negative CK-MB and troponin enzymes. On POD #3, also during the night the patient went into atrial fibrillation. He was rate controlled with lopressor and converted back to a normal sinus rhthym. Cardiac enzymes were again negative The patient remained in NSR until POD#4 where he again had 5 beats of vtach. The patient remained asymptomatic and cardiology consult was called. They reccomended to continue his current medication regimen and to add coumadin for the new onset intermittent afib. This was discussed with his PCP who asked for him to be started on 2mg/day. The patient also had elevated blood sugars for the last 2 days of his hospital stay which were discussed with his PCP who [**Name9 (PRE) 10240**] no home treatment and that he would follow and decide whether the patient need outpatient treatment. The patient continued to do well and was sent home on POD#6 in good condition with VNA assistance, home PT, and close f/u with his PCP and [**Name Initial (PRE) **] new cardiologist, Dr. [**Last Name (STitle) 10241**], due to the fact that his cuurent cardiologist is leaving town. Medications on Admission: lovastatin 20, toprol xl Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 7. Outpatient [**Name (NI) **] Work Pt/INR daily. Call Dr. [**Last Name (STitle) 1266**], [**Telephone/Fax (1) 608**] with results. 8. Outpatient [**Telephone/Fax (1) **] Work Basic Metabolic panel on 1st blood draw for INR. Once. 9. Diovan 160 mg Tablet Sig: One (1) [**11-19**] Tablet PO once a day. Disp:*30 * Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: s/p right colectomy for CA, new onset intermittent afib Discharge Condition: good Discharge Instructions: [**Name8 (MD) **] M.D. if fever > 100.4, abdominal pain, nausea, vomiting, chest pain, shortness of breath, blood in stool or urine, or other concerns. Pt. started on coumadin 2mg daily will need INR's drawn daily until followup with Dr. [**Last Name (STitle) 1266**]. Please draw first INR INR>3. Followup Instructions: call Dr.[**Name (NI) 10242**] office for f/u in 2 weeks. f/u with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10243**] in 1 week. Please call for appt. # [**Telephone/Fax (1) 608**]. Cardiology appointment on [**2137-6-18**] for echo @ 8:00 AM and appt. with Dr. [**Last Name (STitle) 7965**] at 9:00 AM. Please call the office at [**Telephone/Fax (1) 902**] prior to confirm. Completed by:[**2137-5-16**]

[ "153.6", "427.31", "428.0", "V45.81", "272.4", "427.1" ]

icd9cm

[ [ [] ] ]

[ "45.73", "54.23" ]

icd9pcs

[ [ [] ] ]

4168, 4226

1831, 3203

268, 289

4325, 4331

1144, 1808

4678, 5104

906, 992

3278, 4145

4247, 4304

3229, 3255

4355, 4655

1007, 1125

220, 230

318, 616

638, 890

80,030

100,442

63+55181

Discharge summary

report+addendum

Admission Date: [**2119-6-7**] Discharge Date: [**2119-7-18**] Date of Birth: [**2063-7-15**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 695**] Chief Complaint: Unresponsive Major Surgical or Invasive Procedure: evacuation of abdominal wall hematoma and paracentesis re-exploration of abdominal wall hematoma with surgicel packing History of Present Illness: 55yoF with alcoholic cirrhosis s/p TIPS [**1-/2118**] found down by her husband. The patient has a history of depression which her husband, [**Name (NI) **], reports has been exacerbated lately by several stressful situations including her chronic back pain, finances, etc. She was last seen to be interactive and appropriate at 06:00am this morning by her husband. [**Name (NI) **] son saw her at 11am, but thought the patient was asleep and did not attempt to wake her. She was subsequently found down on the floor by her husband at 3pm, 9 hours after last being seen, who describes her as being in a fetal position with her eyes rolled to the back of her head and her mouth wide open. Her husband began to lift the patient off the floor and she bit him on the shoulder and did not appear to recognize him. She was take to [**Hospital6 33**] where she was was found to be responsive to verbal stimuli but unable to interact appropriately. She was intubated. Coffee grounds returned from her OGT and she was hypotensive in the 80's/40's. FS was 22 and received glucose, T was 94.6, and she was placed on a bear hugger. pH was 6.8, lacate 25, creatine 3.2, bicarb 4. She was received 2 amps bicarb, 1 amp D50, and blood cultures were drawn from her central line. She was started on bicarb drip, levophed gtt for SBP 80's. She not making urine after 6L IVF. She was transferred to [**Hospital1 18**] for further management. R IJ was placed at the OSH and 2 peripheral IVs. . Per the husband's report, the patient does have a history of surreptitious alcohol ingestion on occasion but he has not noticed or detected any alcohol use recently. He denies the likelihood of illicit drug use or prescription drug overdose, stating the only medication she has access to is Tramadol, which she had not been taking. He denies recent vocalizations by the patient regarding suicidal ideation. . In the [**Hospital1 18**] ED, initial VS: 123 113/29 27 100% The patient was noted to have 150cc dark coffee ground output from her OGT, but stool was guiac negative. Hepatology was consulted, and the patient was started on an Octreotide gtt and Pantoprazole gtt, and aggressive flushing of the OGT was recommended. She was ordered to be transfused 1 unit PRBC. She was empirically treated with Vanc/Levo/Flagyl and CT torso was obtained, which showed no evidence of infection or acute bleed. She received 8L IVF in the ED, and was increased on Levophed 0.4mcg/kg/hr. Renal was consulted as the patient had a poor UOP and was acidotic, and CVVH vs hemodialysis was discussed. The patient was given Calcium gluconate 2gm, Bicarb gtt @150cc/hr, and was prepared for possible CVVH tomorrow. Transfer VS were: 112/47, HR 117, 99% 60% PEEP 5, TV 450 . On arrival to the MICU, the patient was intubated and opening her eyes to verbal stimuli but not following commands. Her husband was available to give a brief history, which is detailed above. Past Medical History: - Alcoholic cirrhosis s/p TIPS placement [**1-/2118**] (per GI OSH neg hepatitis serology, had pos Anti-SMA but neg [**Doctor First Name **]) - h/o GIB [**11/2117**] s/p banding of esophageal varices - h/o myomectomy Social History: - Tobacco: Has not smoked since her 20s. - EtOH: History of heavy alcohol use x 20 years, sober since [**8-25**]. - Illicit Drugs: Remote cocaine history. - Lives with her husband. Family History: Father with CAD. Otherwise non-contributory. Physical Exam: Admission physical exam VS: 98.9 126 -> 110 139/55 -> 92/49 24 99% GEN: Intubated, NAD HEENT: Pupils small (<1mm) but equal and reactive to light, sclear anicteric, MMM, no jvd, intubated with ETT in place CV: Tachycardic, regular rhythm, normal S1/S2, GII holosystolic murmer at LSB, S3 heard best at LSB RESP: CTAB anteriorly and laterally with with good air movement throughout, no wheezes/rales/rhonchi ABD: Soft, mild abdominal distension without appreciable fluid wave, diffuse tenderness to palpation in RUQ and LUQ without rebound or guarding but with grimacing on exam. +b/s EXT: no c/c/e, 2+ DP pulses b/l SKIN: no rashes/no jaundice NEURO: Responds to verbal stimuli but does not follow commands Pertinent Results: [**2119-6-6**] 10:50PM BLOOD WBC-10.7 RBC-2.80* Hgb-9.9* Hct-30.2* MCV-108* MCH-35.2* MCHC-32.7 RDW-14.6 Plt Ct-47* [**2119-6-6**] 10:50PM BLOOD PT-19.0* PTT-41.5* INR(PT)-1.7* [**2119-6-6**] 10:50PM BLOOD Glucose-170* UreaN-24* Creat-3.2* Na-146* K-4.1 Cl-98 HCO3-14* AnGap-38* [**2119-6-6**] 10:50PM BLOOD ALT-204* AST-1699* CK(CPK)-1496* AlkPhos-145* TotBili-4.2* DirBili-3.2* IndBili-1.0 [**2119-6-6**] 10:50PM BLOOD Albumin-2.8* Calcium-6.0* Phos-8.1* Mg-1.7 [**2119-6-6**] 10:43PM BLOOD Glucose-148* Lactate-14.6* Na-142 K-4.3 Cl-101 calHCO3-14* [**2119-7-5**] 05:00PM BLOOD WBC-11.1* RBC-3.29* Hgb-10.1* Hct-26.6* MCV-81* MCH-30.8 MCHC-38.0* RDW-17.6* Plt Ct-115* [**2119-7-5**] 11:26AM BLOOD PT-19.2* PTT-43.1* INR(PT)-1.7* [**2119-7-5**] 11:26AM BLOOD Glucose-125* UreaN-24* Creat-2.0* Na-140 K-3.7 Cl-106 HCO3-19* AnGap-19 [**2119-7-5**] 03:09AM BLOOD ALT-16 AST-60* AlkPhos-45 TotBili-11.9* [**2119-7-18**] 06:04AM BLOOD WBC-17.2* RBC-3.54* Hgb-11.1* Hct-32.4* MCV-92 MCH-31.3 MCHC-34.2 RDW-20.9* Plt Ct-215 [**2119-7-18**] 06:04AM BLOOD Glucose-92 UreaN-8 Creat-0.6 Na-140 K-3.8 Cl-112* HCO3-19* AnGap-13 [**2119-7-18**] 06:04AM BLOOD ALT-12 AST-42* AlkPhos-85 TotBili-5.4* [**2119-7-18**] 06:04AM BLOOD Calcium-8.0* Phos-2.1* Mg-1.6 Imaging summary: - [**6-7**] liver u/s: 1. TIPS patent. No prior ultrasound is available to compare the velocities. High velocities can suggest interval hyperplasia in the TIPS. 2. Cholelithiasis. 3. Diffuse symmetric thickening of the wall of the gallbladder, likely related to chronic liver disease. 4. Fatty liver. Other forms of more advanced liver disease such as fibrosis or cirrhosis cannot be excluded. 5. Liver vessels are patent. Reverse flow is seen in the left and right anterior portal vein. The right posterior portal vein is not visualized due to breathing artifact - [**6-15**] fluid study: negative for malignancy - [**6-22**]: Flexsig no active bleeding - [**6-23**]: endoscopy: no active bleeding - [**6-25**]: CT abdomen: 15-cm left anterior abdominal/pelvic wall hematoma and correlation with trauma or intervention is suggested. No free intraperitoneal air with extensive ascites and cirrhotic liver as before. Unchanged hepatic hypodensities, too small to be characterized. Unchanged multiple vertebral body compression fractures - [**6-26**]: GIB study: No active GI bleeding during the imaged time period - [**2119-6-27**] EGD no active bleeding - [**2119-7-4**] CT ab/pelv LLQ abdominal wall hematoma - [**2119-7-4**] Colonoscopy no active bleeding - [**2119-7-5**] Paracentesis 2+PMNs, no microorg. . - [**2119-7-6**] Paracentesis 2+PMNs, no microorg. - [**7-8**] CXR: Moderate bilateral pleural effusions, edema and lower lobe atelectasis/pneumonia - [**7-9**] CXR: Minimal improvement of pulmonary edema which is still severe - [**2119-7-12**] paracentesis - [**2119-7-12**] ucx 10-100,000 VRE - [**2119-7-11**] UA few bac, 19 RBC, 9 WBC Brief Hospital Course: 55yoF with alcoholic cirrhosis s/p TIPS [**1-/2118**] found down by her husband and admitted to MICU with GIB and resp failure. Improved in the MICU and was extubated [**6-14**]. On the floor, Ms. [**Known lastname 696**] was noted to have AMS likely [**1-18**] Korsakoff's amnesia. 1. Abdominal wall hematoma: pt began to complain of pain at site of what was originally though to be a ventral hernia in LLQ. the abd protrusion was palpated and had crepitus and could be reduced, so no action was taken and mass was thought to be a hernia at that time. Pt was supposed to go for colonoscopy but K+ was low, so it was delayed until [**2119-7-4**]. pt felt diarrhea had improved this day. Creatinine was elevated to 2.1 and this thought to be [**1-18**] poor renal perfusion. pt started on albumin 100mg. Renal u/s was negative for obstruction. Her hct was 17.5 at midnight and pt received 2 units PRBC, repeat hct was 24.8. Pt's abdominal protrusion had approx doubled in size and was very tender. Pt went to GI suite for colonoscopy, which did not show a source of bleeding. After colonoscopy, abdominal protrusion was over twice as large as in the AM and continued to progress rapidly throughout day. It developed a bluish appearance - surgery was consulted and pt sent for non con CT which showed a hematoma. Repeat Hct after CT was 21.0, so pt given another unit of PRBC and also transfused 1 unit FFP, and 100mg cryoprecipitate. Cr was down to 2.0 after albumin but jumped again in the PM to 2.3, likely [**1-18**] ongoing blood loss. 2. post-operative course: Patient was taken for evacuation of hematoma on [**2119-7-5**] and [**7-6**] with intraop 2L paracentesis. Intraop: 1u prbc, 1u FFP, albumin. Patient extubated and responsive postop. Patient transfused 2u PRBC's for Hct 25 in setting of active bleeding. Additional 7u PRBC next 2 nights. JP putting out sanguineous fluid, Hct decreasing. Transfused 2u PRBC, 2 FFP, 1 cryo. Direct pressure applied to LLQ. JP Hct sent. Ceftriaxone started for SBP per Hepatology recs. on [**7-7**] U PRBC given, started 1/2cc per cc replacement of JP output. UOP adequate. Pain control adequate. on [**7-8**], 2u FFP given for INR 1.7. High JP output continued, so NS repletion increased to cc per cc. Pt later became acutely dyspneic with desaturation to high 70s. CXR was consistent with flash pulmonary edema. IVF were discontinued, and pt responded well to BiPAP and 40 IV Lasix. Pt later weaned to nasal cannula. IVF repletion of JP output resumed at 1/2cc per cc ratio. Remained persistently tachycardic throughout. Increasing PVCs improved with K repletion. Regular diet started. Overnight, she had a burst of tachycardia to the 170s, EKG unchanged and troponin was negative. She was transferred from the ICU to the floor on [**7-10**]. She complained of shortness of breath during the day when she was sitting but also had a component of anxiety. She ambulated, was tolerating a regular diet, and making good urine. She continued on her ceftriaxone. On [**7-12**], she underwent a diagnostic and therapeutic paracentesis, 3L was taken off and sent for studies, which showed clearance of her SBP. She was switched to ciprofloxacin. She ambulated with physical therapy. Tolerating regular diet. 3. Mental status: On transfer to the floor from MICU, the patient was noted to be confused with AMS. Differential was initially anoxic brain injury vs. hepatic encephalopathy vs. delerium vs. withdrawal. Psych and neuro were consulted. Benzos were weaned. Lactulose was provided and an MRI brain revealed no evidence of anoxic brain injury. Given the prominence of the patient's confabulations and the absence of memory loss, it was suspected by neurology that the patient was suffering from Korsakoff's amnesia. The patient's family was informed of this diagnosis. 4. GIB: Patient with coffee grounds out of NG tube on admission and noted to have bright red blood coming from NG tube during first several days of admission. She was started on Octreotide and Pantoprazole gtt's. She was given 1u plts, 3u FFP, 3u PRBC's, 10 mg IV Vitamin K through admission. Liver was consulted, and felt since imaging showed patent TIPS that UGIB from portal HTN was unlikely. Pt was eventually scoped which showed 2cm non-bleeding ulcer with clot overlying and she was given an NG tube holiday to prevent irritation and allow healing. Also showed mild portal gastropathy. Hct was stable by call out of MICU. On the floor, the patient was HD stable. On [**6-23**], it was noted that the patient was tachycardic to the 140s. HCT fell from 34.4 to 28.7 and BRBPR was noted. The patient had undergone a sigmoidoscopy to evaluate for ?ischemic colitis the day prior without a bleeding source noted. On the AM of [**6-23**] she underwent an endoscopy also without evidence of a bleeding source. The patient was transfused with appropriate HCT response and remained stable without BRBPR afterward. Source of bleeding was likely hemorrhoidal. From [**6-27**] - [**6-29**] she was transfused 4u pRBCs total. 5. Hypotension: Fluid resuscitated with crystalloid and colloid. Started on Levophed gtt. Arterial line placed. She was given broad spectrum ABx (Vanc/Zosyn) and the only culture which grew out was MSSA in her sputum. Echo was normal. Of note, after weaned from pressors and stabilized, necessitated diuresis for volume overload/pulmonary edema. 6. Renal failure: Felt to be ATN due to hypotension vs HRS vs mild rhabdomyolysis given mildly elevated CK's. She was initially on a HCO3 gtt, and was fluid resuscitated. Electrolytes were very abnormal (K, Phos, and Ca) and were repleted aggressively until they normalized. She never needed dialysis and her renal function improved. 7. Alcoholic Cirrhosis s/p TIPS: Patient with US in the ED showing patent TIPS. She received IV thiamine and IV Folate. She was started on Lactulose and Rifaxamin after extubation; and liver recommended starting Pentoxyfyline x30 days when pt able. Repeat U/S on [**2119-7-15**] again showed patent TIPS 8. AFib: She had an episode of AFib with RVR that flipped back to NSR with IV Metoprolol. No further issues. Medications on Admission: - Folic Acid 1 mg daily - Thiamine HCl 100 mg daily - Ciprofloxacin 250 mg daily for SBP prophylaxis - Pantoprazole 40 mg EC daily - Simethicone 80 mg qid - Furosemide 20 mg daily - Spironolactone 100 mg daily - Docusate Sodium 100 mg [**Hospital1 **] prn - Senna 8.6 mg Tablet: 1-2 Tablets [**Hospital1 **] prn - Tramadol 25 mg q12h prn pain: No more than 50 mg/day. Discharge Medications: 1. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times a day). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. pentoxifylline 400 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO TID (3 times a day). 5. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. insulin lispro 100 unit/mL Solution Sig: follow sliding scale units Subcutaneous ASDIR (AS DIRECTED). 8. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 9. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 12. MagOx 400 mg Tablet Sig: One (1) Tablet PO once a day. 13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Outpatient Lab Work Labs twice weekly for chem 10 fax results to [**Telephone/Fax (1) 697**] attention [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN coordinator 16. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. 18. potassium chloride 20 mEq Packet Sig: Two (2) Packet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: abdominal wall hematoma alcoholic cirrhosis ascites 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 hepatobiliary service at [**Hospital1 18**] after evacuation of your abdominal wall hematoma. You have 2 JP drains in what used to be the hematoma cavity, which have put out serosanguinous and ascites fluid. Drain care: Your drains will be left in place until output is minimal and you are seen in [**Hospital 702**] clinic. Please continue drain dressings and emptying drains daily. Diet: continue on a regular diet with supplements to increase caloric intake. Activity: Please ambulate as tolerated multiple times per day. Medications: Continue on discharge medications and all home medications. We have increased your lasix to 40 mg [**Hospital1 **] from your home 20 mg daily dose. Followup Instructions: Provider: [**Name10 (NameIs) 703**] [**Location 704**] [**Location 705**] / IOUS [**Location 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2119-7-24**] 9:00 Provider: [**Name10 (NameIs) 706**] CARE,FIVE [**Name10 (NameIs) 706**] CARE UNIT Phone:[**Telephone/Fax (1) 446**] Date/Time:[**2119-7-26**] 8:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2119-7-26**] 3:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2119-7-18**] Name: [**Known lastname 45**],[**Known firstname 46**] D Unit No: [**Numeric Identifier 47**] Admission Date: [**2119-6-7**] Discharge Date: [**2119-7-18**] Date of Birth: [**2063-7-15**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 48**] Addendum: UTI: The patient had a urine culture positive for VRE on [**7-12**],000-100,000 organisms. The urine culture was repeated on [**7-16**] and was positive for >100,000 VRE. She was started on a 7 day course of linezolid 600 PO Q12H on discharge to rehabilitation center. Discharge Disposition: Extended Care Facility: [**Hospital1 49**] - [**Location (un) 50**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**] Completed by:[**2119-7-18**]

[ "275.3", "482.41", "789.59", "537.89", "531.40", "287.5", "785.52", "790.01", "571.2", "276.2", "456.1", "E849.7", "785.50", "572.3", "V15.82", "518.81", "998.12", "785.0", "584.5", "E879.4", "303.92", "574.50", "291.1", "995.92", "570", "787.91", "427.31", "455.8", "038.9", "211.2", "728.88", "442.0", "286.9", "276.8", "572.4", "416.9" ]

icd9cm

[ [ [] ] ]

[ "86.28", "45.25", "51.88", "45.13", "45.16", "88.76", "38.93", "51.85", "96.72", "86.04", "54.91", "96.6" ]

icd9pcs

[ [ [] ] ]

18393, 18617

7616, 10882

315, 436

16171, 16171

4677, 7593

17093, 18370

3878, 3925

14193, 15980

16096, 16150

13800, 14170

16354, 17070

3940, 4658

262, 277

464, 3419

16186, 16330

3441, 3660

3676, 3862

60,037

133,981

55032

Discharge summary

report

Admission Date: [**2167-4-29**] Discharge Date: [**2167-5-6**] Date of Birth: [**2090-1-14**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 9160**] Chief Complaint: Abdominal distension, hypoxia, acute renal failure Major Surgical or Invasive Procedure: Paracentesis Nasogastric tube placement History of Present Illness: 77 y.o male with DM, CKD stage III, hypertension and CAD s/p stent who initially presented for an EUS with Dr. [**Last Name (STitle) **] and was found to be hypoxic with an O2 sat of 88% on RA. The patient was recently admitted in [**Month (only) 958**] to [**Hospital6 4287**] for diverticulitis, where a CT of the abdomen demonstrated an incidental pancreatic mass. Since then, he has had stable abdominal pain in the 4 weeks prior to his current presentation, as well as increasing abdominal distention. He then developed shortness of breath as well as nausea and vomiting over the past several days. He reports significantly decreased PO intake over the last 4 days PTA. Said had temps to 99 at home, but no chills. Denies cough but had one episode of bloody in sputum recently. No dysuria; no pain in calves or thighs; no blood in stool. He denies recent intake of NSAIDs or other pain Rx other than APAP/codeine about a month ago for belly pain. In the interim, he had also underwent a colonoscopy which showed diverticulitis but was negative for malignancy. However, this procedure did not go beyond the distal transverse colon. In the ED, initial VS were: 97.6 88 110/59 18 97% 4L. The patient's labs were notable for hyperkalemia to 5.8, gap metabolic acidosis with bicarbonate of 17, BUN of 137 and creatinine of 7.4 He was also noted to have a WBC count of 17.7. The patient received 10U of insulin, 30 of kayexalate and 80mg of lasix. Nephrology was consulted who felt that there was no emergent need for dialysis at this time. His repeat potassium was 4.5. On arrival to the [**Name (NI) 153**], pt is not c/o any pain. Denies CP, SOB, abdom pain. Past Medical History: CAD s/p stent in early [**2154**]'s Hypertension DM Prostatic hypertrophy Diverticulitis Stage III CKD (b/l creatine 1.4-1.6) Pancreatic mass found on incidental CT scan in [**2167-2-12**] Social History: Worked as electrical engineer. Married, has 3 children. Denies tobacco or illicits, rare EtOH. Family History: Father had unspecified abdominal surgery; no other family h/o CA. Physical Exam: ADMISSION EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated (is 6-7cm at 30 deg), no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: coarse breath sounds anteriorly, no wheezes. bibasilar crackles, R>L. Abdomen: markedly distended and tense, tympanic to percussion, distended flanks. bowel sounds not appreciated, no tenderness to palpation, no rebound or guarding. GU: foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, erythema. Only trace edema pretibially. Neuro: CNII-XII intact, 5/5 strength upper/lower extremities Bladder pressure: 21 on [**4-29**]/12pm Pertinent Results: ADMISSION LABS: [**2167-4-29**] 03:00PM BLOOD WBC-17.7* RBC-4.69 Hgb-13.5* Hct-41.3 MCV-88 MCH-28.8 MCHC-32.8 RDW-13.3 Plt Ct-370 [**2167-4-29**] 03:00PM BLOOD Neuts-91.4* Lymphs-5.3* Monos-2.9 Eos-0.2 Baso-0.2 [**2167-4-29**] 04:26PM BLOOD PT-12.7* PTT-24.4* INR(PT)-1.2* [**2167-4-29**] 03:00PM BLOOD Glucose-227* UreaN-137* Creat-7.4* Na-130* K-5.8* Cl-90* HCO3-17* AnGap-29* [**2167-4-29**] 03:00PM BLOOD ALT-12 AST-20 CK(CPK)-68 AlkPhos-59 TotBili-0.3 [**2167-4-29**] 03:00PM BLOOD Lipase-36 [**2167-4-29**] 03:00PM BLOOD Albumin-3.3* Calcium-8.9 Phos-12.1* Mg-3.6* [**2167-4-29**] 03:00PM BLOOD D-Dimer-3678* [**2167-4-29**] 03:00PM BLOOD Osmolal-324* [**2167-4-29**] 05:58PM BLOOD Type-[**Last Name (un) **] O2 Flow-2 pO2-57* pCO2-40 pH-7.31* calTCO2-21 Base XS--5 Intubat-NOT INTUBA Comment-GREEN TOP [**2167-4-29**] 05:27PM BLOOD Lactate-3.9* URINE: [**2167-4-29**] 05:54PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013 [**2167-4-29**] 05:54PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2167-4-29**] 05:54PM URINE RBC-4* WBC-2 Bacteri-FEW Yeast-NONE Epi-<1 [**2167-4-29**] 05:54PM URINE Hours-RANDOM Creat-300 Na-10 K-GREATER TH Cl-11 [**2167-4-29**] 05:54PM URINE Osmolal-346 PERITONEAL FLUID: [**2167-4-30**] 10:05AM ASCITES WBC-725* RBC-2100* Polys-38* Lymphs-20* Monos-4* Macroph-2* Other-36* [**2167-4-30**] 10:05AM ASCITES TotPro-4.0 Glucose-165 LD(LDH)-336 TotBili-0.5 Albumin-2.5 MICROBIOLOGY: [**2167-4-29**] UCx: NO GROWTH [**2167-4-29**] BCx: *** [**2167-4-29**] MRSA screen: NEGATIVE [**2167-4-30**] Peritoneal fluid Cx: *** STUDIES: [**2167-4-29**] EKG: Sinus rhythm. Borderline left axis deviation. Leftward precordial R wave transition point. [**2167-4-29**] CXR: Bibasilar atelectasis and small left pleural effusion, underlying consolidation cannot be excluded in the appropriate clinical setting. [**2167-4-29**] CT abd/pelvis: 1. Large volume ascites with extensive omental nodularity concerning for metastatic disease secondary to known pancreatic primary malignancy. 2. Diverticulosis without diverticulitis. 3. Small left pleural effusion with bibasilar atelectasis. 4. No hydronephrosis or renal abnormality to account for acute renal failure [**2167-4-30**] Peritoneal Fluid cytology: ***** [**2167-4-30**] Abd U/S with dopplers: 1. No evidence of thrombosis. 2. Somewhat flat hepatic venous waveforms which are non-specific. 3. Multiple hypoechoic nodules suspicious for metastases within a fatty liver. 4. Ascites. 5. Gallbladder sludge. [**2167-4-30**] LENIs: No evidence of clot in bilateral lower extremities with limited evaluation of the left sided calf veins. [**2167-5-1**] V/Q scan: Low likelihood ratio for recent pulmonary embolism. [**2167-5-1**] CXR: Low lung volumes and bibasilar atelectasis. [**2167-5-1**] Renal U/S with dopplers: 1. No evidence of hydronephrosis, stones, or masses within the kidneys. 2. Gross patency of renal vasculature bilaterally. However, bilateral high-resistance pattern of renal arterial waveforms, with no antegrade diastolic flow. These findings may be seen with acute or chronic renal disease such as parenchymal diseases or ATN. Brief Hospital Course: 77yo man with recent pancreatic mass seen on CT in [**2-23**], DM, CKD stage III, hypertension and CAD s/p stent who initially presented for an EUS with Dr. [**Last Name (STitle) **] and was found to be hypoxic with an O2 sat of 88% on RA, now with omental studding on CT, likely malignant ascites, and acute renal failure. . ACTIVE ISSUES: . # Ascites: Upon admission, his ascites was causing significant distention; bladder pressure was 21 upon admission. Peritoneal fluid was exudative, likely [**1-15**] peritoneal carcinomatosis, given his CT findings. While in the ICU, he was covered for SBP with CTX and given albumin. He underwent therapeutic paracentesis for comfort, which removed 3L. Ascitic fluid was sent for cytology on [**2167-4-30**], which was positive for malignant cells. . # Pancreatic mass/omental nodularity: Most likely metastatic pancreatic adenocarcinoma. He was evaluated by heme/onc, who did not recommend chemo. The [**Hospital Unit Name 153**] team discussed the situation with the family on [**5-2**], and the decision was made to transition to DNR/DNI. . # Acute on chronic renal failure / Hyperkalemia: Admitted with Cr of 7.4, from baseline of about 1.3-1.4. Initially thought to be pre-renal, but did not improve with volume challenge at admission. [**Month (only) 116**] have also be from hypoperfusion due to increased intraabdominal pressure from ascites, although his urine output did not improve much after paracentesis. There was no clear evidence obstruction on CT either. His Cr worsened to 9.6 on [**2167-5-3**]. The patient and his family decided not to pursue dialysis. Nephrology was consulted and also did not recommend dialysis if his suspected malignancy was not going to be untreated. . # Hypoxia: Differential included pulmonary embolism (he had elevated d-dimer to 3678 and did have one isolated event of bloody sputum recently and likely underlying pancreatic malignancy), but no evidence of right heart strain or hemodynamic effects, and V/Q scan was low probability. More likely, however, was poor ventilation due to abdominal distention and possible hydrothorax. LE Dopplers were negative. He remained on 2-3L supplemental O2. . # Nausea: Likely [**1-15**] functional bowel obstruction given omental studding. Pt was still having BMs. We placed an NG tube for decompression, which significantly improved the nausea. Also written for other IV anti-emetics, which offered minimal additional marginal effect. . # Goals of care: A family meeting was held on [**2167-5-3**], at which the wife/family decided to make the patient comfort measures only. Palliative Care was consulted to assist with discharge planning. Ultimately, the wife felt strongly about transition to inpatient hospice. Prior to planned discharge to hospice, he became agitated and more tachypneic. Thus, he was kept in the hospital and treated with IV Dilaudid to treat his tachypnea and Zyprexa to treat acute agitation. He developed increased secretions, which was managed with a Scopolamine patch. The patient died at 9:11pm on [**2167-5-6**]. Family and PCP were notified immediately. Medications on Admission: Medications (reconciled with pt [**2167-4-29**] and [**Hospital3 **] records): Zoloft - 50mg - PO (By mouth) - daily Crestor - 40mg - PO (By mouth) - daily (not in past few days atenolol (Tenormin) - 25mg - PO (By mouth) - daily aspirin - 81mg - PO (By mouth) - daily colace - 100mg - PO (By mouth) - prn omeprazole (Prilosec) - 20mg - PO (By mouth) - prn nitroglycerin - 0.4mg - SL (Sublingual) - as directed, has not used recently vitamin D - 1000 unit capsule - PO (By mouth) - daily multivitamin - 1 tab - PO (By mouth) - daily Flomax - 0.4mg - PO (By mouth) - only used twice two months prior Actos - 15mg - PO (By mouth) - prescribed recently - pt did not start it and is not taking xalatan 0.005% - 1 drop - OP (Ophthalmic) - both eyes daily Discharge Medications: 1. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for nausea. Disp:*10 Tablet, Rapid Dissolve(s)* Refills:*0* 2. lorazepam 2 mg/mL Concentrate Sig: 0.5 mL PO every four (4) hours as needed for nausea. Disp:*30 mL* Refills:*0* 3. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 15-30 mg PO Q30 minutes as needed for pain. Disp:*30 mL* Refills:*0* Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 68723**] [**Hospital **] [**Hospital **] Hospice Home [**Location (un) 112346**] Discharge Diagnosis: Pancreatic mass Acute renal failure Hypoxemia Encephalopathy Discharge Condition: N/A Discharge Instructions: None Followup Instructions: None needed [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**] Completed by:[**2167-5-7**]

[ "799.02", "307.9", "157.2", "787.02", "789.51", "306.1", "560.89", "197.6", "414.01", "585.3", "562.10", "403.90", "V45.82", "250.00", "348.30", "V66.7", "584.5", "600.00", "V49.86", "276.7", "197.7" ]

icd9cm

[ [ [] ] ]

[ "54.91" ]

icd9pcs

[ [ [] ] ]

10841, 11010

6484, 6810

354, 395

11115, 11120

3245, 3245

11173, 11307

2440, 2507

10401, 10818

11031, 11094

9628, 10378

11144, 11150

2522, 3226

264, 316

6825, 9602

423, 2100

3261, 6461

2122, 2312

2328, 2424

42,412

114,867

43797

Discharge summary

report

Admission Date: [**2165-12-19**] Discharge Date: [**2165-12-25**] Service: MEDICINE Allergies: Levaquin Attending:[**First Name3 (LF) 4760**] Chief Complaint: hypoglycemia Major Surgical or Invasive Procedure: none History of Present Illness: This is a 86 year-old male multiple medical problems who presents with hypoglycemia since last night. The patient was admitted to the hospital from [**Date range (1) 68760**] wtih hypoglycemia. He was evaluated by endocrinology at that time and the most likely etiology of his hypoglycemia was felt to be pre-diabetes causing hyperinsulinemia. Work-up revealed an elevated C-peptide (18.1), elevated insulin level of 41, negative sulfonylurea screen, and low beta-hydroxybutyrate. These labs had all been pending at the time of discharge. He was discharged home with instructions to eat frequent small meals (to prevent hyperinsulinemia), follow fasting and post-prandial fingersticks, and follow-up with his [**Date range (1) 3390**] and endocrinology. Family has been checking FS multiple times daily, mostly ranging 80-150's. Reportedly had a similar episode at some point in the '90s. . Pt had been feeling in his usual state of health until several days ago when he developed cough, low-grade fevers (to 38 degrees celsius over the weekend, more recently normal) and dyspnea with ambulation. He was seen by his [**Date range (1) 3390**] yesterday and was found to have rales at the R mid and lower lung fields, afebrile, breathing comfortably. He was started on levoquin for empiric CAP coverage. PA and lateral CXR was negative for pneumonia. . Last night around 10pm he became tremulous and diaphoretic. FS was noted to be in the 40s. His family gave him juice and honey. At 2am, he had a similar episode with tremors, FS in the 40s, and again received juice and honey. He slept well until 8am when he had a third episode. At this point, they called EMS. On arrival, FS was 48. He was given an amp of D50 and his FS improved to 180. Family declined having him brought to the ED. Less than one hour later, his FS again dropped to the 40s. At this point, EMS was called again and he was brought to the ED. . In the ED, initial vitals were T 96.7, BP 145/115, HR 70, RR12, 100% on RA. Mental status was at baseline. Exam notable for left-sided rhonchi. CXR was clear. UA negative. No leukocytosis. Given levofloxacin. FS on arrival was 49 and he received 1 amp D50. FS dropped again to 40s within an hour, symptomatic with tremors, and he was given another amp of D50. Started D5 drip and admitted to the [**Hospital Unit Name 153**] for close FS monitoring. Past Medical History: #. Tension headache #. Benign Essential Tremor #. ? Alzheimer's Dementia #. CAD s/p CABG #. Chronic Diastolic CHF, EF 60% #. Sick sinus s/p PPM - comlpicated by pacer infection [**2159-2-23**] with note of significant cognitive problems since that prolonged hospitalization0 #. Paroxysmal atrial fibrillation - on coumadin #. Peripheral vascular disease #. s/p aorto-iliac bypass #. Chronic kidney disease #. Dyslipidemia #. Hypertension #. Colonic adenoma #. s/p cholecystectomy #. Anemia #. Benign prostatic hypertrophy Social History: The patient is Russian-speaking only and lives with his wife in [**Name (NI) **]. The patient was previously employed as an electrician. They have a home aide that comes twice a week to help with cooking, cleaning and bathing the patient. He walks with a cane at baseline, is able to dress himself, transfer to commode, feed himself. Tobacco: None ETOH: Rare social use previously Illicits: None Family History: noncontributory Physical Exam: Vitals: T: 97 BP: 177/57 HR: 64 RR: 19 O2Sat: 99% on RA GEN: Well-appearing, well-nourished, elderly male no acute distress HEENT: EOMI, PERRL, sclera anicteric, mildly dry MM, OP Clear NECK: No JVD, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: rales at R mid-lower lung fields, otherwise clear, no wheezes ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and year. 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: scattered ecchymoses on his bilateral upper extremities Pertinent Results: [**2165-12-19**] 11:03AM COMMENTS-GREEN TOP [**2165-12-19**] 11:03AM LACTATE-2.1* [**2165-12-19**] 10:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2165-12-19**] 10:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2165-12-19**] 10:25AM GLUCOSE-36* UREA N-63* CREAT-2.7* SODIUM-140 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-21* ANION GAP-18 [**2165-12-19**] 10:25AM WBC-5.2 RBC-4.54* HGB-12.2* HCT-36.7* MCV-81* MCH-26.9* MCHC-33.3 RDW-16.7* [**2165-12-19**] 10:25AM WBC-5.2 RBC-4.54* HGB-12.2* HCT-36.7* MCV-81* MCH-26.9* MCHC-33.3 RDW-16.7* [**2165-12-19**] 10:25AM PLT COUNT-165 [**2165-12-19**] 10:25AM PT-30.2* PTT-71.8* INR(PT)-3.1* . CXR:[**Hospital 93**] MEDICAL CONDITION: 86 year old man with h/o chf but now with recent fevers, cough, rales right lung fields REASON FOR THIS EXAMINATION: r/o pneumonia Final Report INDICATION: 86-year-old man with history of CHF, now with recent fevers, cough, rales in the right lung field. Rule out pneumonia. COMPARISON: Multiple chest radiographs, most recent on [**12-2**], [**2164**]. TECHNIQUE: PA and lateral views of the chest. FINDINGS: Left-sided pacer leads are intact and terminate in the expected location in the right atrium and ventricle, unchanged. Midline sternotomy wires are again noted with a small fracture in the third wire, which is unchanged since [**2159**]. Vascular engorgement has improved since the prior study. The lungs appear clear with no evidence of pneumonia. Cardiomegaly is stable. The aorta is calcified and slightly tortuous. IMPRESSION: No evidence of pneumonia. Improved vascular engorgement since prior study. . Renal Ultrasound: NDINGS: This study is limited by patient body habitus and limited ability to cooperate with the exam. The left kidney measures 9.9 cm and the right kidney measures 9.1 cm. There is no nephrolithiasis or hydronephrosis in either kidney. There is a simple cyst arising from the mid pole of the left kidney. The bladder is obscured by shadowing from the air within the urinary bladder, likely due to air of Foley catheter placement. IMPRESSION: 1. Limited study. No hydronephrosis. 2. Non-visualization of the bladder due to air within the bladder. If further evaluation is required, consider alternative imaging methods (MR) or cystoscopy. . CT abdomen/pelvis [**2165-12-23**]: NDICATION: Dementia, hematuria and anticoagulation with drop in hematocrit. Please evaluate for retroperitoneal bleed. COMPARISON: CT abdomen [**2161-9-17**]. TECHNIQUE: MDCT axially acquired images were obtained from the lung bases to the symphysis without contrast. Multiplanar reformatted images were obtained and reviewed. CT ABDOMEN WITHOUT CONTRAST: There are small bilateral pleural effusions with associated passive atelectasis. Evaluation of the lung parenchyma is limited given respiratory motion. No large mass is detected. Pacer wires are detected within the right ventricle and right atrium. There is CT evidence of anemia. No pericardial effusion is present. Evaluation of intra-abdominal and intrapelvic parenchymal organs is limited given lack of IV contrast administration. However, no focal mass lesion is identified within the liver. Tiny hypoattenuating lesions within the liver are too small to adequately characterize. The spleen, stomach and pancreas appear grossly unremarkable. There is calcification of the abdominal aorta and iliac branches with a small ectasia of the infrarenal aorta measuring maximum diameter of 2.3 cm. There is atrophy of the right kidney with respect to the left. A probable AML is again noted within the interpolar region of the left kidney. There is a splenule within the splenic hilum. Dense calcified atherosclerotic plaque is noted within the tortuous splenic artery. Dense calcified atherosclerotic plaque is present within the SMA with approximately 50% luminal narrowing (series 3: image 28). There is no evidence of bowel obstruction or retroperitoneal bleed. CT PELVIS WITHOUT CONTRAST: The prostate is enlarged measuring 5.5 cm in greatest transverse dimension. The bladder wall is subjectively thickened with foci of intraluminal air within the bladder lumen. No pelvic or inguinal adenopathy is detected. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are identified. Multilevel degenerative changes are present within the lumbar spine with intervertebral body disc space narrowing and vacuum phenomenon most prominent at L4-5 and L5-S1. IMPRESSION: 1. No retroperitoneal bleed. 2. Prostatic enlargement with subjective bladder wall thickening. Foci of gas within the bladder lumen is presumed secondary to Foley catheter placement. Please correlate clinically. 3. Small bilateral pleural effusions. 4. Anemia. 5. Dense calcified atherosclerotic plaque within the abdominal aorta and major branches without aneurysmal dilitation. , CXR [**2165-12-23**]: FINDINGS: Cardiomediastinal contours are unchanged. Increased opacity overlying the lower thoracic spine on the lateral view likely localizes to the posterior basilar segment of the right lower lobe on the PA projection, and could be due to atelectasis, aspiration, or a developing pneumonia. Followup radiographs may be helpful in this regard. Probable small right pleural effusion. Brief Hospital Course: This is an 86 year-old male with a history of CAD, CHF, afib, HTN, CKD who presented with recurrent hypoglycemia, acute renal failure and delerium. He was initially admitted to the ICU. . # Hypoglycemia: Differential diagnosis on admission included reactive hypoglycemia/pre-diabetes, medication effect from levofloxacin, and insulinoma. Pt had been admitted earlier this month for hypoglycemic episodes, thought to be due to hyperinsulinemia in the setting of pre-diabetes and decreased renal clearance. On the last admission, his insulin levels and C peptide levels were elevated with low hydroxybutyrate which could be consistent with insulinoma. However, these test results are difficult to interpret in the setting of having just received glucagon prior. Per the family, the pt had been checking his fingersticks with his wife up to 4 times a day after his last discharge, with most values in the 100s. The pt was diagnosed with bronchitis or CAP the day prior to admission this time, and was started on levofloxacin. In the ICU the patient required IV d5 overnight to keep FSG>60 (with q1hour FS checks). Endocrine was consulted who originally recommended supervised fast to discern between reactive hypoglycemia and insulinoma. However, the patient had ST depressions overnight with slight bump in his troponins so it was decided not to stress the heart by fasting. On the day after admission the patient started taking PO (diabetic/consistent carb diet). His FSG was maintained >100 overnight and he was called out to the floor. After the pt had been off of levofloxacin for 72 hours, endocrine wanted to pursue a fasting trial for 48 hours, as 90-95% of pts can be diagnosed with insulinoma with only a 48 hr fast (as opposed to 72) hr fast. The lowest his fingerstick dropped to was 79, at which point insulin, beta-hydroxybutyrate, and proinsulin levels were drawn (pending at discharge). He fingerstick quickly came back up to 90 on its own. Endocrine felt based on this fasting test, the pt likely has reactive hypoglycemia and not an insulinoma. The patient should not ever take a fluoroquinolone again given risk of hypoglycemia. He should continue to follow a diabetic diet, eat small and frequent meals (to prevent post-prandial hyperinsulinemia), and check fingersticks fasting in the morning and at various times during the day at home. (in the morning and before meals at rehab). He was provided with a glucagon emergency kit on his last admission. He has outpatient endocrine follow up. . #Acute Renal Faiure: Patient's creatinine increased to 3.1 in the ICU. We stopped lasix and spironolactone. Urine output remained stable, urine lytes were c/w FeUrea of 25%. He was continued on IVF and creatinine fell to 2.3 (back to baseline) at time of discharge. His lasix and aldactone can be restarted if he gains more than 3 lbs or has any evidence of volume overload. . #Demand Ischemia/ Tachycardia; Patient became tachycardic overnight on admission->CK: 55 MB: 11 MBI: 20.0 Trop-T: 0.23, started heparin gtt and called cardiology consult. Cardiology did not feel his presentation was consistent with ACS, so we stopped heparin, and started aspirin 81. CE trended down-> 48/9/0.20 then 37/7/0.21. . # Community-acquired pneumonia: Patient reported cough for the past few days with dyspnea on exertion and R-sided crackles. We had started the patient on levofloxacin but per endocrine there are case reports of levoflox causing hypoglycemia so we changed to cefpodoxime and azithromycin to complete a 5 day course. The pt did have noted RLL ronchi, and later in the hospital stay CXR did show a small RLL infiltrate. He continues to have a cough and some ronchi, which is likely residual from his PNA, +/- bronchitis. Was satting 97% RA at discharge. . # Anemia CKD/Hematocrit drop: Pt had hct drop from 29 to 24 over [**Date range (1) 94100**], down from baseline of 30. At baseline pt is anemic likey due to CKD, and has been receiving epogen as an outpatient. Hct on admission was 36, which is higher than his baseline. Suspect in part this drop was due to dilution. It is possible his hematuria caused a small amount of hct drop as well, but his hematuria resolved over 2 days with some blood clots, but not significant enough to explain [**4-30**] pt hct drop. CT of the abdomen/pelvis was performed to r/o RP bleed, but this was negative. Repeat hct was 26, and the following day was 25. He was given 1 unit PRBC with hct rising to 27 prior to discharge. . # Atrial Fibrillation: Goal INR is 1.5-2.5 per [**Month/Day (3) 3390**] [**Name Initial (PRE) 626**]. INR supratherapeutic at 3.1 on admission, (likely [**1-26**] levoquin and decreased PO intake). No signs of active bleeding. Coumadin was held. On discussion through email with pts [**Month/Day (2) 3390**], [**Name10 (NameIs) **] was decided to hold pts coumadin in the setting of these recent hypoglycemic episodes and risk of fall. He was started on ASA 81 mg a day for his demand ischemia. Given his hematuria and hct drop while here, increasing it to 325 mg daily was deferred. . # Delirium: Pt has underlying dementia, but from caring for pt on last admission pt was less oriented and agitated. Pt had pulled his foley in the ICU, causing hematuria, and a 3 way foley was placed. Upon transfer to the floor the 3 way foley was removed as were soft wrist restraints. He received zyprexa 2.5 mg once with good effect. Delirium was cleared by 48 hours of discharge, but at baseline pt does have some sundowning. . # Hypertension: Patient arrived hypertensive with SBP 170s. We held lopressor as it can mask symptoms of hyperglycemia. His BP was well controlled on hydralazine and Imdur. In the setting of demand and tachycardia, however, his beta blocker was restarted. . # Hematuria: Pt had pulled his foley in the ICU, causing hematuria, and a 3 way foley was placed. Upon transfer to the floor the 3 way foley was removed and the pt continued to pass blood clots without any PVR. No hematuria for 72 hours prior to discharge. . # Coronary Artery Disease s/p CABG: Patient was continued on simvastatin. Lopressor was restarted and ASA was started after it was noted pt had demand ischemia. . # Chronic diastolic CHF: Appears euvolemic/dry. He was continued on imdur, but we held lasix and spironolactone in the setting of acute renal failure. . # Dementia: Continued donepezil and aricept . # Hyperlipidemia: cont statin . # BPH: cont finasteride Medications on Admission: 1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): If you are on lipitor then resume taking lipitor. 8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 10. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Glucagon Emergency 1 mg Kit Sig: One (1) injection Injection once as needed for low blood glucose : Give for fingerstick less than 60 and symptoms unresponsive to food/candy. Disp:*2 kits* Refills:*1* 13. Outpatient Lab Work CBC, PT, PTT, INR, sodium, potassium, chloride, bicarbonate, BUN, creatinine, and glucose to be drawn on [**2165-12-6**] 14. Accu-Chek Aviva Strip Sig: One (1) strip In [**Last Name (un) 5153**] as directed. 15. Accu-Chek Multiclix Lancet Misc Sig: One (1) lancet Miscellaneous as directed. Disp:*100 lancets* Refills:*2* Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO MWF (Monday-Wednesday-Friday). 6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: Hypoglycemia Acute on chronic renal failure Demand cardia ischemic Community acquired pneumonia . Secondary: Dementia Coronary artery disease Atrial fibrillation Discharge Condition: stable Discharge Instructions: You were admitted with hypoglycemia (low blood sugar), felt to be the cause of your symptoms. Your hypoglycemia is thought to be due to pre-diabetes and having taken the antibiotic levofloxacin. You should not take this antibiotic in the future, nor any other antibiotic in its class. . You were treated for pneumonia with antbiotics. You have completed this course of antibiotics. . Your coumadin was stopped upon discussion with Dr. [**Last Name (STitle) **]. We feel that with these recent episodes of low blood sugar, you are at risk of falling and hitting your head. If you are on coumadin, this can increase your risk of bleeding. We would like you to start taking aspirin instead.. . You were noted to have acute kidney failure. Your lasix was held while you were here. Your kidney failure improved with IV fluids. . You received 1 unit of blood for your anemia while you were here. . You should check your fingerstick fasting (before breakfast) and 2 hours after breakfast several mornings a week, and bring these readings with you to Dr. [**Last Name (STitle) **]/Abrahmson of endocrine at [**Last Name (un) **]. . You were provided with a glucagon pen on your last admission. This is an injection that someone can give you if you are found to have low blood sugars again (fingerstick less than 60) and unable to eat. The glucagon pen is for emergencies only when you cannot eat with a low fingerstick. If your fingerstick is less than 70, you should drink juice or eat candy to try to bring your fingerstick up to at least 70s-80s. If your fingerstick is very low (less than 60) or you have symptoms of low blood sugar, you should eat candy and sugar, then use the glucagon emergency kit if your fingersticks are still low and don't respond to food. (ie remains less than 60) . You should eat small and frequent meals (5 small meals a day as opposed to 3 large meals a day. This is to prevent your sugar levels from dropping. . Call your doctor or return to the ER for recurrent shaking, fingerstick less than 60 or symptoms from low blood sugar, odd facial/bodily movements, confusion, lightheadedness/fainting, nausea/vomiting, fevers, palpitations, or any other concerning symptoms. Followup Instructions: 1. Primary Care: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2166-1-3**] 3:40 PM . 2. Endocrine: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10145**] and Dr. [**Last Name (STitle) **] at the [**Hospital **] Clinic [**1-5**], 3:00 PM, [**Hospital Ward Name 517**] [**Hospital1 **]; Address: One [**Last Name (un) **] Place [**Location (un) 86**], [**Numeric Identifier 718**] General Info and Appointments: ([**Telephone/Fax (1) 4847**] . Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2166-3-31**] 1:00 Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2166-4-23**] 11:30

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icd9cm

[ [ [] ] ]

[ "57.95", "99.04" ]

icd9pcs

[ [ [] ] ]

19024, 19101

9783, 16241

231, 237

19307, 19316

4414, 5162

21563, 22428

3605, 3622

17788, 19001

5202, 5293

19122, 19286

16267, 17765

19340, 21540

3637, 4395

179, 193

5325, 9759

265, 2630

2652, 3175

3191, 3589

612

149,838

24487

Discharge summary

report

Admission Date: [**2101-5-27**] Discharge Date: [**2101-6-8**] Date of Birth: [**2021-12-25**] Sex: F Service: SURGERY Allergies: Codeine Attending:[**First Name3 (LF) 148**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ERCP History of Present Illness: 79y female who presented to [**Hospital6 33**] with 5 days of abdominal and mid-back pain that worsened severely on the morning of admission. She had mulitple episodes of dry heaving and vomited a small amount of blood. She was quickly transported to [**Hospital1 18**] for acute pancreatitis. Ultrasound revealed gallstones and peripancreatic fluid. She was admitted to the ICU for futher management. Past Medical History: Diverticulosis Hypertension Osteoarthritis Coronary artery disease chronic back pain gastroesophageal reflux disease Past Surgical History: cholecystectomy left knee surgery Social History: Remote smoking history. No alcohol. Married, lives with husband, has three children. Family History: Father died of myocardial infarction at age [**Age over 90 **]. Mother died of leukemia. Physical Exam: Vitals: 100.1, HR 96, BP 147/72, RR 21, 98% RA Alert and oriented PERRLA, EOMI RRR, no murmur Lungs clear to auscultation bilaterally, with decreased sounds at the bases bilaterally Abdomen: soft, obese, tender to palpation in epigastrum; involuntary guarding, no rebound Ext: no clubbing, cyanosis or edema Pertinent Results: [**2101-5-28**] 12:03AM BLOOD WBC-11.2* RBC-4.26 Hgb-13.4 Hct-40.4 MCV-95 MCH-31.4 MCHC-33.1 RDW-13.0 Plt Ct-154 [**2101-5-28**] 12:03AM BLOOD PT-12.5 PTT-22.7 INR(PT)-1.0 [**2101-5-28**] 12:03AM BLOOD Glucose-153* UreaN-21* Creat-0.9 Na-143 K-4.5 Cl-110* HCO3-20* AnGap-18 [**2101-5-28**] 12:03AM BLOOD ALT-840* AST-663* AlkPhos-165* Amylase-1376* TotBili-4.7* [**2101-5-28**] 12:03AM BLOOD Lipase-2886* [**2101-5-28**] 12:03AM BLOOD Albumin-4.0 Calcium-8.7 Phos-2.7 Mg-1.8 [**2101-6-8**] 06:37AM BLOOD WBC-11.8* RBC-3.57* Hgb-10.9* Hct-32.9* MCV-92 MCH-30.6 MCHC-33.2 RDW-13.3 Plt Ct-274 [**2101-6-6**] 05:58AM BLOOD Glucose-155* UreaN-27* Creat-0.7 Na-135 K-4.2 Cl-100 HCO3-26 AnGap-13 [**2101-6-8**] 06:37AM BLOOD Amylase-404* [**2101-6-8**] 06:37AM BLOOD Lipase-818* Cholangiogram [**5-27**]: Dilated common bile duct that is not well filled with contrast Brief Hospital Course: Ms. [**Known lastname 1662**] was admitted to the ICU for aggressive fluid resusciation. She underwent emergent ERCP. This revealed severe pancreatitis with bulging of the major papilla suggestive of an impacted stone. A sphincterotomy was done, and stone fragments removed from the bile duct using a balloon catheter. She tolerated the procedure well. On hospital day three, she was transferred to the floor and started on a clear diet. She was treated with levofloxacin and flagyl. She did not tolerate an oral diet, and therefore was made NPO and started on TPN. Sips were then slowly reintroduced. Her amylase and lipase levels decreased throughout her stay. Physical therapy worked with her during her hospital course. Her TPN was tapered, and by hospital day 12, it was discontinued. She tolerated a regular diet. The decision was made to discharge her to home. Medications on Admission: Toprol XL 25mg daily Protonix 40mg daily HCTZ 25mg daily Discharge Medications: 1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation: While taking pain medications. Disp:*60 Capsule(s)* Refills:*2* 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: Gallstone pancreatitis hypertension coronary artery disease hypvolemia Discharge Condition: Good Discharge Instructions: [**Name8 (MD) **] MD or go to ER for temp >101, persistent nausea, vomiting or pain, or any other questions. You may resume a regular diet and your regular home medications. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1231**] Follow-up appointment should be in 2 weeks

[ "577.0", "414.01", "530.81", "276.5", "562.10", "574.51", "401.9", "724.2", "715.90" ]

icd9cm

[ [ [] ] ]

[ "51.88", "99.15", "38.93", "38.91", "51.85" ]

icd9pcs

[ [ [] ] ]

4082, 4101

2361, 3242

281, 288

4216, 4222

1474, 2338

4445, 4608

1041, 1131

3349, 4059

4122, 4195

3268, 3326

4246, 4422

886, 921

1146, 1455

227, 243

316, 723

745, 863

937, 1025

29,731

143,035

31251+57738

Discharge summary

report+addendum

Admission Date: [**2180-11-10**] Discharge Date: [**2180-11-14**] Date of Birth: [**2127-4-5**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Asymptomatic with recent MI Major Surgical or Invasive Procedure: [**2180-11-10**] Coronary Artery Bypass Graft x 2 (LIMA to LAD, Free RIMA to Diag) History of Present Illness: 53 y/o male s/p STEMI with BMS on [**6-22**], referred for routine stress test which was positive. Underwent cardiac cath which showed single vessel LAD disease with 60% ISR and diag stent with 95% ISR. Past Medical History: Hyperlipidemia, Hypertension, Coronary Artery Disease s/p Myocardial Infarction s/p BMS to LAD [**6-22**], Elbow bursa, s/p Hernia Repair Social History: Self employed. Quit smoking 3 months ago after 3-4ppd x 30yrs. Denies ETOH. Family History: Non-contributory Physical Exam: VS: 63 16 188/96 5'8 172# Gen: NAD, lying in bed Skin: Unremarkable HEENT: EOMI, PERRL, OP benign Neck: Supple, FROM -JVD Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused -c/c/e, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**11-10**] Echo: Pre Bypass: The left atrium is mildly dilated. A patent foramen ovale is present. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. [**2180-11-10**] 12:07PM BLOOD WBC-15.5*# RBC-3.40* Hgb-11.4* Hct-33.9* MCV-100* MCH-33.5* MCHC-33.6 RDW-14.9 Plt Ct-125* [**2180-11-13**] 06:55AM BLOOD WBC-7.0 RBC-2.11* Hgb-7.2* Hct-20.9* MCV-99* MCH-34.3* MCHC-34.5 RDW-14.9 Plt Ct-119* [**2180-11-10**] 12:07PM BLOOD PT-13.4* PTT-40.2* INR(PT)-1.2* [**2180-11-12**] 01:17AM BLOOD PT-13.8* PTT-28.6 INR(PT)-1.2* [**2180-11-10**] 01:18PM BLOOD UreaN-18 Creat-1.1 Cl-108 HCO3-25 [**2180-11-13**] 06:55AM BLOOD Glucose-105 UreaN-20 Creat-1.1 Na-132* K-5.0 Cl-99 HCO3-27 AnGap-11 [**2180-11-14**] 06:30AM BLOOD Hct-27.8*# Brief Hospital Course: Mr. [**Known lastname **] was a same day admit after undergoing all pre-operative work-up as an outpatient. On the day of admission ([**11-10**]) he was brought directly to the operating room where he underwent a coronary artery bypass graft x 2. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. Post-op day one he was started on beta blockers and diuretics and gently diuresed towards his pre-op weight. On post-op day two his chest tubes were removed and he was transferred to the SDU for further care. On post-op day three his epicardial pacing wires were removed. His hematocrit was low (20.9) and he was transfused 2 units of blood and started on Iron and Vit C. He was ready for discharge home on POD #4. Medications on Admission: Aspirin 325mg qd, Plavix 75mg qd, Toprol XL 25mg qd, Zocor 40mg qd, Lisinopril 10mg qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. Ferrous Gluconate 300 (35) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*28 Tablet(s)* Refills:*0* 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. Disp:*56 Capsule, Sustained Release(s)* Refills:*0* 10. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Partners [**Name (NI) **] [**Name2 (NI) **] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2 PMH: Hyperlipidemia, Hypertension, Myocardial Infarction s/p BMS to LAD [**6-22**], Elbow bursa, s/p Hernia Repair Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**2-19**] weeks Dr. [**Last Name (STitle) 29357**] in [**1-18**] weeks Completed by:[**2180-11-14**] Name: [**Known lastname 3205**],[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Unit No: [**Numeric Identifier 12226**] Admission Date: [**2180-11-10**] Discharge Date: [**2180-11-14**] Date of Birth: [**2127-4-5**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 741**] Addendum: medication change Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Ferrous Gluconate 300 (35) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*28 Tablet(s)* Refills:*0* 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. Disp:*56 Capsule, Sustained Release(s)* Refills:*0* 9. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 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. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 12. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every four (4) hours as needed. Disp:*qs qs* Refills:*0* Discharge Disposition: Home With Service Facility: Partners [**Name (NI) **] [**Name2 (NI) **] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2180-11-14**]

[ "414.01", "412", "V45.82", "401.9" ]

icd9cm

[ [ [] ] ]

[ "36.16", "39.61" ]

icd9pcs

[ [ [] ] ]

7795, 7993

2575, 3471

350, 434

5268, 5274

1249, 2552

5609, 6279

936, 954

6302, 7772

5070, 5247

3497, 3585

5298, 5586

969, 1230

283, 312

462, 666

688, 827

843, 920

8,649

105,551

11320

Discharge summary

report

Admission Date: [**2171-9-28**] Discharge Date:[**2171-10-18**] Date of Birth: [**2138-1-22**] Sex: M ADMITTING DIAGNOSIS: Multitrauma, Status post unrestrained passenger in a motor vehicle accident. 33 y.o. male with unknown past medical history who was found unrestrained motor vehicle accident in which he was the driver. There was approximately 15 minute extrication time from the vehicle. The patient was found to be transiently hypotensive with systolic blood pressure in the 90s which responded quickly to approximately 300 cc of fluid resuscitation. The patient arrived in the Emergency complaining of bilateral leg pain and back pain. He had a and subsequently had to be intubated to facilitate full trauma team evaluation. There was a questionable loss of consciousness during the accident. PAST MEDICAL HISTORY: Unknown. PAST SURGICAL HISTORY: Unknown. ALLERGIES: Unknown. MEDICATIONS: Unknown. PHYSICAL EXAMINATION: Vital signs revealed pulse 55, blood pressure 160/48. Head, eyes, ears, nose and throat, atraumatic head with no obvious signs of injury. Tympanic membranes were intact. No blood in the outer ears. Chest was clear to auscultation bilaterally, nontender. Cardiovascular, normal sinus rhythm. Abdomen was soft, nontender, nondistended. Pelvis was stable and tender. Rectal with normal tone, guaiac negative. Extremities with left thigh deformity, palpable dorsalis pedis, posterior tibial bilaterally, right open tibial-fibula fracture, palpable posterior tibial but dorsalis pedis was nonpalpable on the right side. Back, no obvious stepoff or deformity. LABORATORY DATA: Radiographic studies, lateral cervical spine showed C1 through C7 within normal limits, no obvious fractures. The patient did have a left femur displaced, comminuted fracture and an open Grade 2 right tibia-fibula fracture. Computerized tomography scan of the head was negative. Computerized tomography scan of the neck was also negative. The patient had thoracolumbosacral films subsequently which showed approximately 10% compression fracture of T12. HOSPITAL COURSE: The patient was seen in the Trauma Bay by the Trauma Team where a full trauma evaluation was carried out. He was started on intravenous fluids for resuscitation and then was taken to the Operating Room for fixation of his left femur and right tibia-fibula fractures. He had left femur intramedullary rodding, he had transverse femoral shaft fracture and a washout and fibular rodding of the right open tibia-fibula fracture. The patient tolerated the procedure well and postoperatively was transferred to the Surgical Intensive Care Unit where he remained stable for the next few days. He was subsequently extubated at which time he complained of back pain. Orthopedic Spine was once again consulted and recommendation for TLSO brace to be worn when out of bed for six to twelve weeks was made. The patient was subsequently fitted for a TLSO. The toxicology screen during the common workup was positive for alcohol and the patient also has a history of recreational drug use. The patient was postoperatively noted to have troponin leak with a troponin of 2.6 in the Surgery Intensive Care Unit. The Cardiology was consulted and they felt that the patient had a cardiac contusion in the setting of a motor vehicle accident. He had persistent delirium through [**9-10**] to 24 which is attributed to either questionable head injury or over sedation from opioids or benzodiazepines and it was felt unlikely to represent alcohol withdrawal. His mental status improved by [**10-5**]. On [**10-6**], he was noted to have left upper extremity weakness and diminished left biceps and brachioradialis reflexes. He had subsequent magnetic resonance imaging scan of the head, demonstrated diffuse axonal injury, magnetic resonance imaging scan of the neck with C5-6 and C6-7 disc protrusion. On [**2171-10-10**] he underwent surgical decompression of these herniations. On [**10-11**], the patient started complaining of some dyspnea at rest associated with some left-sided chest discomfort. His oxygen saturations were a little lower than what they had been. He was 93% on room air. His electrocardiogram showed a persistent sinus tachycardia, inferior T waves without acute change from previous study. Medicine was consulted and they felt that the patient had left lower lobe pneumonia. He was started on Ceftriaxone 1 gm intravenously q. 24 which subsequently will be switched to Levaquin 500 mg p.o. q. day for 14 days upon the patient's discharge. On [**2171-10-14**] the patient had swallow study requested for the patient's continued inability to swallow. Speech swallow saw the patient and recommended pureed diet with thick liquid, positioning the patient upright for meals, staff supervision at the time of meals and also a video-assisted swallowing study. Neurology was also consulted on [**10-15**] regarding the patient's continued mental state. He was unable to carry out a normal thought process. He was unable to recall why he was in the hospital and was perseverating about hunger and not being able to call for help. Neurology consult saw the patient and felt that his behavior represented diffuse axonal injury and residual shortterm neurological deficit. They recommended follow up in Behavioral Neurology Unit for longterm cognitive neurologic issues as well as follow up in the General [**Hospital 878**] Clinic with Dr. [**Last Name (STitle) **]. They felt that the patient needed cognitive rehabilitation as well as physical rehabilitation. The patient otherwise made steady progress while in the hospital. A rehabilitation bed was obtained for him and he was transferred to rehabilitation on [**2171-10-17**]. DISCHARGE MEDICATIONS: 1. Lopressor 25 mg p.o. b.i.d., hold for systolic blood pressure less than 100 and heartrate less than 55 2. Lovenox 30 mg b.i.d. 3. Ativan .5 mg p.o. b.i.d. prn 4. Colace 100 mg p.o. b.i.d. 5. Dulcolax 10 mg p.r. q. day prn 6. Percocet one to two tabs p.o. q. 4 hours prn 7. Droperidol .625 mg intramuscularly q. 6 hours prn 8. Levaquin 500 mg p.o. q. day times 14 days DISCHARGE INSTRUCTIONS: Specific treatment and frequency - The patient will be touch-down weightbearing on the right and left lower extremity. He will TLSO for ten weeks when out of bed. Follow up appointments: 1. Follow up with Dr. [**First Name (STitle) 1022**] in two weeks, please call his office to schedule an appointment, office # [**Telephone/Fax (1) 36310**]. 2. Follow up in Behavioral Neurology Unit for longterm cognitive/neurologic issues. 3. Follow up in the General [**Hospital 878**] Clinic with Dr. [**Last Name (STitle) **]. Please call [**Telephone/Fax (1) 2756**] to reach Dr.[**Name (NI) 36311**] office. Diet - The patient is to have pureed diet with mixed thick liquid. He is to position himself upright for meals. He should be supervised at meals and should be monitored for aspiration. If the patient seems to be coughing with meals would seek medical attention. His medication should be crushed and administered with applesauce. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] M.D.20-231 Dictated By:[**Name8 (MD) 36312**] MEDQUIST36 D: [**2171-10-16**] 15:47 T: [**2171-10-16**] 17:09 JOB#: [**Job Number 36313**]

[ "E812.0", "486", "305.90", "305.00", "821.00", "823.92", "997.3", "722.0" ]

icd9cm

[ [ [] ] ]

[ "79.66", "93.54", "78.55", "81.02", "80.51", "78.57" ]

icd9pcs

[ [ [] ] ]

5798, 6178

2120, 5775

6203, 6368

884, 940

963, 2102

6392, 7376

142, 827

850, 860

73,363

174,481

10395

Discharge summary

report

Admission Date: [**2144-1-31**] Discharge Date: [**2144-2-4**] Date of Birth: [**2091-4-28**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: angina, dyspnea on exertion Major Surgical or Invasive Procedure: [**2144-1-31**] Coronary artery bypass grafting x3 with left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the ramus intermedius branch and the first marginal branch. History of Present Illness: This is a 52 year old male with known coronary disease, who has now developed recurrent angina. Despite undergoing successful [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] to the ramus in [**2143-4-24**], he continued to experience chest pain. A recent cardiac catheterization showed 50% left main lesion with patent ramus DES. Given his worsening angina, he was referred for surgical revascularization. Past Medical History: - Ishemic Heart Disease, s/p Taxus stent to Ramus [**2143-4-24**] - Hypertension - Dyslipidemia/Elevated TG's - Metabolic Syndrome - Anemia - History of Migraine Past Surgical History: - Left Hip Replacement - Facial surgery Social History: Mr. [**Known lastname 34428**] lives with his wife. [**Name (NI) **] works in construction. He quit smoking 5 years ago after a 20 pack year history. He is a recovering alcoholic, sober for the last 5 years. Family History: Mr. [**Known lastname 34429**] uncle died from a myocardial infarction at age 52. Physical Exam: Pulse: 62 Resp: 16 O2 sat: 100% B/P Right: 131/72 Left: 138/73 General: WDWN male in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] - no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur - none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema - none Varicosities: None [X] Neuro: Grossly intact 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 - none Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 34430**] (Complete) Done [**2144-1-31**] at 9:05:40 AM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2091-4-28**] Age (years): 52 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Chest pain. Coronary artery disease. Left ventricular function. ICD-9 Codes: 786.51, 424.2 Test Information Date/Time: [**2144-1-31**] at 09:05 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW001-0:00 Machine: AW5 Echocardiographic Measurements Results Measurements Normal Range Aorta - Ascending: 3.0 cm <= 3.4 cm Aorta - Arch: 2.5 cm <= 3.0 cm Findings LEFT ATRIUM: Normal LA size. No thrombus/mass in the body of the LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). 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. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pre-bypass: The left atrium is normal in size. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Post bypass: Preserved biventricular funciton, LVEF >55%. Aortic contours intact. Reamaining exam is unchanged, all findings discussed with surgeons at the time of the exam. Brief Hospital Course: On [**2144-1-31**] Mr. [**Known lastname 34428**] was taken to the operating room and underwent a Coronary artery bypass grafting x3 with left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the ramus intermedius branch and the first marginal branch. This procedure was performed by Dr. [**First Name (STitle) **] [**Name (STitle) **]. Please see the operative note for details. He tolerated this procedure well and was transferred in critical but stable condition to the surgical intensive care unit. He was extubated and weaned from pressors. His chest tubes were removed. He was transferred to the surgical step down floor. His epicardial wires were removed and he was seen in consultation by the physical therapy service. By post-operative day four he was ready for discharge to home per Dr. [**Last Name (STitle) **]. All follow-up appointments were advised. Medications on Admission: Toprol XL 50mg qd, Simvastatin 40mg qd, Tricor 100mg qd, Aspirin 81mg qd, Plavix 75mg qd, Relpax prn, Effexor XR 225mg QD, Ambien CR prn Discharge Medications: 1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*2* 6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3) Capsule, Sust. Release 24 hr PO DAILY (Daily). Disp:*90 Capsule, Sust. Release 24 hr(s)* Refills:*2* 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*2* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: coronary artery disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with dilaudid prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Primary Care Dr [**First Name8 (NamePattern2) 30623**] [**First Name8 (NamePattern2) 30624**] [**Doctor Last Name **] in [**1-25**] weeks [**Telephone/Fax (1) 30837**] Cardiologist Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14522**] in [**1-25**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2144-2-4**]

[ "277.7", "458.29", "V45.82", "414.8", "V15.82", "303.93", "346.90", "272.4", "V43.64", "411.1", "E878.2", "414.01", "285.9", "401.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7884, 7942

5550, 6465

348, 562

8010, 8106

2226, 5527

8731, 9264

1505, 1589

6653, 7861

7963, 7989

6491, 6630

8130, 8708

1219, 1261

1604, 2207

281, 310

590, 1012

1034, 1196

1277, 1489

11,950

102,642

13267+13226

Discharge summary

report+report

Admission Date: [**2182-8-13**] Discharge Date: [**2182-8-21**] Date of Birth: [**2107-10-19**] Sex: F Service: GEN SURGER ADMITTED DIAGNOSIS: Status post hemorrhoidectomy. PHYSICAL EXAMINATION: Head, eyes, ears, nose and throat: pupils equal, round and reactive to light. Mucous membranes moist. No evidence of cervical lymphadenopathy. Chest: Clear to auscultation bilaterally. Cardiac: Regular rate and rhythm, no murmurs. Abdominal examination: Evidence of multiple postpartum striae. Abdomen nondistended, soft, no signs of rebound tenderness or gross tenderness to palpation. Gastrointestinal/Genitourinary: The area of hemorrhoidectomy is clean. No evidence of purulence, mild serosanguinous drainage, no evidence of gross bleeding. HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old female who underwent hemorrhoidectomy on [**2182-8-19**] and was admitted for postoperative pain control and observation. Patient's pain was managed initially on subcutaneous and intravenous morphine and transitioned to po dilaudid. Patient experienced intermittent breakthrough discomfort, however, these episodes were subdued with po Dilaudid. Since continued hospitalization posed more risk of nosocomial infection than benefit, patient was discharged with instructions to follow-up with Dr. [**Last Name (STitle) 1888**] and was discharged with 90 tablets of Dilaudid for adequate pain management. Patient was specifically instructed to use 30 cc of mineral oil three times daily and at least seven [**Last Name (un) **] baths daily to prevent wound infection. At the time of discharge, patient's wound site was clean without evidence of blood or infection or purulent discharge. CONDITION OF DISCHARGE: Good. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSIS: Status post hemorrhoidectomy. [**Last Name (NamePattern4) 1889**], M.D. [**MD Number(1) 1890**] Dictated By:[**First Name3 (LF) 40404**] MEDQUIST36 D: [**2182-9-1**] 20:40 T: [**2182-9-1**] 20:40 JOB#: [**Job Number 40405**] 1 1 1 DR Admission Date: [**2182-8-13**] Discharge Date: [**2182-9-11**] Date of Birth: [**2107-10-19**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old female status post aortobifemoral bypass on [**2182-6-19**] by Dr. [**Last Name (STitle) **] secondary to spinal cord ischemia and paraplegia and sigmoid ischemia secondary to a slow gastrointestinal bleed. The patient was discharged and readmitted on [**7-19**]. Esophagogastroduodenoscopy showed a single erosion and a hiatal hernia, and colonoscopy with a resolving ischemic colitis. The patient was discharged again on [**7-26**]. Patient went to [**Hospital 1319**] Hospital with continued gastrointestinal bleed and diarrhea, and was transfused last Thursday. A nasogastric tube was placed today, begun tube feeding, and a KUB showed free air under the diaphragm and the patient was transferred to [**Hospital1 69**]. Patient has no fevers, chills, nausea, or vomiting. PAST MEDICAL HISTORY: Ischemic bowel disease, anemia, hypertension, cervical spondylolisthesis, depression, paraplegia, noninsulin dependent diabetes mellitus, osteoarthritis, coronary artery disease, right lacunar infarct, hypercholesterolemia, coronary artery bypass. PHYSICAL EXAMINATION: In general, the patient was not in acute distress. HEENT: Pupils are equal, round, and reactive to light. Extraocular movements are intact. Oropharynx is clear. Neck: No lymphadenopathy, supple. Heart: Regular, rate, and rhythm, no murmurs. Chest was clear to auscultation bilaterally. No wheezes, rhonchi, or crackles. Abdomen is distended, tender to palpation in the epigastric area. Lack of feeling in the mid abdomen and below. Patient was guaiac positive. Extremities: The patient has lower leg edema. No clubbing or cyanosis. Patient was diagnosed with a sigmoid bowel perforation and started on ampicillin, levofloxacin, and Flagyl, and taken to the operating room. A left colectomy with a colostomy was performed for the perforated sigmoid. After surgery the patient was admitted and on the following day was noted to have acute coldness of her right foot with loss of pulses. It was determined that her right foot had become ischemic and patient was taken back to the operating room for a thrombectomy of her right aortobifemoral limb and right femoral artery. While in the SICU, the patient had a sputum culture that grew yeast and a wound culture that grew Staph. Her antibiotic coverage was changed to Vancomycin, imipenem, and fluconazole. Once becoming stable enough, the patient was transferred to the floor where a number of issues were also addressed including her insulin/diabetes control, as well as her lack of physical ability to ambulate as well as her lack of nutrition. By the fact that the patient was able to eat, she was unable to eat in sufficient quantities, regimen of liquid nutritional supplements was instituted which still did not resolve her low-calorie intake. For that reason, a feeding tube was placed and the patient was placed on nasogastric tube feedings. Also while in the hospital, her diabetes control remained poor with erratic blood sugars ranging from the 60s range to low 300s. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was requested who evaluated her and adjusted her diabetic medications with a slight improvement of her diabetes control. Physical therapy was also consulted on the patient, who indicated to the team that the patient needed extensive physical therapy in a rehabilitation facility setting. Despite our recommendations, discharge planning found the team focusing on getting the patient home at the family's request. The daughter and daughter-in-law, both nurses, preferred to have their mother at home, where they would aid [**Name (NI) 269**] and physical therapy and caring for their mother. Therefore the final week or so of the patient's stay in the hospital, found the team acquiring different necessities for home healthcare including a [**Doctor Last Name **] lift and VAC draining machine. During that week, the patient broke out in a rash, which according to Infectious Disease and Dermatology was likely a drug-induced rash. The patient was therefore, suspended from her current antibiotic regimen and started on po Flagyl and levofloxacin. Patient was being discharged in stable condition with home nursing care and physical therapy on levofloxacin and Flagyl for four weeks. The patient is to followup with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 1888**], Infectious Disease, the [**Last Name (un) **] Diabetes Center, and the dietician. FINAL DIAGNOSIS: Sigmoid perforation status post left colectomy with colostomy and right foot ischemia status post thrombectomy. [**Last Name (NamePattern4) 1889**], M.D. [**MD Number(1) 1890**] Dictated By:[**Last Name (NamePattern1) 1332**] MEDQUIST36 D: [**2182-9-11**] 21:16 T: [**2182-9-18**] 12:44 JOB#: [**Job Number 40320**]

[ "569.83", "707.0", "557.0", "998.59", "682.6" ]

icd9cm

[ [ [] ] ]

[ "46.10", "39.49", "99.15", "38.93", "45.75" ]

icd9pcs

[ [ [] ] ]

1798, 2201

6748, 7107

3336, 6730

2230, 3041

3064, 3313

10,958

136,631

15142

Discharge summary

report

Admission Date: [**2181-7-25**] Discharge Date: [**2181-8-1**] Date of Birth: [**2106-1-21**] Sex: F ADMISSION DIAGNOSES: 1. Probable ovarian cancer. 2. Asthma. 3. Hypertension. 5. Hiatal hernia. 6. Pleural effusion. DISCHARGE DIAGNOSES: 1. Ovarian carcinoma. 2. Left pleural effusion; status post chest tube placement and removal. 4. Asthma. 5. Hypertension. 6. Arthritis. 7. Hiatal hernia. 8. Pleural effusion. HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old gravida 5, para 2-0-1-2, who presented with probable ovarian cancer. She had previously been seen by a surgeon for repair of her hiatal hernia. On a preoperative chest x-ray a large left pleural effusion was noted. This was removed with a thoracentesis twice. The patient reports that the cytology results were inconclusive. This prompted a CT of the abdomen and pelvis which revealed a large amount of ascites. There was a probable appearance of seeding with some nodularity on the anterior surface of the peritoneum and the mid and upper abdomen. There seemed to be some nodularity of the mesenteric fat. There was an ill-defined soft tissue mass in the right lower abdomen and pelvis. The patient reported a 40-pound weight loss over the past few months. She had shortness of breath prior to the thoracentesis but is currently is much better. She had constipation which is a big change for her. She denies any bleeding from any site. PAST MEDICAL HISTORY: 1. Asthma. 2. Hypertension. 3. Arthritis. 4. Hiatal hernia. PAST SURGICAL HISTORY: 1. Breast lump removal. 2. Vaginal hysterectomy. ALLERGIES: QUININE and SULFA. MEDICATIONS ON ADMISSION: Current medications included Lasix, Accupril, Lipitor, Evista, [**Last Name (LF) 44137**], [**First Name3 (LF) **], Serevent, Flovent, Flonase, albuterol, Percocet, and Compazine. PAST OBSTETRICAL HISTORY: Two vaginal deliveries. PAST GYNECOLOGICAL HISTORY: Last PAP smear was one year ago and was normal. Last mammogram was less than one year ago and was normal. FAMILY HISTORY: The patient has had two sisters with lung cancer. A daughter with breast cancer. No history of ovarian cancer. SOCIAL HISTORY: The patient does not smoke or drink. REVIEW OF SYSTEMS: Review of systems revealed a 40-pound weight loss over two months. She has occasional shortness of breath which is improved with her thoracentesis. She has had constipation. She has muscle and joint pain occasionally. Review of systems is otherwise negative. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, she was well-developed but thin. Head, eyes, ears, nose, and throat revealed sclerae were anicteric. Lymph node survey was negative. Lungs were clear on the right, but the left was dullness to percussion two thirds of the way up the lung field. Heart was regular without murmurs. Breasts were normal. The abdomen was soft and distended with obvious ascites, suggestion of multiple palpable abdominal masses. Extremities were without edema. On pelvic examination, vulva and vagina were normal. On bimanual and rectovaginal examination, the vaginal walls were smooth, cervix was surgically absent. A palpable mass in the cul-de-sac on rectal examination which was intrinsically normal. HOSPITAL COURSE: The patient was admitted after being consented for surgery. She underwent a exploratory laparotomy, drainage of ascites, bilateral salpingo-oophorectomy, omentectomy, and tumor debulking. Please see the Operative Report for a detailed discussion of the case. The patient did well postoperatively. She was sent to the Intensive Care Unit due to her multiple medical problems. She was extubated without any complications. A chest tube was placed in the Intensive Care Unit, and on postoperative day two she was sent to the floor for observation and management during the rest of her hospital course. The remainder of her hospital course was uncomplicated. Her pain was managed with Demerol and Vistaril. Her chest tube was removed on postoperative day seven. She was saturating 100% on room air prior to discharge. A left apical pneumothorax was visualized on chest x-ray two days prior to discharge. It was stable before discharge. A CT scan was also obtained which confirmed this finding. The patient tolerated orals. Her urine output was an issue, but she responded very well to Lasix. She did not require any Lasix before discharge. Her electrolytes had to be repleted. Her potassium and magnesium; specifically. Her blood pressure was under control as well as her asthma throughout her hospital course. She was started on all of her outpatient medications while in house. She was also given albuterol and Atrovent nebulizers. She had an internal jugular line which was also removed prior to discharge. Her staples were to remain in place until she was seen by Dr. [**First Name (STitle) 1022**] in the clinic. PERTINENT LABORATORY DATA ON DISCHARGE: Her discharge laboratories were as follows; hemoglobin was 10.3, hematocrit was 32.1. Sodium was 137, potassium was 3.9, chloride was 103, bicarbonate was 26, blood urea nitrogen was 11, creatinine was 0.5. White blood cell count was 8. Calcium was 7.2, magnesium was 1.5, phosphate was 2.6. FOLLOW-UP INSTRUCTIONS: 1. The patient was to follow up with Dr. [**First Name (STitle) 1022**] in the next few days for staple removal. 2. She was also to follow up with Pulmonary as discussed with them for management of her lung issues; more specifically, they will consider at that time whether or not she needs anymore treatment. 3. She was also given heavy lifting precautions and told to return to the hospital for any nausea, vomiting, shortness of breath, fever, chills, drainage from the wound, or vaginal bleeding. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4871**] Dictated By:[**Last Name (NamePattern1) 44138**] MEDQUIST36 D: [**2181-8-1**] 17:28 T: [**2181-8-8**] 11:05 JOB#: [**Job Number 44139**]

[ "183.0", "493.90", "511.9", "197.5", "401.9", "789.5" ]

icd9cm

[ [ [] ] ]

[ "34.04", "65.61", "34.91", "54.4" ]

icd9pcs

[ [ [] ] ]

2061, 2175

260, 443

1673, 2043

3292, 4953

1562, 1646

138, 239

4968, 5264

2251, 3273

472, 1452

5288, 6092

1474, 1539

2193, 2231

7,614

146,426

47435

Discharge summary

report

Admission Date: [**2176-12-29**] Discharge Date: [**2177-1-10**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: fatigue, weakness, respiratory distress Major Surgical or Invasive Procedure: intubation History of Present Illness: Mr. [**Known lastname 100345**] is an 81 yo male with a h/o facioscapulohumeral muscular dystrophy, IDDM, "TIAS", neuropathy, and OSA who presented to the ED with a week of increasing fatigue. In the ED, temp was 102. SBP 80s increased to 120s w/500cc NS. Ceftaz and vancomycin were given and an IJ was placed for possible sepsis. On preparation for transfer, he was felt to be in resp compromise so he was intubated. Past Medical History: 1. CAD with evidence of 3vessel disease on cardiac cath [**9-3**]. 2. CHF with EF of 55% 3. CRI (b/l 1.7) 4. OSA 5. HTN 6. Diabetes Social History: Lives with wife in [**Name (NI) **], MA. Has visiting nurse during days. Son and daughter live locally and are quite involved in their father s care. Tobacco: 90 pack-yr history. Quit 7 yrs ago. Denies current EtOH. Family History: per son, nobody else in family with symptoms of or diagnosis of FSH musc dystrophy. No other family h/o neurologic disease. Daughter died of pancreatic cancer last year Physical Exam: 98.7 113/63 63 14 100%on AC650 X 14 w/PEEP5 and FIO2 100% Intubated, sedated on propofol being transitioned to fentanyl/versed MMM Poor air movement Nl S1/S2 Soft, nt, nd, +BS WWP X 4 Pertinent Results: CXR: Poor quality AP film w/RLL PNA and appropriately positioned ETT [**2176-12-29**] 12:00AM PT-13.5* PTT-29.6 INR(PT)-1.2* [**2176-12-29**] 12:00AM PLT COUNT-184 [**2176-12-29**] 12:00AM WBC-18.1*# RBC-4.95 HGB-14.8 HCT-43.5 MCV-88 MCH-30.0 MCHC-34.1 RDW-20.5* [**2176-12-29**] 12:00AM CK-MB-9 cTropnT-0.46* [**2176-12-29**] 12:12AM LACTATE-2.0 [**2176-12-29**] 03:10AM LACTATE-1.2 [**2176-12-29**] 10:28AM LACTATE-1.0 Brief Hospital Course: Resp failure most likely secondary to sepsis in setting of PNA on CXR- unlikely to be related to fluids since patient is presenting with picture of sepsis. He was hypotensive, low UOP, elevated WBC, febrile in the ED and found to have a RLL PNA on CXR. Also has underlying COPD. extubated [**2177-1-5**], doing well. Note that the patient started at a baseline of multiple comorbidities so it is possible that only a small insult was necessary to exacerbate his FTT. SV02 was 78 - sputum culture grew: pseudomonas([**Last Name (un) 36**] to ceftaz) and strep pneum([**Last Name (un) 36**] to pcn) - legionella negative - on levaquin 750 po q daily (started [**2177-1-3**]) requiring 14 day course ending on [**2177-1-17**] (switched to q 48 hours for CrCl of 34) - pt was OOB to chair with chest PT doing well - blood culture negative - U/A negative, urine culture negative . Cardiac: -Hypertension: -- metoprolol 25 [**Hospital1 **] -CAD: No evidence active ischemia on EKG. -- troponin 0.46, 0.38, 0.27, 0.26 -- on ASA and atorvastatin . Eye surgery: opthomalogy consulted and evaluated patient and recommended erythromycin ointment to eye - spoke with optho on phone, stitch stays in place for > 6 weeks - continue to monitor for signs of infection . COPD- continue nebs/ inhalers on vent. steroids stopped [**1-1**] . DM- Tight control while in ICU. on ISS. would continue this in rehab. . Renal failure: creatinine had gone up in setting of lasix and diuresis. (1.6 appears to be baseline.) - discharge home with 40 po lasix q daily . FEN- on TF. able to tolerate thick nectar, soft po intake for meds with assistance. NGT left in place. . Psych meds: - continued on celexa as well as home dose ritalin and zyprexa for agitation and anxiety . Prophylaxis: PPI, pneumoboots, heparin SQ . Code- DNR/DNI Medications on Admission: Accupril five milligrams daily Lipitor ten milligrams daily Neurontin 300 mg four times a day Ritalin-SR Celexa Zyprexa Provigil Valtrex Spiriva Advair. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Disp:*30 syringes* Refills:*2* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours). 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 8. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). 9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 10. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4-6H (every 4 to 6 hours) as needed. 14. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Methylphenidate 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 16. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO q 48 hours for 5 days. 17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 18. Morphine 2 mg/mL Syringe Sig: [**12-3**] Injection Q2H (every 2 hours) as needed for pain/ anxiety. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: RLL pneumonia requiring intubation and antibiotic therapy Discharge Condition: stable and improving Discharge Instructions: You were hospitalized for a recent pneumonia requiring intubation and ICU level care for 2 weeks. You are improving each day and should continue on the medications prescribed during your hospitalization. You will be prescribed an antibiotic, Levaquin which you should continue for 7 more days. You were also started on metoprolol during your hospitalization. Lastly, your steroids were stopped. If you should develop any fever, chills, nausea, vomiting, respiratory distress, cough, chest pain or shortness of breath you should call the facility physician or return to the ED. Followup Instructions: Follow up with the rehab facility PCP frequently to ensure that your health continues to improve. Monitor creatinine and electrolytes while on lasix

[ "327.23", "482.1", "783.7", "998.0", "403.91", "481", "359.1", "998.59", "250.92", "511.9", "427.1", "E849.8", "585.6", "E878.8", "584.9", "995.91", "518.81", "428.0", "414.01", "496", "038.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "96.72", "38.91" ]

icd9pcs

[ [ [] ] ]

5525, 5591

2025, 3838

303, 315

5693, 5716

1566, 2002

6345, 6498

1172, 1342

4041, 5502

5612, 5672

3864, 4018

5740, 6322

1357, 1547

224, 265

343, 767

789, 923

939, 1156

50,321

193,086

52484

Discharge summary

report

Admission Date: [**2179-8-19**] Discharge Date: [**2179-8-23**] Date of Birth: [**2098-5-24**] Sex: F Service: SURGERY Allergies: Prochlorperazine / Celexa / Dilaudid / Ambien / Methotrexate Attending:[**Doctor First Name 5188**] Chief Complaint: Right neck pain Major Surgical or Invasive Procedure: Total thyroidectomy with right modified radical neck dissection and intraoperative nerve monitoring History of Present Illness: The patient is an 81-year-old woman with a previous medical history significant for coronary artery disease and status post coronary artery bypass graft, diabetes, hypertension, left carotid endarterectomy for carotid stenosis, rheumatoid arthritis, iron deficiency anemia, cholecystectomy, urinary incontinence, and Factor V leiden disease. The patient presented with a relatively newly diagnosed papillary thyroid carcinoma with large and multiple lymph node metastases in the right neck lateral compartment. The patient was scheduled for total thyroidectomy and modified radical neck dissection. The patient was evaluated and cleared for surgery by cardiology and was also seen as a preoperative anesthesiology consult. Past Medical History: Papillary thyroid carcinoma with lymph node metastases Syncope due to recurrent polymorphic ventricular tachycardia CAD s/p CABG Diabetes HTN PVD Left CEA for carotid stenosis Rheumatoid arthritis Factor V Leiden Depression Iron def anemia Hypothyroidism Failure to thrive Cholecystectomy Urinary incontinence Interstitial lung disease Restless leg syndrome Seizure 30 years ago Recurrent Anemia requiring multiple tranfusions as per son, details unknown (possible GI losses w/negative work-up) Social History: Per medical records: Patient lives at the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] as does her husband. [**Name (NI) **] according to Nurse practitioner [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] has good and bad days, some days she is more alert, verbal and interactive than others. Ambulates with a wheelchair due to knee pain. Family History: Her son had a papillary thyroid cancer that was removed. Rare throat cancer of her sister. [**Name (NI) **] history of radiation exposure. Physical Exam: Vitals: Tm 98.5, Tc 98.1, HR 70, BP 155/73, RR 20, O2Sat 94% RA General: Elderly lady in no acute distress. Alert and oriented x 3. In moderate pain, hoarse sounding (baseline voice?) Cardiac: RRR Resp: in no respiratory distress Abd: Soft, nontender, non-distended, no rebound or guarding Ext: warm and well perfused; pneumo boots not in place (refused by pt) Incision: clean, dry and intact; edema and ecchymosis that is stable compared to previous exams at inferior incision. Pertinent Results: [**2179-8-19**] CXR: FINDINGS: In comparison with the study of [**8-9**], there is no evidence of elevation of the left hemidiaphragm. However, the medial aspect of the hemidiaphragm is not as sharply seen, suggesting some static change in this region. No evidence of vascular congestion or pneumothorax. [**2179-8-19**] thyroid pathology: pending [**2179-8-22**] Ca: 8.2 WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2179-8-20**] 8.4 3.01* 7.6* 25.0* 83 25.2* 30.3* 17.9* 289 Brief Hospital Course: Mrs.[**Known lastname 4145**] was admitted to the surgery service following a total thyroidectomy and right modified radical neck dissection for her papillary thyroid carcinoma. She tolerated the procedure well. Swelling of the inferior aspect of the incision was noted on POD0, but the swelling and ecchymosis remained soft, warm and stable throughout her stay. She denied symptoms of hypocalcemia, and her pain was well controlled once the patient was placed on her home dose of prednisone; the majority of her post-operative pain appeared to stem from her arthritis. Mrs.[**Known lastname 4145**] had an episode of O2 desaturation down to 88% on POD2; this resolved quickly after humidified air and deep coughing produced a large mucus plug. She remained hemodynamically stable throughout her admission. Of note, patient refused to be moved out of bed to chair day prior to discharge and also declined pneumatic boots for DVT prophylaxis. Medications on Admission: Prednisone 5mg daily, Albuterol inh q6hr prn, Ipratropium inh q6hr prn, Trazodone 50 qhs prn, Levothyroxine 112 mcg daily, Mirtazapine 7.5 qhs, Donepezil 10mg qhs, Lisinopril 10mg daily, Simvastatin 20mg daily, Amiodarone 200 [**Last Name (LF) **], [**First Name3 (LF) **] 81mg daily, Ca 500mg daily, Cholecalciferol 400 U daily, Fe Sulfate 300mg TID, docusate 100mg [**Hospital1 **] prn, Senna 8.6mg [**Hospital1 **] prn, Omeprazole 40mg [**Hospital1 **], Acetaminophen 325 q4hr prn, Polyvinyl Alcohol-Povidone 1.4-0.6 % eye gtt, Lispro, Glucagon, Metoprolol 12.5mg daily, levothyroxine 125mcg daily, Heparin TID Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol Sulfate Inhalation 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 4. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 7. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO [**Hospital1 6089**]. 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Calcium Carbonate 500 mg (1,250 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 13. Cholecalciferol (Vitamin D3) 400 unit Capsule Sig: One (1) Capsule PO once a day. 14. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. 17. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO twice a day. 18. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 19. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: One (1) Ophthalmic once a day. 20. Insulin Lispro Subcutaneous 21. Glucagon (Human Recombinant) Injection 22. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO once a day. 23. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 24. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: Papillary thyroid carcinoma with regional lymph node metastases Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the surgery service following a total thyroidectomy and right modified radical neck dissection. Please call your doctor or go to the emergency department if: *You experience new chest pain, pressure, squeezing or tightness. *You develop new or worsening cough, shortness of breath, or wheeze. *You are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. *Your pain is not improving within 12 hours or is not under control within 24 hours. *Your pain worsens or changes location. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *You develop any concerning symptoms, such as symptoms associated with low calcium: tingling near your mouth or fingertips, muscle spasms in your hands. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: *Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until cleared by your surgeon. *You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please call Dr.[**Name (NI) 6045**] office for a follow-up appointment: ([**Telephone/Fax (1) 15350**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5340**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2179-9-14**] 2:20 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2180-3-17**] 10:00 [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]

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icd9cm

[ [ [] ] ]

[ "06.4", "40.41" ]

icd9pcs

[ [ [] ] ]

6896, 7018

3344, 4290

337, 439

7126, 7126

2819, 3321

9730, 9779

2164, 2305

4954, 6873

7039, 7105

4316, 4931

7302, 8424

9218, 9707

2320, 2800

8456, 9203

282, 299

9803, 10243

467, 1191

7141, 7278

1213, 1710

1726, 2148

31,037

131,245

33983

Discharge summary

report

Admission Date: [**2190-5-6**] Discharge Date: [**2190-5-12**] Date of Birth: [**2171-11-23**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Subdural Hematoma and IPH Major Surgical or Invasive Procedure: none History of Present Illness: 18 y/o male skateboarding without helmet, fell off skateboard hit head on concrete with positive loss of consciousness. Awoke after 2 minutes was medflighted directly here. On arrival according to report he was GCS of 14. Past Medical History: Depression and ADHD Social History: Father died of traumatic brain injury 4 years ago lives with his Mother. Smokes marijuana frequently, no cigarettes, alcohol on weekend Family History: non-contributory Physical Exam: O: T: BP: 134/71 HR:51 R24 O2Sats 100% Gen: Having foley place, swearing prefers eyes closed HEENT: Pupils: [**5-7**] EOMs full, occiptal hematoma, no hemotympan Neck: In collar with paplable pain Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Prefers eyes closed, percerbative, swears intermittently but cooperative Orientation: Oriented to person, and date. Recall: 0/3 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, to 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 [**5-10**] throughout. No pronator drift Sensation: Intact to light touch, Reflexes: B T Br Pa Ac Right 2+ 2+ Left 2+ 2+ Toes downgoing bilaterally Coordination: normal on finger-nose-finger Pertinent Results: [**2190-5-11**] 06:10AM BLOOD WBC-9.7 RBC-5.33 Hgb-15.5 Hct-43.5 MCV-82 MCH-29.0 MCHC-35.6* RDW-13.9 Plt Ct-357 [**2190-5-8**] 01:58AM BLOOD PT-13.5* PTT-25.4 INR(PT)-1.2* [**2190-5-11**] 06:10AM BLOOD Glucose-102 UreaN-16 Creat-0.7 Na-135 K-4.0 Cl-99 HCO3-24 AnGap-16 [**2190-5-6**] 06:10PM BLOOD Amylase-67 [**2190-5-10**] 01:38AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.2 [**2190-5-6**] 06:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2190-5-6**] 06:18PM BLOOD Glucose-157* Lactate-2.4* Na-139 K-3.2* Cl-102 calHCO3-25 [**2190-5-6**] 06:18PM BLOOD freeCa-1.11* ===== CT C-spine: IMPRESSION: No cervical spine fracture or malalignment. CT head ([**2190-5-6**]): IMPRESSION: 1. Small acute right subdural hematoma, with traumatic subarachnoid hemorrhage and right inferior frontal intraparenchymal hemorrhage. Together, these exert moderate local mass effect, with 4-mm leftward subfalcine herniation, and likely early right uncal herniation. 2. Left skull base fracture, extending from diastasis of the left occipital mastoid suture, through the left temporal bone, left petrous apex, and terminating in the sphenoid sinus, which is opacified with blood. Small focus of air is seen in the left carotid canal, with fracture extending through this region, and CTA is recommended to exclude injury to the carotid artery. CTA neck ([**2190-5-6**]) IMPRESSION: No evidence of carotid artery injury. For further description of the skull base fracture please see concurrent CT of the temporal bones. head CT repeat ORBITS/SELLA ([**2190-5-6**]): IMPRESSION: Redemonstration of the left skull base fracture extending from a diastasis of the left occipital mastoid suture and through the left temporal bone, petrous apex and terminating in the sphenoid sinus. Again, there is concern for injury to the carotid canal which has a small focus of air. Please see concurrent CTA of the neck to evaluate for carotid injury. CT head ([**2190-5-7**]): IMPRESSION: Since the previous study right frontal hemorrhagic contusion and right-sided acute subdural hematoma are unchanged in size and extent. There is decrease in cerebral edema and decrease in mass effect with better visualization of the basal cisterns compared to the prior study. CT head ([**2190-5-8**]): IMPRESSION: No significant interval change since [**2190-5-7**]. Stable right frontal intraparenchymal and right frontal subdural hemorrhages. No new hemorrhage. CT head ([**2190-5-11**]): IMPRESSION: No significant interval change since [**2190-5-8**]. Stable right frontal intraparenchymal and subdural hemorrhages with no new hemorrhage or mass effect. Brief Hospital Course: Patient was initially admitted for the Trauma ICU for close clinical observation. His only complaint was headache, likely related to his traumatic subarachnoid hemorrhage. He sustained very little deficits after his fall. Mom was at the bedside most of the time and found his personality to be a bit more impulsive than his baseline. It was explained to mom that this change in his behavior might be secondary to his intraparenchymal hemorrhage. He is already followed up by a psychologist as an outpatient, and it was recommended to mom that he gets a repeat evaluation upon discharge. Additionally, due to difficulty with headache management, the pain team was consulted. There were recommendations to start toradol and trial fioricet. This appeared to work better for him than percocet, and he was sent home on such. Medications on Admission: Celexa and intermittent Concerta Discharge Medications: 1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*1* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): in order to assist with regular bowel movements. 5. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-6**] Tablets PO Q8H (every 8 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 6. Motrin 400 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:*150 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1) basilar skull fracture 2) right-sided subdural hematoma 3) right inferior frontal intraparenchymal hemorrhage. 4) traumatic subarachnoid hemorrhage. Discharge Condition: good; no difficulties with vision, speech, ambulation, strength. Mainly complaining of headache that was treated well with a dose of fioricet. Discharge Instructions: You sustained a basilar skull fracture, a small right sided subdural hematoma, a right inferior frontal intraparenchymal hemorrhage and a traumatic subarachnoid hemorrhage. You may continue to have headaches, and this is why we consulted the pain service during this admission. Please use your medications only as truly needed. Remember that Fioricet is a combination drug (tylenol - caffeine- and butalbital). You must be careful not to take extra tylenol in combination with this. Also, please avoid alcohol intake in association with this medication. We are also recommending that you take motrin to assist with the inflammation associated with your injury. This medication must also be used sparingly because you may also suffer from rebound headaches due to overuse of this drug. *** Please contact the neurosurgery office or return to the nearest emergency room if you experience any difficulty with your vision; any weakness on a particular side of your body; any involuntary movements of a particular side of your body; difficulty with walking; or difficulty with talking. Followup Instructions: Please call the office of Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1669**]) for follow-up as an outpatient. You will need a reevaluation and also a check up on your dilantin level. Completed by:[**2190-6-8**]

[ "314.01", "873.0", "348.4", "296.80", "276.1", "801.22", "E885.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6513, 6519

4905, 5734

346, 353

6715, 6861

2236, 4882

7998, 8221

818, 836

5817, 6490

6540, 6694

5760, 5794

6885, 7975

851, 1162

280, 308

381, 605

1459, 2217

1177, 1443

627, 649

665, 802

1,580

111,714

20386

Discharge summary

report

Admission Date: [**2126-2-23**] Discharge Date: [**2126-3-7**] Date of Birth: [**2081-5-14**] Sex: Service: HISTORY OF PRESENT ILLNESS: A 44-year-old female with history of hepatitis C diagnosed 2 months ago, treated with interferon and ribavirin for 2 months, who presented from outside hospital with acute pancreatitis. The patient reports 2-month history of abdominal pain with weekly interferon and ribavirin injections, followed by abdominal and back pain, nausea, vomiting, decreased appetite, and increased abdominal distention. On [**2126-2-21**], the patient was admitted in an outside hospital with 10/10 abdominal pain, fever, and severe nausea and vomiting. Labs at the outside hospital were significant for hematocrit of 39, white blood cell count of 8.6, glucose of 129, calcium 9.1, lipase of 740, AST of 198, oxygen saturation 98 percent on room air. CAT scan from the 18 showed peripancreatic fluid surrounding the pancreas at the head with stranding. Abdominal ultrasound was negative in terms of gallbladder disease. The patient was treated with IV fluids, pain control, imipenem 500 IV q.6 h. with progressive decline in function and, therefore, was transferred to [**Hospital1 18**] ICU for further management. In the ICU, the patient's course was notable for persistent hypoxia, worsening abdominal distention, post initiation of tube feeds via postpyloric feeding tube. Additionally, the patient had been persistently febrile, despite treatment with imipenem. There is no clear-cut source of her infection thus far. Repeat CT of the abdomen did not reveal necrotic pancreas from [**2126-2-24**]. Upon transfer, the patient was reporting abdominal pain to be controlled with a PCA. She was denying sensation of shortness of breath, chest pain, nausea, or vomiting. Her last bowel movement was on transfer. Noted that her abdomen was more distended this a.m. PAST MEDICAL HISTORY: Hepatitis C x2 months on ribavirin and interferon. Fibromyalgia. TAH. Lumpectomy. SOCIAL HISTORY: Negative for tobacco or alcohol use. The patient is currently in the process of getting a divorce. FAMILY HISTORY: Noncontributory. ALLERGIES: TO SULFA, WHICH CAUSES A RASH. PHYSICAL EXAMINATION: From transfer, T max 102.2, heart rate 107 to 111, blood pressure 128/62, respiratory rate 18 to 24, 93 to 96 percent on 6 liters nasal cannula, 24 hour I&Os 4 liters and 2.8 liters for the length of stay; however, the patient was positive at 6 liters. General: In no apparent distress. HEENT: Negative. Cardiac exam: Regular tachycardia, no murmurs. Pulmonary exam: Upper expiratory wheezes, bibasilar crackles, and egophony E to A, abdominal distention, decreased bowel sounds, mild epigastric tenderness to palpation, no ecchymosis in the flank or back region. Extremities: Trace edema, no calf tenderness, 1+ dorsalis pedis. The patient has a NG tube in place, Foley in place, and a PICC line in place. LABORATORY DATA: From admission, white blood cell count 6.3, hematocrit of 30.8, MCV 95, platelets 156. Chemistry profile within normal limits with a calcium of 7.2, magnesium 2.1, phosphorus 0.8. HOSPITAL COURSE: Acute pancreatitis. There was no obvious risk factors, however, the thought was entertained and perhaps this was secondary to interferon and ribavirin injections. The patient ransom criteria on presentation was 0, at 48 hours it was 3 to 4. On [**2126-2-24**], CT showed no necrosis and appeared to be to be stabilized clinically. The patient's lipase from the 22nd was 70 at the outside hospital was as high as 700. Her abdominal distention was concerning for possible ileus; however, the patient was passing stool and felt that overall her abdominal exam was improving. There was no evidence of Clostridium difficile colitis. However, given her persistent fevers and elevated white blood cell count, this was monitored closely as well as for potentially worsening hepatobiliary disease. The patient was maintained on IV fluids, Dilaudid PCA, Zofran, and Phenergan for antiemetic support. The patient was maintained on imipenem. KUB did not reveal any evidence of obstruction. GI service continued to follow the patient and recommended continuing tube feeds to maintain integrity of the gut flora. Hypoxia. The patient was hypoxic in the ICU. DIFFERENTIAL DIAGNOSES: Pneumonia. Congestive heart failure. Atelectasis versus pulmonary embolus. A chest x-ray did show effusions and left lower lobe atelectasis and vascular prominence mainly in the left perihilar region. Question was what could this be, early ARDS versus cardiogenic pulmonary edema mostly likely from 3rd spacing, however, given the patient's overall 6 liter positive IV fluid intake, the patient maintained adequate urine output. Repeat echocardiogram was obtained. The patient reportedly had had a normal one in the outside hospital, but given her new findings on chest x-ray and clinically a repeat study was performed, which showed preserved systolic function, normal valves, and no wall motion abnormalities. Fever. This is likely from pancreatitis, but the patient was persistently pan cultured, her urine did grow enterococcus for which she was adequately covered with antibiotics. She also had E. coli in her urine with repeat urine cultures, no growth to date. The patient's fever curve began to decrease as her symptoms began to improve with loss of abdominal distention and less diarrhea. All of her blood cultures remain negative to date. Given the patient's positive urine culture, the Foley catheter was removed. Nutrition. The patient was on NG tube feeds; however, the NG tube fell out on the evening of the 20th and the patient refused to have a second one placed. Therefore, the patient was maintained on TPN and was slowly advanced to a BRAT diet, which she tolerated. Depression and anxiety. The patient was instructed to follow up with her outpatient therapist. Abdominal pain. Thought was that this is likely related to the patient's known condition of hepatitis C and surrounding inflammation in the area. Persistently followed her LFTs without any major abnormalities detected. Repeat imaging was not warranted. DISCHARGE DIAGNOSES: Acute pancreatitis. Urinary tract infection. Hepatitis C. Fibromyalgia. Depression and anxiety disorder. DISCHARGE STATUS: The patient will be discharged to home. DISCHARGE CONDITION: The patient is stable without an oxygen requirement, tolerating a p.o. diet. RECOMMENDED FOLLOWUP: The patient is instructed to follow up with her PCP as well as Gastroenterology in 1 to 2 weeks since discharge. SURGICAL OR INVASIVE PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: PICC line placement for TPN. Postpyloric feeding tube. DISCHARGE MEDICATIONS: 1. Lorazepam 0.5 mg q.6 h. p.r.n. for anxiety. 2. Senna p.r.n. for constipation. 3. Percocet 1-2 tablets q.[**3-12**] h. p.r.n. for pain. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5704**], [**MD Number(1) 5705**] Dictated By:[**Last Name (NamePattern1) 12866**] MEDQUIST36 D: [**2126-5-29**] 12:58:47 T: [**2126-5-29**] 16:25:39 Job#: [**Job Number **]

[ "428.0", "729.1", "599.0", "577.0", "070.54" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "99.15" ]

icd9pcs

[ [ [] ] ]

6420, 6763

2154, 2216

6232, 6398

6786, 7193

3176, 6210

2239, 3158

156, 1913

1936, 2019

2036, 2137

3,425

182,758

13833

Discharge summary

report

Admission Date: [**2144-1-21**] Discharge Date: [**2144-4-13**] Date of Birth: [**2094-5-22**] Sex: M Service: SURGERY Allergies: Morphine Sulfate / Adhesive Tape Attending:[**First Name3 (LF) 974**] Chief Complaint: Fistula Major Surgical or Invasive Procedure: [**1-21**] PICC placed [**2-12**] 10-F biliary catheter advanced into jejunum [**2-14**] Antegrade placement of a 10Fr locking pigtail catheter, 35 cm in length for tube feeding [**2144-2-21**] Wound EUA [**2144-3-3**] IR feeding tube [**3-12**] RUE PICC site erythema/swelling/pus -> new PICC line History of Present Illness: 49y M with history of Crohn's disease s/p multipled surgeries, dilations/diversions/fistula, recently operated on for enterocutaneous fistula on [**2144-1-2**]. He was discharged home on [**2144-1-6**] after ileoanal pouch resection, segmental SB resection, takedown and reconstruction of ileostomy, extensive enterolyss, and cystoscopy w/ urethral stents complicatd by bladder rupture. Pt reported weakness and pain in his legs that worsened after discharge. Pt mistakenly took too much of his PO dilaudid secondary to the pain. His wife found him unresponsive and he was admitted to [**Hospital6 **] on [**2144-1-15**], during which he was found to have bilateral DVTs by ultrasound, he was started on Coumadin until therapeutic. He was also found to have a UTI, resistent to ciprfloxaxacin, but sensitive to Ampicillin and per ID was started on Amox 500 tid. The patient was disharged to [**Hospital **] Rehab, yesterday [**1-20**] developed leakage from the superior aspect of his abdominal wound, from the area previously covered by the VAC. Pt had no fevers, chills, sweats, or abdominal or other evidence of infection. His vitals were normal and he was afebrile. Past Medical History: *PE *IVC filter *Severe Crohn's disease *s/p proctocolectomy and ileoanal pouch formation [**2125**] *Exploratory laparotomy and lysis of adhesions [**2137**]. *Recurrent small bowel and pouch strictures requiring dilitations. Colonoscopy and balloon dilation (last [**2-8**], [**4-9**] and [**5-10**]) *SB resection, end ileostomy [**2142-10-2**] *Gout *Depression *Anxiety Social History: Lives at home with family; they are very involved and supportive. Pt has a remote 10 pack-year smoking history, but quit approximately twenty-five yrs ago. Occasional ETOH. Denies illicit drugs. Family History: No family history of inflammatory bowel disease or colon cancer. Positive for diabetes and coronary artery disease. Physical Exam: On admission: PE: 97.4, 110, 102/60, 18 96% RA GEN: NAD resting comfortably HEENT: NCAT, PERRL, EOMI, OP wnl PULM: CTA bilaterally, no r/r/w CARDs: RRR, s1,s2 wnl, no m/r/g ABD: large healing incision, w/ 5cmx5cm large area superiorly. open, with granulatin tissuue at base, and small, ?cm area of ? bowel/fistula, from which yellow-green liquid draining. Inferior aspect of wound w/ granulation tissue, but appears intact. EXT: DP 2+ bil SKIN: warm and dry Pertinent Results: [**2-26**] Fistulogram: anterograde flow [**3-5**] Fistulogram: forward antegrade flow of contrast through non-dilated efferent bowel loops and normal intestinal fold pattern. No evidence of obstruction of the efferent limb of the fistula. [**3-23**] CT abd: Supraumbilical midline enterocutaneous fistula, connecting with a loop of small bowel immediately subjacent to the anterior abdominal wall. [**3-26**] BLE U/S: Non-occlusive 1cm thrombus L common femoral DVT to greater saphenous vein. No DVT in RLE. Brief Hospital Course: Patient admitted [**1-21**] with a diagnosis of new Enterocutaneous fistula and chronic intraabdominal fluid collections. He was noted to have an acute on chronic DVT in both CFA's into both iliacs and even extending into IVC to level of IVC filter. A PICC was placed on HD 1 ([**1-22**]) for TPN and Abx. A dobhoff was also placed for enteral access. Urology saw the patient for penile / scrotal edema which resolved with elevation and antifungal cream. He was continued on coumadin with a goal of 2.0 to 3.0. On [**1-24**] a GI consult was obtained who had no acute inteventions but would follow up as an outpatient. On [**4-12**] Tube feeds were attempted but caused profuse fistula output and it was eventually removed on [**2-9**]. In order to improve the fistual output, a long dobhoff was advanced through the ostomy to the mid jejunum under IR guidance on [**2-12**], but this did not hold and eventually feel out on [**2-13**]. It was attempted again on [**2-14**] and this was sutured in place with better result. He had some increased nursing concern on [**2-16**] and was transferred to the ICU for less than 24 hours. TPN was begun [**2-18**] and tube feeding and continued until he tolerated oral food [**4-5**]. He went to the operating room on [**2-21**] for EUA and removal of foreing body from fistulous tract; small bowel sewed over Feeding tube, which was secured in place. He tolerated this procedure well (see OP note for futher information). He had multiple issues with the feeding tube over the ensuing week, and it was finally secured and stayed [**3-4**]. However, he did not toelrate tube feeds as they caused large output and they were held, TPN continued. On [**3-11**] his J-tube removed, and Tubefeeds were stopped and we started octreotide. A PICC line was removed for induration/erythema and replaced via IR. On [**3-17**] the PICC site was swollen/painful, but an U/S demonstrated no DVT, and so he was treated with elevation/compression of the extremity as needed. A hematology consult was obtained for chronic anemia with eventual iron supplementation for anemia. A CT performed on [**3-23**] demonstrated a supraumbilical midline enterocutaneous fistula, connecting with a loop of small bowel immediately subjacent to the anterior abdominal wall. Patient was preoperatively evaluated for enterocutaneous fistula takedown. Urology again consulted for planned procedure and possible stenting. No urological management was recommended. Hematology was consulted for recommendations regarding treatment of his anemia. On [**3-26**] a repeat US of the lower extremtimities revealed a 1 cm thrombus in Left common femoral to greater saphenous vein. Warfarin therapy continued. On [**3-31**] he was taken to the OR for an exploratory laparatomy, fistula takedown, and LOA (see OP note for futher information). He tolerated the procedure well and was transferred back to the floor postoperatively. As his ostomy output improved he was transitioned to oral food and TPN discontinued. He continued to do well and all his medications were changed to oral. By [**2144-4-13**] he was cleared for discharge. He was carefully made aware of what to watch out for regarding his abdomen and ostomy. He was told to hold his coumadin dose [**4-13**] and [**4-14**] and then to take his normal dose for an INR of 3.4 He was told to specifically follow up with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17108**] on [**4-16**], and Dr. [**Last Name (STitle) 17108**] was spoken with as well, who agreed with this plan to follow his INR / coumadin. He will see Dr. [**Last Name (STitle) **] in follow up in two weeks. He was ammenable to discharge and left [**4-13**] in the afternoon. Medications on Admission: [**Last Name (un) 1724**]: allopurinol 300, amoxicillin500''', dalteparin 900u SQ [**Hospital1 **], lasix 60, lidocaine patch 5%, 2 (both thighs, on for 12 hours between 9am-9pm), ditropan 5''', protonix 40, paxil 20, trazedone 25 qhs, ambien 2.5 qhs. Tylenol 650 q4, dilaudid 4-6mg q3, lactulose 20g', maaolox PRN. Coumadin (dose from [**Hospital3 **]) 2mg on Tues,Sat, 1mg M/W/Th/F/[**Doctor First Name **]. Discharge Medications: 1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 7. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for agitation. 8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety / agitation. 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM starting [**2144-4-15**]. HOLD [**4-13**], [**4-14**]. 14. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO BID (2 times a day). 15. Oxycodone 5 mg/5 mL Solution Sig: [**12-6**] PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: 1) Crohn's Disease 2) enterocutaneous fistula 3) chronic DVT 4) malnutrition Discharge Condition: stable Discharge Instructions: Return to ER if: - persistent fever > 101.4 - severe abdominal pain, nausea, vomiting - shortness of breath, chest pain, vision changes - significant increased or decreased ostomy output Followup Instructions: 1) Please call ([**Telephone/Fax (1) 14703**] to make a follow up appointment in the [**Hospital **] clinic in 2 weeks 2) Please call Dr.[**Name (NI) 18535**] office [**Telephone/Fax (1) 18052**] to make an appointment in two weeks time 3) Please see your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17108**] ([**Telephone/Fax (1) 41537**], this week, Thursday [**4-16**] or Friday [**4-17**].

[ "453.2", "V58.61", "V12.51", "568.0", "263.9", "E879.8", "274.9", "V02.54", "453.41", "V55.2", "555.0", "599.0", "999.31", "041.4", "V09.80", "530.81", "280.0", "309.28", "V02.59", "569.81", "608.86", "553.21", "607.83" ]

icd9cm

[ [ [] ] ]

[ "53.59", "96.6", "54.59", "46.73", "46.74", "99.15", "38.93", "97.03", "54.0" ]

icd9pcs

[ [ [] ] ]

9167, 9242

3577, 7331

300, 600

9363, 9372

3041, 3554

9607, 10022

2428, 2547

7791, 9144

9263, 9342

7357, 7768

9396, 9584

2562, 2562

252, 262

628, 1800

2576, 3022

1822, 2199

2215, 2412

4,103

174,106

44101

Discharge summary

report

Admission Date: [**2140-5-6**] Discharge Date: [**2140-5-11**] Date of Birth: [**2067-7-16**] Sex: M Service: MEDICINE Allergies: Pollen Extracts / Benzodiazepines Attending:[**First Name3 (LF) 1148**] Chief Complaint: suicide attempt Major Surgical or Invasive Procedure: Intubation for airway protection History of Present Illness: 72 YOM who presents after suicide attempt. He was found unresponsive by wife this am with an empty bottle of temazepam at his side. He was given 2 of narcan by EMS without any improvement. Recent hx of suicidal expression and was admitted to [**Hospital Unit Name 153**] in [**5-/2139**] for similar episode. Intubated in ED for respiratory protection. Apparently has been haveing increasing depression over last couple of months in regards to failing health (Prostate CA, bad knees, hearing loss). He is being transferred to the [**Hospital Unit Name 153**] for observation of respiratory status overnight since the half-life of flumazenil is about [**11-24**] the half life of temazepam (8-25h). . Med list from EMS: cipro, sulfa, flomax, tamazepam, flurazepam. His wife is searching at home for any additional medications. . In the ED: - intubated for respiratory protection - UTox and STox only showed benzodiazepines -> Toxicology consult came by to see him and decided not to administer flumazenil out of concern for benzodiazepine withdrawl or of unmasking an underlying seizure disorder. - administered charcoal - while in the ED -> he was hypotensive while on propofol -> changed to etomidate bolii for sedation - he was bradycardiac in the ED to 48 (while at CT scanner) -> but otherwise has been in the 50s -> his wife is checking at home for additional medications. - CT Head: negative for ICH (wet read) - EKG: NSR - 2 PIVs Past Medical History: 1. Prostate cancer s/p brachytherapy on [**2138-5-19**]. s/p TURP 2. appendectomy 3. b/l hernia 4. tendonitis 5. Recurrent major depression - since early [**2112**] analyst on and off since [**2102**], Dr. [**First Name8 (NamePattern2) 20180**] [**Last Name (NamePattern1) 7739**], who practices out of [**Hospital1 8**] ([**Telephone/Fax (1) 94591**] 6. Recurrent UTIs Social History: Born in NY. Moved to [**Location (un) 86**] area as child when his father began Ophthalmology training. Only child of married parents. Mo and Fa died of medical illness in the [**2102**]'s or 80's. Pt said he began medical training but dropped out when he felt it was too difficult. Later went to grad school for Master's in French Lit. Worked "on and off" (not clear what field) but had problems working consistently due to mental illness. Married; has adult children and 1 granddaughter. . Denies any hx of frank substance abuse and reports that he drinks ETOH only very rarely now. However, he does admit that for some period in the past, he took a cocktail of "valium, alprazolam, and a small amount of vodka" each night to help him sleep. Says he no longer does this as he quit drinking ETOH many yrs ago. Denies any abuse of his Restoril but does say he has occasionally had to take a double dose to get to sleep. Family History: noncontributory Physical Exam: Vitals: T:94.4 P:61 BP:105/72 R: SaO2:100% General: Sedated, intubated HEENT: Pupils pinpoint. OP with ET tube Neck: supple, no JVD Pulmonary: Lungs: good air movement bilaterally Cardiac: RRR, nl. S1S2 Quiet heart sounds Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Neurologic: -mental status: Cannot assess -cranial nerves: cant assess -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -sensory: cant asses. Pertinent Results: [**2140-5-10**] 07:35AM BLOOD WBC-8.5 RBC-3.99* Hgb-13.4* Hct-38.4* MCV-96 MCH-33.6* MCHC-34.9 RDW-13.0 Plt Ct-245 [**2140-5-10**] 07:35AM BLOOD Glucose-108* UreaN-7 Creat-0.7 Na-139 K-3.7 Cl-102 HCO3-29 AnGap-12 [**2140-5-6**] 11:30AM BLOOD CK(CPK)-222* Amylase-102* [**2140-5-6**] 11:30AM BLOOD CK-MB-6 cTropnT-<0.01 [**2140-5-10**] 07:35AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.2 [**2140-5-6**] 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG urine culture ngtd . Head CT: IMPRESSION: No evidence of intracranial hemorrhage or mass effect. . CHEST AP: The endotracheal tube has been advanced with the tip now approximately 5 cm above the carina. Nasogastric tube is well positioned within the stomach. The appearance of the chest is otherwise stable compared to one and a half hours earlier. . CXR: IMPRESSION: No active pulmonary disease. Brief Hospital Course: 72yo male admitted after benzo overdose in suicide attempt. In the ED, he was intubated for airway protection. His UTox and STox only showed benzodiazepines. Toxicology consult came by to see him and decided not to administer flumazenil out of concern for benzodiazepine withdrawl or of unmasking an underlying seizure disorder. He recieved charcoal. He briefly became hypotensive while on propofol -> changed to etomidate for sedation. He was bradycardiac in the ED to 48 (while at CT scanner) which resolved. He had a prolonged QTc (520) which also resolved back to normal. His CT Head was negative for ICH. . In the [**Hospital Unit Name 153**], he was monitored and then extubated on [**5-7**]. He was given 3 days of ceftriaxone for a UTI. Psych saw him and felt that he may not leave AMA and needed in patient psych admission. He did not require any benzos for withdrawal nor any haldol for agitation; on morning of admit he did get 2mg ativan for some anxiety. Believe major depressive disorder; recommend avoiding restarting benzos in his treatment protocol. His TSH was normal, orthostatics were normal. Restarted tamsulosin for BPH as well; patient able to void independently without foley. Medications on Admission: temazepam proscar flomax Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Until patient regularly ambulating. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO QID PRN (). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Bismuth Subsalicylate 262 mg Tablet, Chewable Sig: One (1) Tablet PO TID (3 times a day) as needed. 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO BID (2 times a day). 8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Discharge Disposition: Extended Care Discharge Diagnosis: Benzodiazepine overdose Suicide attempt/ideation Depression Urinary tract infection Discharge Condition: Stable Discharge Instructions: Patient admitted after suicide attempt with benzodiazepine overdose. Please have patient see doctor or return to the hospital if develops increased depression, suicidal language, signs of benzo withdrawal such as tremulousness, tachycardia, hypertension. Followup Instructions: Once you are discharged from a psych facility, please arrange a follow up appointment with your primary care doctor in [**12-26**] weeks ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**] [**Telephone/Fax (1) 15863**]).

[ "458.9", "780.01", "780.79", "780.4", "V10.46", "E950.3", "599.0", "296.30", "427.89", "969.4" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

6687, 6702

4652, 5861

309, 344

6830, 6839

3756, 4251

7143, 7386

3159, 3176

5937, 6664

6723, 6809

5887, 5914

6863, 7120

3621, 3737

3191, 3575

254, 271

372, 1752

1761, 1811

4260, 4629

3590, 3604

1833, 2205

2221, 3143

164

182,743

22655

Discharge summary

report

Admission Date: [**2116-12-28**] Discharge Date: [**2117-1-16**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: SOB, DOE Major Surgical or Invasive Procedure: VATS History of Present Illness: 82 yo man with history of prostate CA, hyperlipidemia, recently diagnosed Afib (incidentally found while doing an elective hand surgery)several mos ago, who presented to [**Hospital1 2025**] several weeks ago ([**2116-12-12**]) with pleuritic chest pain and cough with productive green/yellow sputum; had a RUL PNA and STEMI (Troponin peak at 70 with an EKG that showed 2 mm ST segment elevation in V2-V5); med management. Was d/c'ed on ASA and coumadin. In house, pt had adenosine MIBI, which showed anterior apical and inferoapical fixed defect with peri-infarct, a reversible defect; EF 65%. CXR showed likely PNA (Prior xray [**10-8**] done at WH showed interstitial markings c/w fibrosis). ECHO showed mild MR [**First Name (Titles) 151**] [**Last Name (Titles) **] of 63%, mod dilated RV with depressed RVSF and mild PAH, moderately dilated RA, mod depressed LV function. Since discharge, pt has been doing poorly, and was re-admitted to the [**Hospital1 18**] c/o SOB and DOE. Was in CCU from [**12-29**] till [**1-2**] when was transferred to MICU for management of ? underlying pulm process. His initial presentation was felt to be consistant with subacute MI and periMI CHF as well as PNA. He has been on NRB from admission till [**1-1**] pm when he failed a trial of BIPAP and was intubated. He was net > 3L negative without improvement in oxygenation. Pt was initially on dopa and vasopressin; now vasopressin weaned off. Was initially on levofloxacin; switched to zosyn/vanco on [**12-31**]. Initial CXR showed diffuse alveolar opacities. [**12-31**] CT shows diffuse ground glass, multifocal consolidations, loculated effusions. After intubation, an attempt was made to place cordis (unsuccessful); needs SGC to r/o decompensated CHF; then bronch and possible VATS. Past Medical History: prostate cancer 3 yrs ago AFIB on coumadin STEMI 1 mos ago: never cath'ed TTE EF decreased to 40%, o/w unchanged from previous Social History: occasional etoh, never smoked; lives with family Family History: N/C Pertinent Results: [**2116-12-28**] 12:50PM WBC-16.4* RBC-3.59* HGB-11.4* HCT-33.8* MCV-94 MCH-31.7 MCHC-33.7 RDW-13.5 [**2116-12-28**] 12:50PM PLT COUNT-145* [**2116-12-28**] 12:50PM NEUTS-84.1* LYMPHS-11.7* MONOS-4.0 EOS-0.1 BASOS-0.1 [**2116-12-28**] 12:50PM PT-33.5* PTT-46.1* INR(PT)-7.1 . [**2116-12-28**] 12:50PM GLUCOSE-123* UREA N-25* CREAT-0.6 SODIUM-138 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-26 ANION GAP-14 . [**2116-12-28**] 12:50PM CORTISOL-40.6* [**2116-12-28**] 04:53PM LACTATE-1.0 [**2116-12-28**] 12:50PM CK(CPK)-69 [**2116-12-28**] 12:50PM CK-MB-NotDone cTropnT-0.12* . [**2116-12-28**] 01:11PM URINE COLOR-LtAmb APPEAR-Clear SP [**Last Name (un) 155**]-1.023 [**2116-12-28**] 01:11PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2116-12-28**] 01:11PM URINE RBC-[**2-6**]* WBC-[**5-14**]* BACTERIA-RARE YEAST-NONE EPI-0-2 TRANS EPI-[**2-6**] [**2116-12-28**] 04:53PM PO2-65* PCO2-44 PH-7.42 TOTAL CO2-30 BASE XS-3 Brief Hospital Course: 1. Respiratory failure: Initial differential diagnosis included (and was felt likely a combination of these): CHF in the setting of a recent MI, PNA, ARDS, interstitial disease or PE given RLE DVT. There was a question of iatrogenic pneumothorax during L subclavian line placement, which resolved on serial chest x-rayds. Pt was clinically diagnosed with ARDS and put on ARDS net ventilation (6cc/kg). Pt required increased PEEP of at least 10 to maintain oxygenation. Esophageal balloon was placed for a period of time to measure more accurate PEEP. FiO2 was titrated down to 0.50. He was empirically treated for pneumonia with broad spectrum antibiotics of vanco, zosyn, levo. Pt was found to be hypotensive requiring pressors and it was unclear if he was in heart failure vs sepsis. A swan ganz catheter was placed, which was more consistent with septic physiology. Pt was unable to be diuresed secondary to his persistently lowish blood pressures both on and off pressors. Bronch was performed on [**1-3**] which was negative for legionella, fugus, viruses, DFA, PCP. [**Name10 (NameIs) 23463**] fluid was exudative by Light's criteria. Sputum culture from [**1-3**] found 2+ GNR and all other culture data including blood and urine remained negative during the hospitalization. Pt's ESR was 84 and was ANCA and [**Doctor First Name **] negative. Serial CXRs remained unchanged showed patchy alveolar and interstitial opacity of the left chest greater than the right, consistent with ARDS. CTA was negative for PE and showed biltaeraly [**Doctor First Name **] effusion, persistent diffuse ground glass opacity with multifocal parenchymal consolidation in an asymmetric pattern consistent with diffuse multifocal pneumonia, ARDS, and less likely asymmetric congestive heart failure. Repeat echo was unchanged with slightly depressed LV systolic function (>50%), 3+ TR, and no pericardial effusion. Pt had a VATS procedure performed by thoracic surgery on [**1-11**] with a lung biopsy which showed chronic fibrosing lung disease predominantly of end stage lung tissue with honeycomb change. Very little alveolar tissue was present in the biopsy but showed focal evidence of organizing pneumonitis, raising the possibility of a superimposed acute process such as infection. Some of the histologic features of the chronic fibrosing lung disease raised the possibility of usual interstitial pneumonia. Pt was give high dose pulse steroids for 3 days without improvement in his oxygenation and ventilator settings. It was felt that pt did not have steroid responsive interestitial lung disease. Given the fact that pt's clinical status showed no improvement over the past several weeks and it was highly unlikely that the pt could ever come off the ventilator, a family discussion was held and the decision was made to make the pt [**Name (NI) 3225**]. Pt was extubated and he expired shortly thereafter. . 2. CV a. Rhythm: Pt remained in Afib, which was adequately rate-controlled on digoxin. He was anticoagulated with heparin. Pt was noted to be in brachycardia in afib and digoxin was discontinued. b. Ischemia: Pt is s/p STEMI with slightly depressed LV systolic function. Pt was continued on aspirin, statin. Antihypertensives were held in the setting of his hypotension. c. Pump: Ischmemic cardiomyopathy s/p MI. Swan not consistent with cardiogenic shock; more consistent with hypovolemia, sepsis. Severe TR could make swan readings misleaded. Pt was bolused for CVP>12. Very little diuresis was attempted/accomplished since he was likely clinically dry despite total body volume overload. . 3. RLE DVT: A large RLE DVT dx'd [**1-4**] on LE ultrasound. Pt was continued on heparin drip, which he was already on for Afib. CTA was negative for PE . 4. Anemia: Most likely [**1-6**] chronic disease from Fe studies; MCV 95. Folate and B12 both normal. . 5. FEN: NGT placed by fluoro. Given tube feeds. Lytes repleted prn . 6. Proph: PPI, heparin gtt Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: ARDS, chronic interstitial lung disease, Afib, DVT Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

[ "518.84", "453.8", "486", "428.0", "427.31", "427.5", "410.72", "255.4", "515", "286.9", "995.94" ]

icd9cm

[ [ [] ] ]

[ "99.07", "96.04", "33.22", "00.17", "96.6", "99.04", "89.64", "96.72", "93.90", "38.93", "33.28", "33.24" ]

icd9pcs

[ [ [] ] ]

7377, 7386

3367, 7325

271, 277

7480, 7489

2344, 3344

7542, 7549

2320, 2325

7348, 7354

7407, 7459

7513, 7519

223, 233

305, 2087

2109, 2238

2254, 2304

5,451

186,664

19457

Discharge summary

report

Admission Date: [**2150-3-17**] Discharge Date: [**2150-3-20**] Date of Birth: [**2102-8-29**] Sex: M Service: [**Hospital Unit Name 196**] HISTORY OF PRESENT ILLNESS: This patient is 47 year old male with a history of Hodgkin's disease as well as chronic pleural effusions, unknown origin who was admitted to the hospital for a right and left heart catheterization to determine if there is any cardiac evidence or etiology of the pleural effusions. This catheterization was done on [**2150-3-17**]. During the cardiac catheterization, at the conclusion of the right coronary angiography the patient was noted to be dysarthric and flaccid on the right side, having previously been quite conversant and normal after the left coronary angiography. Therefore, the Stroke Team and Dr. [**Last Name (STitle) 1132**] was notified. The patient was sent to Interventional Radiology where he had angiography of the cerebral circulation of the left mid cerebral artery occlusion which was resolved with intraarterial TPA resulting over the course of several hours in the improvement in the patient's neurologic findings. The patient did have a head computerized tomography scan thereafter showing no evidence of acute hemorrhage or infarction prior to this. He was admitted to the Neurosurgery Intensive Care Unit for further monitoring. After being managed in the Neurosurgery Intensive Care Unit, the patient was transferred to [**Hospital Unit Name 196**] for continued post catheterization care. PAST MEDICAL HISTORY: 1. Hodgkin's disease with his last chemotherapy approximately one year ago; 2. Recurrent pleural effusions for which she received periodic thoracentesis in a hospital at some time in [**Location (un) 3844**]; 3. History of pericardial effusion, status post pericardial window; 4. Non-ST elevation myocardial infarction in [**2150-1-1**], status post right coronary artery metal stenting times two; 5. Gastroesophageal reflux disease; 6. Anxiety. MEDICATIONS AT HOME: Paxil 40 mg once a day, Clonazepam 1 mg b.i.d., Lipitor 10 q.d., Toprol 50 q.d., Lasix 40 q.d., potassium chloride 20 b.i.d., sublingual Nitroglycerin prn, Protonix 20 q.d. PHYSICAL EXAMINATION: On transfer to the [**Hospital Unit Name 196**] Service the patient's vital signs revealed temperature 98.8, blood pressure 130/70, pulse 98, respirations 16 and oxygen saturation of 95% on 3 liters of nasal cannula. On physical examination the patient was sitting up in bed, alert in no acute distress and is comfortable with the nasal cannula. In his neck there was no noted jugulovenous distension. His heart was slightly tachycardiac, regular rate and rhythm with no murmurs, rubs or gallops. On his lung examination, the breath sounds were decreased bilaterally, left greater than right up to approximately one-half the way on the chest posteriorly. His abdomen was soft, nontender. There was no lower extremity edema to be noted. Pulses were 2+. LABORATORY DATA: On laboratory evaluation complete blood count was unremarkable. Chemistry panel was unremarkable with normal renal function and electrolytes. The patient's coagulase studies were within normal limits. Chest x-ray, the patient had left lower lobe atelectasis, decreasing in size with bilateral pleural effusions. The head computerized tomography scan done [**3-17**], showed no evidence of acute hemorrhage. The patient, also on [**3-17**], had a computerized tomography scan of the abdomen and pelvis without contrast which was done for some report of back pain, status post catheterization which showed no evidence of retroperitoneal hematoma and the bilateral pleural effusions noted on chest x-ray. HOSPITAL COURSE: 1. Cardiovascular - Per the cardiac catheterization it was noted that the patient had mildly increased right-sided pressures and left-sided pressures with a right atrial pressure of approximately 12 and a mean wedge pressure of 16. There was no evidence of constrictive pericarditis and there was moderate diastolic ventricular dysfunction. These were not felt to be significant for it to be a cause of the patient's pleural effusions. Thus, from a cardiovascular standpoint, management was centered on his coronary artery disease for which Aspirin was restarted on day #2 after the cerebrovascular accident. No further Plavix had been required after the one month for which the patient was on after his stenting in [**2150-1-1**]. The patient's beta blocker will be restarted on day #3, status post a cerebrovascular accident which was held due to the desire to keep his blood pressure approximately 140 systolic after the event of the cerebrovascular accident. Thus, the patient will be continuing on Aspirin and beta blocker for coronary artery disease management after discharge. 2. Cerebrovascular accident - The patient as noted above did have intraarterial TPA administration within the Interventional Neuroradiology Suite by Dr. [**Last Name (STitle) 1132**]. The intraarterial TPA administration was successful, resolving the majority of the patient's symptoms, leaving him with a residual aphasia and word-finding deficit. Immediately following the intervention head computerized tomography scan was negative for any hemorrhage. The patient then had a follow up magnetic resonance imaging scan/magnetic resonance angiography on day #2 of hospitalization which essentially showed infarction in the left mid cerebral artery distribution in varying stages of evolution. From a neurologic standpoint there was no further intervention for this stroke aside from continuing the patient on Aspirin. It was unclear exactly what the etiology of the stroke was. It was felt unlikely that this was a cholesterol-after emboli given that he is in lysis with the TPA and the situation in which this occurred. There was a possibility given that blood clots may have formed surrounding the catheter which a rare occurrence, so hypercoagulable tests were obtained which were pending on discharge. It was not felt likely the patient required a transesophageal echocardiogram during hospitalization but if deemed to be useful, the patient may have this procedure done as an outpatient. 3. For the residual deficits, status post cerebrovascular accident, the patient did have occupational therapy, physical therapy and swallowing evaluation. The swallowing evaluation was normal. They recommended having at some point in time a formal speech evaluation. Occupational therapy and physical therapy also cleared the patient as he was walking well and had normal functionality prior to discharge. Thus, it would be recommended the patient will follow up as an outpatient for language therapy, occupational therapy and physical therapy. 4. For the pleural effusions which are chronic and of unclear etiology, the patient is to continue with thoracentesis as needed. He will be scheduled for pleurodesis per his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**Location (un) 3844**]. The patient will continue with Lasix q.d. which is decreased from b.i.d. dosing due to developing slight dehydration. At the time of discharge on hospital day #4, the patient had significant resolution of his neurologic symptoms, status post the cerebrovascular accident and will continue to follow up with Dr. [**Last Name (STitle) 911**] as needed as well as his primary care physician in [**Location (un) 3844**]. FOLLOW UP: 1. The patient will follow up with Dr. [**Last Name (STitle) 911**] within three to four weeks. 2. The patient will follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within one week. 3. The patient will receive outpatient services, occupational therapy, physical therapy and speech therapy. FINAL DISCHARGE MEDICATIONS: 1. Clonazepam 1 mg p.o. b.i.d. 2. Paroxetine 20 mg p.o. q.d. 3. Lasix 40 mg p.o. q.d. 4. Aspirin 81 mg p.o. q.d. 5. Toprol XL 50 mg p.o. q.d. FINAL DISCHARGE DIAGNOSIS: 1. Right/left heart catheterization for chronic pleural effusions demonstrating mildly right and left-sided pressures, moderate diastolic dysfunction. 2. Left mid cerebral artery embolic infarction, status post intraarterial TPA with evidence of small areas of infarction in the left anterior territory in varying stages of evolution. 3. Hodgkin's disease. 4. Pleural effusions. 5. History of pericardial effusions. 6. Modest elevation myocardial infarction in [**2150-1-1**], status post right coronary artery stent times two. 7. Gastroesophageal reflux disease. 8. Anxiety. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**] Dictated By:[**Last Name (NamePattern1) 13389**] MEDQUIST36 D: [**2150-3-19**] 16:32 T: [**2150-3-19**] 17:09 JOB#: [**Job Number 52858**]

[ "276.5", "401.9", "997.1", "414.01", "511.8", "416.0", "997.02", "427.1", "412" ]

icd9cm

[ [ [] ] ]

[ "36.04", "37.23", "88.56", "99.10" ]

icd9pcs

[ [ [] ] ]

7859, 8013

8034, 8863

3718, 7472

2017, 2191

7483, 7836

2214, 3700

190, 1521

1544, 1995

1,578

168,848

3408

Discharge summary

report

Admission Date: [**2140-7-19**] Discharge Date: [**2140-7-23**] Date of Birth: [**2060-11-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1666**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 79 yo F with multifactorial chronic hypoxemia and dyspnea thought due to diastolic CHF, pulmonary hypertension thought secondary to a chronic ASD and COPD on 5L home oxygen admitted with complaints of worsening shortness of breath. . The patient is a poor historian and therefore history was obtained in part from medical record and in part from interview with Russian interpreter and the patient. . The patient has chronic severe dyspnea requiring numerous inpatient hospitalizations. She reports that her breathing was bad at baseline but appeared acutely worse over the past 2 days. She denies any associated symptoms including no chest pain, diaphoresis, nausea, vomiting, fevers, worsened lower extremity edema or weight gain. The patient does note that her lower extremities were more erythematous and uncomfortable than normal. By patient report this episode is entirely the same as her prior episodes of acute on chronic dyspnea exacerbation. Reports compliance with all of her medications. . The patient initially presented to the [**Hospital1 2177**] ED with complaints of SOB. Vitals on presentation there are unavailable as are all records of assessment and treatment. Written report by nurses upon transfer to [**Hospital1 18**] describe CXR at [**Hospital1 2177**] consistent with volume overload and treatment with furosemide 40mg IV, nitropaste 1inch and aspirin. She refused foley placement. Labs and EKG were largely unremarkable and she was transferred to [**Hospital1 18**]. In the [**Hospital1 18**] ED, 73 132/72 22 95% 4L. The patient refused/did not tolerate BiPAP therapy. She received an additional dose of furosemide 40mg IV. . Of note, the patient is frequently admitted with respiratory distress and hypoxemia likely in part due to poor medication compliance. Most recently, she was admitted from [**2140-5-9**] - [**2140-5-18**] when she was successfully diuresed though did require overnight transfer to the ICU for hypoxia. During that hospitalization, cardiology consult recommended a right heart cath for evaluation of response to sildenafil but the patient refused. Pulmonary consult recommended an empiric, compassionate sildenafil trial due to severe dyspneic symptomology preventing outpatient living. This trial was to occur as an outpatient under her PCP, [**Name10 (NameIs) **] the patient did tolerate an inpatient trial without hypotension. During that hospitalization, the patient's home amiodarone was discontinued out of low likelihood for amiodarone toxicity. Past Medical History: - Atrial septal defect repair [**6-17**] complicated by sinus arrest with PPM placement. - Diastolic CHF, estimated dry weight of 94kg - AF s/p cardioversion x 2. Previously on amiodarone discontinued due to paced rhythm during hospitalization in [**2140-4-23**]. Not anticoagulated due to history of hemorrhagic CVA. - HTN - GERD - TAH/BSO ('[**33**]) for fibroids - Prior hemorrhagic CVA - Pulm HTN (RSVP 75 in [**11-24**]) thought secondary to longstanding ASD - CRI (baseline Cr 2-2.5) - COPD on home O2 (5L NC) with baseline saturation high 80's to low 90's on this therapy. - OSA, not CPAP compliant - Mild mitral regurgitation - Microcytic anemia - Hypothyroidism - S/p APPY, s/p CCY ('[**33**]) - Gallstone pancreatitis s/p ERCP, sphincterotomy - Elevated alk phos secondary to amiodarone Social History: Lives alone in senior living housing, has daughter-in-law who brings her groceries, has VNA once a week. No tob, EtOH, IVDU. Family History: NC Physical Exam: Vital Signs: Temp 95.5, HR 61, BP 119/56, RR 22 93% 4L . Gen: NAD, Obese. HEENT: Unable to assess JVP due to habitus and patient refusal to lay in bed. CV: Systolic ejection murmur loudest at the left sternal border 5th intercostal space. Pulm: Small amount of bibasilar crackles. Poor air movement. Abd: Obese, nontender. Ext: Chronic bilateral venous stasis changes with associated diffuse erythema and taut skin. 2+ bilateral edema. Neuro: A&O x3 Pertinent Results: On Admission: [**2140-7-19**] 06:59AM WBC-4.9 RBC-3.96* HGB-11.0* HCT-34.3* MCV-87 MCH-27.7 MCHC-31.9 RDW-18.6* [**2140-7-19**] 06:59AM PLT COUNT-174 [**2140-7-19**] 06:59AM NEUTS-65.3 LYMPHS-22.8 MONOS-8.3 EOS-3.2 BASOS-0.4 [**2140-7-19**] 06:59AM GLUCOSE-97 UREA N-57* CREAT-2.2* SODIUM-143 POTASSIUM-7.4* CHLORIDE-101 TOTAL CO2-35* ANION GAP-14 [**2140-7-19**] 06:59AM CK(CPK)-107 [**2140-7-19**] 06:59AM cTropnT-0.01 [**2140-7-19**] 06:59AM CK-MB-2 proBNP-3664* [**2140-7-19**] 06:59AM URINE HOURS-RANDOM [**2140-7-19**] 06:59AM URINE GR HOLD-HOLD [**2140-7-19**] 06:59AM PT-13.2 PTT-26.8 INR(PT)-1.1 . CXR: Mild CHF. Recommend imaging after diuresis to exclude underlying pneumonia. . Brief Hospital Course: The patient is a 79 yo Female with multifactorial chronic hypoxemia thought due to chronic diastolic CHF, pulmonary hypertension likely secondary to ASD and reported COPD on 5L home oxygen now admitted with shortness of breath that improved after aggressive diuresis. Pt initially admitted to ICU, diuresed as described in d/c summary [**Hospital 15787**] transfered to floor for further care of hypoxia and dyspnea as noted below. She was arranged for home VNA for daily services (with russian-speaking nurses as prior) on [**2140-7-22**], [**Hospital **] medical status improving, however given patients repeated admissions [**Last Name **] problem is chronic management of diastolic CHF and patient was kept an additional day to try and optimize supports for discharge. Attempts were made to arrange family meetings with daughter in law and social work to again discuss goals and rational of chronic management of diastolic heart failure in an attempt to avoid repeated hospitalizations. However, over the weekend after attempts for the prior day (x3 and repeated attempts x2 on the day of discharge) there was no return communication from listed contacts after messages were left to discuss discharge planning. Discharge instructions were discussed with Russian interpreter who knows ms. [**Known lastname 15676**] well and ms. [**Known lastname **] wished to be discharged to continue care at home with russian speaking VNA. discharge instructions and follow-up were discussed with aid of interpreter and ms. [**Known lastname 15676**] expressed understanding. Follow-up instructions were given and detailed instructions were given for home VNA. Ms. [**Known lastname 15676**] had no further questions regarding her discharge planning and had no additional requests or contacts for me to contact in attempts to corroborate discharge plans in an effort to reenforce importance of medical compliance. Follow-up with her pcp is scheduled in the near future and may be the best venue to discuss rational of chronic management of heart failure and medical compliance. #. Hypoxemia and Dyspnea: Given evidence of pulmonary edema on imaging and hypervolemia, likley secondary to acute on chronic diastolic CHF in setting of poor pulmonary substrate secondary to severe pulmonary hypertension and possible COPD. The patient reported symptomatic improvement with diuresis and had O2 sats > 90% on 5L which is home O2 requirement. Patient had overall significant improvement in symptoms, was able to ambulate up and down [**Doctor Last Name **] in [**Hospital1 **], maintaining an average o2 sat 90% (on 5-6L 02 (her home baseline). IV lasix was changed to po and new regimen of 80mg every am and 40mg every pm was started with instructions for daily weights and additional am lasix as needed for weight gain and to contact PCP. Starting digoxin 0.125 mg was considered, however, was defered to her outpatient pcp/cardiologist, given her chronic kidney disease and need for close monitoring and at this time, there is concern that the short-term potential harm of inconsistent or no monitoring or follow-up of digoxin in the setting of chronic kidney disease, may outweigh any potential long-term benefit. -In-house pulmonary consult was obtained to re-assess initiating sildenafil as discussed prior, however the ultimate recomendation was for NO sildenafil treatment or trial at this point given pt's h/o non-compliance and without attaining both RHC and LHC first, such treatment could potentially have more hazardous effects than benefit. #. Acute on Chronic Diastolic CHF,EF >55%: Estimated dry weight is 94 kg from most recent pulmonary note, continued diuresis this admission with good response. IV lasix changed to po regimen as discussed above. - 80mg po lasix qam, and 40mg po lasix qpm as noted above - Continued lopressor 12.5 mg twice daily - continued daily weights, strict I/O's, fluid and salt restriction and discharge instructions for the same given. - starting digoxin this admission was deferred as discussed above. #. Pulmonary hypertension: Thought secondary to chronic ASD and COPD. The patient has not followed up as an outpatient to initiate empiric sildenafil treatment. Per OMR notes and discussion with pulmonary, there was a plan to attempt trial of Sildenafil in house to ensure hemodynamic tolerance but no plan to start chronically as outpatient until patient could demonstrate compliance and prior authorization obtained. Pt again admitted with same presentation, missed pulm f/u appt (states [**12-19**] to DOE complaints). - no sildenafil trial was initiated as discussed above. - treated diastolic dCHF as above. - held off on anti-coagulation as patient has history of noncompliance and again potential risk of unmonitored therapy likely outweighs benefit. #. COPD: On 5L home oxygen. Last spirometry showed more of a restrictive defect. - continued albuterol nebs PRN, tiotropium, and continuous 02 supplementation. -outpatient pulmonary follow up once again recommended. #. Atrial fibrillation: Patient currently paced, not anticoagulated due to prior hemorrhagic CVA. Amiodarone discontinued on recent hospitalization due to A paced rhythm and potential initiation of sildenafil. - continued home aspirin and lopressor #. Chronic Kidney Disease Stage IV: Baseline Cr approximately 2-2.5, Currently 2.0 with ongoing diuresis - monitored and remained stable with ongoing diuresis, medications were renally dosed. continued home Ca-acetate #. Hypertension, Benign: BP well controlled currently and more lower BP currently, #. Mixed Anemia, secondary to chronic kidney disease and iron deficiency: Currently at bseline - continuef home iron supplementation, - outpatient evaluation for source of iron deficiency recommended if not already done. # Hypothyroidism: Continued home levothyroxine #. GERD: Continued home PPI #. Chronic venous stasis changes with leg pain - compression stockings, leg elevation - continued home gabapentin and oxycodone - has been well described previously, no indication for antibiotics at this time #. Depression NOS: Continued home paroxetine #. Code: Full, confirmed with patient on transfer from ICU HCP - Daughter in law: [**Doctor First Name 13762**] [**Name (NI) 15788**], likely to be health proxy (speaks english) - [**Telephone/Fax (1) 15782**] Medications on Admission: - Gabapentin 100 mg Daily - Paroxetine HCl 10 mg Daily - Pantoprazole 40 mg Twice daily - Levothyroxine 75 mcg Daily - Calcium Acetate 667 mg 3 TIMES A DAY WITH MEALS - Albuterol 90 mcg/Actuation Aerosol 2 PUFFs every 4-6 hours - Aspirin 81 mg Daily - Ferrous Sulfate 325 mg Daily - Oxycodone 5 mg every 6 hours as needed for pain - Tiotropium Bromide 18 mcg Capsule Daily - Metoprolol Succinate 25mg Daily - Furosemide 80mg Daily Discharge Medications: 1. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 2. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. Furosemide 40 mg Tablet Sig: 1-2 Tablets PO twice a day: *****PLEASE TAKE 2 TABS (80 MG) QAM (EVERY MORNING), THEN TAKE 1 TAB (40 MG) QPM (EVERY AFTERNOON/EVENING), YOU [**Month (only) **] NEED EXTRA IN THE MORNING AS GIVEN IN YOUR WRITTEN INSTRUCTIONS. Disp:*150 Tablet(s)* Refills:*0* 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Home With Service Facility: ART of Care Discharge Diagnosis: Primary Diagnosis: Acute on Chronic Diastolic heart failure (you need to take your lasix and follow the instructions above to lessen the chance of your symptoms worsening again requiring you to come back to the hospital) Pulmonary Hypertension Secondary Dx: Chronic Kidney Disease IV Atrial Fibrillation Hypertension Chronic Venous stasis hypothyroidism anemia Discharge Condition: Stable, breathing comfortably on 5liters 02 (home requirement) Discharge Instructions: Please take all medication as listed and prescribed. Adherence to your medications is critical for controlling your poor breathing status along with the following instructions AND importantly seeing your doctors [**First Name (Titles) 3**] [**Last Name (Titles) **] (THIS IS VERY IMPORTANT). Weigh yourself every morning right after urinating, if you weigh more than 2 pounds compared to the day prior - take an extra 40mg lasix that morning. (If you weigh 4 pounds more than the day prior - take an extra 80mg of lasix). Adhere strictly to a 2 gm sodium diet (low salt diet) Followup Instructions: 1. PCP [**Name9 (PRE) 702**] on [**Name9 (PRE) 2974**] [**8-5**] at 9:45am. PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 4606**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**] Completed by:[**2140-7-23**]

[ "427.31", "276.0", "244.9", "428.33", "280.9", "530.81", "403.90", "496", "428.0", "585.4", "416.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13183, 13225

5080, 11450

336, 343

13631, 13696

4347, 4347

14329, 14676

3858, 3862

11931, 13160

13246, 13246

11476, 11908

13720, 14306

3877, 4328

277, 298

371, 2879

13265, 13610

4361, 5057

2901, 3699

3715, 3842

18,940

117,487

22507

Discharge summary

report

Admission Date: [**2104-1-15**] Discharge Date: [**2104-2-19**] Date of Birth: [**2046-1-19**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: 58 year old white male s/p CABG in [**2099**] with TVR and multiple hospitalizations for CHF over past 6 months. Major Surgical or Invasive Procedure: Tricuspid valve replacement with 33mm CE Thermafix Pericardial valve [**2105-1-16**] History of Present Illness: 58 year old white male s/p CABGx4 in [**2099**] with a 6 month history of TR and CHF. He has had 3 admissions for CHF since [**Month (only) 216**] and is treated with Torsemide. An echo [**7-21**] revealed an LVEF of 25%, diffuse hypokinesis, trace AI and severe TR. Cardiac cath [**7-21**] showed an LVEF of 25%, 3 patent grafts, and a 50% lesion in the PDA graft. He is now admitted for TVR. Past Medical History: s/p CABGx4 [**6-/2099**] s/p MI s/p bil. THR s/p bil. detached retinal surgeries s/p bil. cataract [**Doctor First Name **]. obesity Afib CHF ischemic cardiomyopathy HTN GERD RA ^chol. CRI Social History: Lives with wife and daughter Cigs: quit 15 years ago ETOH: 3 glasses wine per day Family History: CAD Physical Exam: Gen: WDWN [**Male First Name (un) 4746**] in NAD AVSS HEENT: NC/AT, PERLA, EOMI, oropharynx has upper dentures, benign Neck: supple, FROM, +JVD, no lymphadenopathy or thyromegaly, carotids 2+=bilat. without bruits. Lungs: CLear to A+P CV: IRRR without R/G +M Abd: obese, soft, nontender, without masses or hepatosplenomegaly Ext: without C/C/E, severe varicosities on bil. LE, well healed surgical scars on leg and L radial site. Neuro: nonfocal Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2104-2-18**] 10:55AM 8.9 3.67* 11.8* 34.8* 95 32.1* 33.8 16.0* 342# DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2104-2-18**] 10:55AM 71.9* 20.3 3.6 3.9 0.4 RED CELL MORPHOLOGY Hypochr Macrocy [**2104-2-18**] 10:55AM 1+ 1+ BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2104-2-18**] 10:55AM 342# Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2104-2-16**] 03:45PM 95 56* 1.8* 138 3.9 97 26 19 [**2104-2-19**] INR: 2.4 Brief Hospital Course: The patient was admitted on [**2105-1-14**] for tricuspid valve replacement and on [**2105-1-16**] he underwent a right thorocotomy and tricuspid valve replacement with a 33mm CE Thermafix Pericardial valve. Total bypass time was 97 mins. and patient was transferred to the CSRU on Propofol, Milrinone, and Levophed in stable condition. He had thick, copious secretions post op and was bronched. He was hypoxic and hypotensive and required ^PEEP. The Milrininone was d/c'd on POD#3 as well as his chest tubes. He continued to have thick, copious secretions with frequent bronchs and required sedation. He was followed by the heart failure service at this time as well. He had a R pneumothorax on POD#5 and had a chest tube placed. He was eventually evaluated by infectious disease as he ws spiking temps to 105 without a clear source. He was continued on Vanco and Zosyn. He only grew out E. coli in the sputum. He had a full course of antibiotics and eventually defervessed and his TEE was negative. He developed a L gluteal necrotic area which has been packed with duoderm gel and foam. He was eventually extubated on POD#15 and continued to require aggressive respiratory therapy and diuresis. He was confused and his mental status waxed and waned. He was evaluated by the electrophysiology service and Dr. [**Last Name (STitle) **] wants the patient to go to rehab, and when he is ready to be discharged from rehab to home, he wants him readmitted to his service and evaluated for an ICD/Biventricular pacer. He continued to slowly improve and was transferred to the floor on POD#25. He was evaluated by psychiatry as he had increased paranoid ideations and delerium and had a negative head CT, MRI, and neurological workup. He was started on Haldol and eventually cleared. [**2104-2-18**] he was diagnosed with an E. Coli UTI which is resistant to most abx. and is being treated with a course of Cefepime for 14 days. He was discharged to rehab on POD#33 in stable condition. Medications on Admission: Lisinipril 20 mg PO daily Carvedilol 6.25 mg PO BID Prilosec 20 mg PO daily Colace 100 mg PO daily Flexeril 10 mg PO TID Lipitor 10 mg PO daily Ferrous sulfate 325 mg PO daily Triazolam 0.25 mg PO daily Percocet 1 PO BID Torsemide 50 mg PO BID MVI Coumadin 3 mg PO daily KCl 20 mEq PO daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Torsemide 100 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 11. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Papain-Urea [**Telephone/Fax (3) 3335**] unit-mg/g Ointment Sig: One (1) Appl Topical PRN (as needed). 14. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 15. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Cefepime HCl 2 g Piggyback Sig: One (1) Intravenous once a day for 14 days. 20. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): INR goal 2-2.5. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Tricuspid regurgitation Prolonged intubation HTN E. Coli UTI Delerium Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [**First Name (STitle) **] when you are released from rehab. Make an appointment with Dr. [**First Name (STitle) **] when you are released from rehab. Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks. When you are ready to be released from rehab, call Dr. [**Name (NI) 49475**] office to arrange to be readmitted for evaluation for ICD/Biventricular pacer. Completed by:[**2104-2-19**]

[ "599.0", "398.91", "518.5", "293.0", "397.0", "707.05", "V43.64", "V45.81", "278.01", "512.1", "287.5", "427.31" ]

icd9cm

[ [ [] ] ]

[ "33.22", "00.14", "89.64", "88.72", "00.17", "35.27", "96.72", "34.09", "96.6", "00.13", "39.61", "33.24" ]

icd9pcs

[ [ [] ] ]

6357, 6431

2359, 4358

434, 521

6545, 6552

1761, 2336

6795, 7233

1275, 1280

4699, 6334

6452, 6524

4384, 4676

6576, 6772

1295, 1742

282, 396

549, 948

970, 1160

1176, 1259

16,156

142,237

43731

Discharge summary

report

Admission Date: [**2147-2-22**] Discharge Date: [**2147-3-5**] Date of Birth: [**2074-4-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2698**] Chief Complaint: NSTEMI Major Surgical or Invasive Procedure: Cardiac catheterization Hemodialysis Tunneled dialysis catheter placement History of Present Illness: The pt is a 72y.o M with a PMH of CAD, AF, CRI now with NSTEMI. Pt initally admitted to OSH with complaints of increased chest discomfort at rest. Found to have NSTEMI with CK peak 362 CKMB 12-16% per report and Trop 2.33. Creatinine [**3-23**]. Being transferred with plan for catheterization on Friday after evaluation by renal team re: possible placement of dialysis catheter for likely need of post cath dialysis. Pt previously admitted with angina [**4-24**] however had an ECG without changes and had flat CE. Since cardiac catheterization would be a high risk procedure in the setting of his chronic renal nsufficiency, he was medically managed. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. On arrival to the medical floor the patient reports [**4-26**] chest tightness without radiation, similar to prior. Denies dyspnea, nausea, diaphoresis. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS [**11/2141**]: -->LMCA without disease -->LAD with diffuse disease and vasospasm, reversed with TNG -->D1: ulcerated 80% lesion -->LCX: distal vasospasm, reversed with TNG -->RCA: Severe diffuse disease with serial 90% lesions in the PDA and 80% stenosis in the mid-RCA FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Acute myocardial infarction, secondary to severe LAD and LCx coronary vasospasm. This was managed by intracoronary and intravenous diltiazem and nitroglycerin therapies. 3. OTHER PAST MEDICAL HISTORY: -Three vessel CAD: see above for details -Perioperative (bowel resection) vasospasm requiring cardiac cath with NTG -Mild-moderate MR [**Name13 (STitle) 37625**] EF: 45% with focal inferior-posterior wall motion abnormalities -Ischemic Colitis: s/p SMA thrombectomy, with [**Doctor Last Name 3379**] pouch and end ileostomy. Also complicated by recent diversion colitis in 2/[**2146**]. -Peripheral [**Year (4 digits) 1106**] disease s/p aortobifemoral bypass [**2131**] -Raynauds -Dementia -Stage IV CKD: baseline creatinine appears to be around [**2-19**] -Atrial fibrillation -H/o perioperative CVA: no deficits -Hyperlipidemia -HTN -H/o Achalasia s/p esophageal dilation -H/o VRE infection Social History: -Tobacco history: 40 pack years, quit 10 years ago -ETOH: None -Illicit drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: 98.4 117/58 68 20 100,2L GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6cm. Bilat carotid bruits. CARDIAC: RRR, normal S1, S2. 2/6 systolic murmur at LLSB, no rubs/gallops. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: NABS. Soft, NTND. EXTREMITIES: No edema. WWP. 2+ DP pulses. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [**2147-2-22**] 10:40PM BLOOD WBC-8.3 RBC-3.38* Hgb-9.2* Hct-28.6* MCV-85 MCH-27.3 MCHC-32.3 RDW-17.0* Plt Ct-238 [**2147-2-24**] 11:00AM BLOOD WBC-9.1 RBC-2.61* Hgb-7.4* Hct-22.1* MCV-85 MCH-28.3 MCHC-33.4 RDW-16.6* Plt Ct-260 [**2147-2-24**] 11:22PM BLOOD Hct-33.1*# [**2147-2-28**] 05:25AM BLOOD WBC-14.9* RBC-4.04* Hgb-11.4* Hct-34.2* MCV-85 MCH-28.2 MCHC-33.3 RDW-17.8* Plt Ct-314 [**2147-3-5**] 04:52AM BLOOD WBC-12.7* RBC-3.58* Hgb-9.9* Hct-31.0* MCV-87 MCH-27.6 MCHC-31.9 RDW-17.5* Plt Ct-228 [**2147-2-22**] 10:40PM BLOOD PT-24.2* PTT-36.3* INR(PT)-2.4* [**2147-2-27**] 05:20AM BLOOD PT-15.7* PTT-73.3* INR(PT)-1.4* [**2147-3-5**] 04:52AM BLOOD PT-21.4* PTT-35.0 INR(PT)-2.0* [**2147-2-22**] 10:40PM BLOOD Glucose-108* UreaN-89* Creat-7.2*# Na-139 K-4.0 Cl-112* HCO3-15* AnGap-16 [**2147-3-5**] 04:52AM BLOOD Glucose-81 UreaN-28* Creat-4.9*# Na-134 K-4.9 Cl-97 HCO3-28 AnGap-14 [**2147-2-22**] 10:40PM BLOOD CK(CPK)-171 [**2147-3-4**] 12:15PM BLOOD CK(CPK)-69 [**2147-2-22**] 10:40PM BLOOD CK-MB-9 cTropnT-0.26* [**2147-2-23**] 07:10AM BLOOD CK-MB-8 cTropnT-0.32* [**2147-2-24**] 02:46PM BLOOD CK-MB-NotDone cTropnT-0.45* [**2147-2-25**] 05:56AM BLOOD CK-MB-NotDone cTropnT-0.68* [**2147-3-4**] 12:15PM BLOOD CK-MB-NotDone cTropnT-0.10* [**2147-2-25**] 05:56AM BLOOD calTIBC-281 Ferritn-74 TRF-216 [**2147-2-23**] 07:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE [**2147-2-23**] 07:10AM BLOOD HCV Ab-NEGATIVE [**2147-3-4**] 02:41PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004 [**2147-3-4**] 02:41PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR [**2147-3-4**] 02:41PM URINE RBC-<1 WBC-4 Bacteri-FEW Yeast-NONE Epi-<1 TTE ([**2-23**]): The left atrium is elongated. Mild regional left ventricular systolic dysfunction with mid inferolateral wall to distal inferior wall akinesis. LVEF 50-55%. [**11-18**]+ MR. Mild pulmonary artery systolic hypertension. Carotid U/S ([**2-23**]): 1. Calcified plaque with 40-59% stenosis of the right internal carotid artery. 2. Calcified plaque with less than 40% stenosis of the left internal carotid artery. Cardiac cath ([**2-24**]): 1. Selective coronary angiography of this co-dominant system demonstrated severe three vessel coronary artery disease. The LMCA had no angiographically apparent disease. The LAD had a 70% very distal to apical disease. There was an 80% diffuse stenosis in a small to medium 1st diagonal branch. The LCX had a second OM with a 90% stenosis and a TO in the OM3. There was insignificant plaquing in the large L posterolateral branch. The RCA had an 80% distal stenosis and a diffuse 60-70% stenosis in a small PDA. 2. Resting hemodynamics revealed elevated right and left ventricular enddiastolic filling pressures at 13 and 16 mmHg. The mean PA pressure was 23 mmHg (phasic 35/13 mmHg). The PCWP was 16 mmHg. The cardiac index was 3.5 L/min/m2. The mean systemic arterial pressure was 91 (161/56 mmHg). 4. Successful PTCA and stenting of the RCA with a 3.0x18mm Vision stent. Final angiography revealed no residual stenosis, no angiographically apparent dissection and TIMI III flow (See PTCA comments). 4. Successful PTCA and stenting of the OM2 with a 2.0x23mm Mini Vision stent. Fianl angiography revealed no residual stenosis, no angiographically apparent dissection and TIMI III flow (See PTCA comments). 5. Unsuccessful attempt to PTCA of the small 1st diagonal branch. Brief Hospital Course: 1. NSTEMI: His cardiac markers trended down at [**Hospital1 18**]. He was initially started on heparin and nitroglycerin drips, and continued on ASA, clopidogrel, carvedilol, and statin. Echo showed new akinesis of inferior/inferolateral walls, although preserved EF. He went to cardiac cath, where he had stenting of RCA and OM2. He was transferred to the CCU afterwards for HTN. He was initially controlled with nitroprusside and nitroglycerin gtt. Upon arrival to CCU patient was only on nitroglycerin gtt and this was quickly weaned off. He had slightly higher BPs in the morning and was started on captopril, later changed to lisinopril. CK and CKMB were followed and trended down. He was subsequently asymptomatic except for an episode of CP with dynamic ST depressions after an HD session, resolved with NTG SL, cardiac markers flat. His isosorbide dose was increased from 10mg TID to 30mg TID and he had no further symptoms. 2. End-stage renal disease: Patient's outpatient nephrologist felt he was ready to begin HD. He received acetylcysteine 1200mg PO BID x4 doses as well as bicarb hydration prior to/after cardiac cath for renal protection, but HD was still deemed necessary. He received HD initially in the CCU via a temporary catheter. He later had a right chest tunneled catheter placed and underwent Tu/Th/Sat HD via this. He noted some intermittent extremity cramping, associated with fasciculations on exam, felt related to his newly started dialysis. These improved during the admission. He was also continued on Ca acetate, started on sevelamer, and received iron at HD. Hepatitis serology and PPD were negative. 3. Atrial Fibrillation: Remained in sinus rhythm during this admission. Initially on heparin alone with warfarin held for his tunneled catheter placement. After this, warfarin was restarted and bridged with heparin until his INR was therapeutic. His warfarin dose was increased from 2.5mg to 5mg daily to achieve this, and will be checked at his outpatient lab 2 days after discharge. 4. Hypertension: BP was intially elevated and managed in the CCU as above. On the floor, he had further HTN that improved with his HD sessions. He was discharged normotensive on lisinopril and carvedilol. 5. Anemia: Early in admission, his hematocrit trended down to 22.1 with no evidence of active bleeding. He was transfused two units pRBCs with ~10 point improvement in hematocrit, which remained stable. 6. Bruits: Had carotid and abdominal bruits on exam. Carotid U/S obtained showed noncritical ICA stenosis. Review of CT abdomen from last year showed significant aortic calcifications, stable from prior study, which was felt to be the cause of his abdominal bruit. Medications on Admission: Isosorbide mononitrate 60mg [**Hospital1 **] Omeprazole 20mg daily ASA 81mg daily Carvedilol 12.5mg [**Hospital1 **] Loperarime 2mg [**Hospital1 **] Warfarin 2.5mg daily Lovastatin 20mg daily Phoslo 667mg TIDWM Ferrous sulfate 325mg TID NTG prn Epogen q other week prn Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Loperamide 2 mg Tablet Sig: One (1) Tablet PO twice a day as needed. 4. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*180 Capsule(s)* Refills:*2* 6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual as needed. 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:*30 Tablet(s)* Refills:*0* 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three times a day: with meals. Disp:*90 Tablet(s)* Refills:*2* 11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Isosorbide Dinitrate 30 mg Tablet Sig: One (1) Tablet PO three times a day: on dialysis days, give after HD. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Non ST-elevation myocardial infarction End stage renal disease Secondary: Hypertension Chronic systolic heart failure Atrial fibrillation Discharge Condition: Stable Discharge Instructions: You were admitted to [**Hospital1 18**] after having a small heart attack. You had two stents placed in your coronary arteries (that supply the heart muscle) and your heart pumping function remains good. You were also started on dialysis for your kidney failure and received 2 units of blood for anemia (low red blood cells). Please go to all follow up appointments and take all medications as prescribed. We have made the following medication changes: 1. Increase aspirin to 325mg daily for one month, then you may resume the 81mg daily dose. 2. Take clopdiogrel daily for one month to prevent clots in your stents. 3. Decreased your isosorbide MONOnitrate to isosorbide DInitrate 30mg three times daily. 4. Decreased your carvedilol to 6.25mg twice daily. 5. Increased your calcium acetate (Phoslo) to 2 tabs three times daily. 6. Started sevelamer, which helps prevent phosphate from becoming too high. 7. Stopped your oral iron (you will get this at dialysis). 8. Started nephrocaps, a vitamin for patients with kidney damage. 9. Started lisinopril, a blood pressure medicine that also helps the heart. 10. Changed omeprazole to pantoprazole, as this is less likely to interact with your heart medications. 11. Increased warfarin to 5mg daily as your blood test (INR) was not high enough on 2.5mg daily. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. If you experience chest pain or pressure, trouble breathing, fevers, chills, palpitations, lightheadedness, dizziness, or any other concerning symptoms, please seek medical attention or come to the ER immediately. Followup Instructions: Please go to your regular laboratory on Tuesday [**3-7**] to have an INR drawn to check if your warfarin dose is appropriate. Have the results faxed to Dr. [**Last Name (STitle) 30176**] at [**Telephone/Fax (1) 93989**]. If this can be done at dialysis instead, that would be acceptable. You will have dialysis on Tuesday, Thursday, and Saturday at [**Location (un) **] Dialysis Center. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD Phone:[**Telephone/Fax (1) 2998**] Date/Time:[**2147-3-13**] 11:00 Please follow up with your primary care doctor, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 30176**], on Thursday [**4-6**] at 10:00 am. Phone: [**Telephone/Fax (1) 30242**]. Please follow up with your cardiologist, [**First Name8 (NamePattern2) 518**] [**Last Name (NamePattern1) 8579**], on [**4-3**] at 9:00 am. Phone: [**Telephone/Fax (1) 23882**] Completed by:[**2147-3-6**]

[ "403.91", "433.10", "428.22", "288.60", "530.0", "410.71", "785.9", "272.4", "427.31", "414.01", "428.0", "275.3", "585.6" ]

icd9cm

[ [ [] ] ]

[ "38.95", "36.06", "37.23", "88.56", "00.42", "00.66", "39.95", "00.46" ]

icd9pcs

[ [ [] ] ]

11831, 11880

7437, 10135

321, 397

12072, 12081

3973, 7414

13755, 14699

3226, 3341

10454, 11808

11901, 12051

10161, 10431

2168, 2383

12105, 12539

3356, 3954

1844, 2151

12559, 13732

275, 283

425, 1749

2414, 3109

1771, 1824

3125, 3210

31,808

158,347

28310

Discharge summary

report

Admission Date: [**2108-8-14**] Discharge Date: [**2108-8-17**] Date of Birth: [**2060-8-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 1402**] Chief Complaint: atrial fibrillation Major Surgical or Invasive Procedure: Atrial Fibrillation Ablation Cardioversion History of Present Illness: Mr. [**Known lastname 68733**] is a 48 yo male with a history of chronic atrial fibrillation who is transferred to the CCU s/p pulmonary vein isolation with successful ablation procedure. Course was complicated by post-procedure hypotension with SBP 90. Patient was mentating and asymptomatic. He was started on a dopamine drip and paced at HR 70 with atrial lead due to severe sinus node bradycardia. . 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, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Post-procedure he complained of low back pain and palpitations consistent with arrhythmia detected on telemetry. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. Past Medical History: 1. Persistent chronic atrial fibrillation: Patient has a history of chronic atrial fibrillation diagnosed approximately 11 years ago. He was initially diagnosed after developing dizziness, palpitations and presyncope while playing basketball. He has been treated with both Amiodorone and Sotalol in the past, without success. Of note, the patient has never taken Coumadin and has never undergone cardioversion. He reports being persistently in atrial fibrillation for at least the past five years. He recently underwent echocardiogram at an OSH which demonstrated an EF of 40%. He subsequently underwent cardiac catheterization at [**Hospital **] Hospital which revealed normal coronary arteries. He was referred in [**Month (only) **] for EP consultation with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] to discuss options for treatment of his atrial fibrillation. 2. Cardiomyopathy-EF 45% 3. Right arthroscopic shoulder surgery 4. Tonsillectomy Social History: He is married with four children. He does not smoke. He drinks alcohol on occasion and occasionally smokes marijuana. He is an avid basketball player. He works for Fidelity Investment. Family History: There is no family history of premature coronary artery disease or sudden death. There is no family history atrial fibrillation, diabetes, or hypertension. His paternal grandfather died of a myocardial infarction. Physical Exam: VS: BP 111/63 on dopa gtt @ 5 mcg/kg/min, HR 65, RR 14, O2 96% on RA Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 7 cm. CV: regular rhythm, PMI located in 5th intercostal space, midclavicular line. RR, 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, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial 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 Pertinent Results: [**2108-8-14**] 07:45AM GLUCOSE-92 UREA N-26* CREAT-1.2 SODIUM-141 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15 [**2108-8-14**] 07:45AM estGFR-Using this [**2108-8-14**] 07:45AM WBC-4.6 RBC-4.25* HGB-13.9* HCT-39.0* MCV-92 MCH-32.8* MCHC-35.7* RDW-13.6 [**2108-8-14**] 07:45AM PLT COUNT-207 [**2108-8-14**] 07:45AM PT-13.3 PTT-25.4 INR(PT)-1.1 Echo ([**2108-8-14**]): The left atrium is dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No mass/thrombus is seen in the left atrium or left atrial appendage. Mild spontaneous echo contrast is seen in the body of the right atrium. The right atrial appendage ejection velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is mildly depressed. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is no pericardial effusion. IMPRESSION: No intracardiac thrombus identified. Brief Hospital Course: Mr. [**Known lastname 68733**] is a 48 yo male with chronic atrial fibrillation who was admitted to the CCU s/p successful ablation procedure, complicated by hypotension, who was subsequently weaned off dopamine drip and reverted back to atrial fibrillation. The patient was then electively electrically cardioverted and was discharged to home. . # Rhythm: Patient converted back to atrial fibrillation after electrical cardioversion subsequent to failed ablation procedure, was summarily given anticoagulation after the procedure . # Hypotension: Patient was weaned off of dopamine drip, and progressed with BP's in 120's/60's, was restarted on his beta blocker and his Ace-I. . # Pump: Patient was shown to have an EF 45%. A TTE here revealed a dilated left atrium, reflecting structural changes due to chronic arrhythmia. Medications on Admission: Metoprolol 100mg daily Lisinopril 5mg daily Aspirin 325mg daily Discharge Medications: 1. Outpatient Lab Work Please draw INR on Sunday [**8-19**] and call results to Dr. [**Last Name (STitle) 4427**]: [**Telephone/Fax (1) 26828**]. Please ask for the doctor on call. 2. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO Q8H (every 8 hours) as needed for AF. Disp:*100 Tablet Sustained Release(s)* Refills:*0* 3. Enoxaparin 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous [**Hospital1 **] (2 times a day). Disp:*10 syringe* Refills:*1* 4. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO once a day as needed for Af ablation. Disp:*60 Tablet(s)* Refills:*0* 5. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO every eight (8) hours. Disp:*140 Tablet Sustained Release(s)* Refills:*1* 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Atrial Fibrillation Discharge Condition: stable. INR 1.2 [**8-17**]. Oumadin 5mg PO [**8-14**], [**8-15**]. Coumadin 10 mg [**8-16**]. QTc=.32 on [**8-17**] Discharge Instructions: You had an atrial fibrillation ablation that did not successfully keep you in a normal rhythm. You then had a cardioversion that did change your rhythm into a normal sinus rhythm. You were started on Quinidine gluconate to try to keep you in a normal rhythm. You will go home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor to track your rhythm at home. You are also going home on coumadin which is to prevent blood clots. Written information was given to you and discussed with you about side effects, diet, drug interactions and when to call your doctor. You need to keep a coumadin blood level (or INR) between [**2-5**]. Until your coumadin level is > 2, you will need to take Lovenox injections twice a day. Dr. [**Last Name (STitle) 4427**] will tell you when to stop taking your Lovenox. You need to take a full 325mg tablet of aspirin daily. Please keep all of your follow-up appts. . Call Dr. [**Last Name (STitle) 4427**] of Dr. [**First Name (STitle) 4223**] if you have heavy bruising, dark or red stools, severe nosebleeds or any other signs of bleeding. Also call your physician if you have palpitatations, dizziness, chest pain or nausea/vomiting. . Dr. [**Last Name (STitle) 4427**] will follow your INR and tell you how much coumadin to take every day. Please get your INR drawn at the [**Hospital 5871**] Hospital on Sunday morning [**8-19**] and have them call results to Dr. [**Last Name (STitle) 4427**]. The covering physician will tell you how much coumadin to take on Sunday. You had 5 mg of coumadin on [**8-14**] and [**8-15**]. This was increased to 10 mg Coumadin on [**8-16**] and [**8-17**]. You should take 6 mg of coumadin on Saturday [**8-18**], then wait to take your coumadin on Sunday with dose as per Dr. [**Last Name (STitle) 4427**]. Followup Instructions: Provider: [**Known firstname **] [**Last Name (NamePattern1) 4427**], MD Phone: [**Telephone/Fax (1) 26828**] Date/Time: Monday [**8-27**] at 4pm. Dr. [**Last Name (STitle) 4427**] will follow INR and prescribe coumadin. Cardiology: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: Wednesday [**9-19**] at 3pm. Please call Dr.[**Name (NI) 4279**] office next week to see if he would like to see you in the next month as well. Completed by:[**2108-8-22**]

[ "V45.89", "427.31", "458.29", "425.4" ]

icd9cm

[ [ [] ] ]

[ "37.27", "37.34", "37.26" ]

icd9pcs

[ [ [] ] ]

6819, 6825

5006, 5834

335, 380

6889, 7007

3751, 4983

8867, 9376

2646, 2861

5949, 6796

6846, 6868

5860, 5926

7031, 8844

2876, 3732

276, 297

408, 1441

1463, 2428

2444, 2630

29,629

122,718

27334

Discharge summary

report

Admission Date: [**2170-6-19**] [**Month/Day/Year **] Date: [**2170-6-23**] Date of Birth: [**2113-2-16**] Sex: M Service: MEDICINE Allergies: Adefovir Attending:[**First Name3 (LF) 943**] Chief Complaint: s/p seizure Major Surgical or Invasive Procedure: Lumbar puncture Central venous line insertion and removal History of Present Illness: 57 yo M w/ hep B cirrhosis on [**First Name3 (LF) **] list brought in by EMS after a witnessed seizure, BG 29- improved to 200 with glucose supplementation and his MS improved. In the middle of transport had a 1 minute episode of a witnessed tonic clonic seizure which resolved w/ 1mg IV ativan. . In the emergency department, initial vitals: HR 60 BP 97/63 RR 17 O2 sat 100 on NRB. In the ER he rec'd levofloxacin, vanc 1g x 1 and ceftriaxone 2g x 1 in addition to acyclovir 600mg IV x 1. Given 5L NS w/ SBPs in the 80s and then started on levophed and a L IJ was placed. Retrocardiac opacity noted and given levofloxacin. Had a few seconds of complete heart block on tele. Concern for meningitis so antibiotics given but no LP performed given concern for CHB. . Upon arrival to the ICU the patient was somnolent- states he feels tired and weak. + frontal HA w/o visual changes, no photophobia, no N/V, no neck pain or stiffness. His HA is chronic and "much longer than 1 month." No CP, no SOB, no focal weakness. Past Medical History: 1. DM-insulin dependent 2. ESLD awaiting [**First Name3 (LF) **]: [**1-29**] hep B, hepatic encephalopathy and recurrent ascites, esophageal varices, portal hypertension 3. History of tuberculosis s/p 6 months INH 4. GERD 5. HTN 6. History of E. Coli septicemia in [**12-1**] 7. Hx of Acute renal failure thought [**1-29**] Hepsera in [**3-4**] Social History: Pt is married with 4 children, lives in [**Location 686**], does not smoke, drink, or use illicit drugs. Family History: No family history of hepatocellular carcinoma or cirrhosis. Physical Exam: On admission: VITAL SIGNS: T 96.0 PO HR 70 BP 88/44 RR 14 O2 100% on NRB -> 100% on 2L GEN: lethargic, sleeping, able to arouse, AOx2 HEENT: MM dry, OP clear, EOMI, PERRL (3 -> 2mm), JVP 6cm- varies greatly w/ respirations CHEST: CTAB anteriorly and laterally CV: hyperdynamic, RRR, no m/r/g ABD: mod distension, no ascites, no tenderness, no masses EXT: WWP, no c/c/e NEURO: AOx2, somnolent but arousable. PERRL, moving all 4 extremities- [**5-1**] bicep, tricep, delt, grip, quad, hamstring, plantarflex, dorsiflex, reflexes 2+ biceps, triceps, patellar, toes downgoing bilaterally. Not participating with cerebellar testing. DERM: no rashes Pertinent Results: On admission: [**2170-6-19**] 08:55AM BLOOD Glucose-135* UreaN-15 Creat-0.8 Na-134 K-3.4 Cl-100 HCO3-23 AnGap-14 [**2170-6-19**] 08:55AM BLOOD ALT-51* AST-89* AlkPhos-278* TotBili-3.9* [**2170-6-19**] 08:55AM BLOOD WBC-4.2 RBC-2.90* Hgb-10.2* Hct-28.9* MCV-100* MCH-35.1* MCHC-35.2* RDW-16.0* Plt Ct-37* [**2170-6-19**] 11:58AM BLOOD Type-MIX pO2-113* pCO2-48* pH-7.29* calTCO2-24 Base XS--3 [**2170-6-19**] 09:58PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-95* POLYS-70 LYMPHS-12 MONOS-18 [**2170-6-19**] 09:58PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-[**Numeric Identifier 4576**]* POLYS-73 LYMPHS-10 MONOS-16 EOS-1 [**2170-6-19**] 09:58PM CEREBROSPINAL FLUID (CSF) PROTEIN-42 GLUCOSE-95 On [**Month/Day/Year **]: [**2170-6-23**] WBC 2.1* Hb 10.2* Hct 29.6* Plt 39* [**2170-6-23**] Gluc 71 BUN 10 Cr 0.8 Na 137 K 4.1 Cl 103 HCO3 30 AG 8 [**2170-6-23**] Ca 8.1* Phos 2.7 Mg 1.5* [**6-19**] CT HEAD IMPRESSION: No evidence of acute hemorrhage. Hypodense appearance of the left insular cortex in some locations is of uncertain significance given the rotated position; however, MR [**Name13 (STitle) 430**] can be considered to evaluate for ischemia/infarction and seizure focus. [**6-19**] CXR IMPRESSION: New left lower lobe airspace opacity could represent aspiration or pneumonia. [**6-19**] CXR IMPRESSION: 1. Left lower lobe aspiration or pneumonia. 2. Left internal jugular venous catheter tip touching outer wall of the upper SVC. ABDOMINAL ULTRASOUND [**6-20**] INDICATION: Hypotension, possible portal vein thrombosis. FINDINGS: Comparison is made with prior CT from [**6-13**] and ultrasound from [**2170-5-31**]. The liver is diffusely echogenic with coarse echotexture consistent with known cirrhosis. There is no focal liver lesion. There is no detectable flow in the main portal vein consistent with portal vein thrombosis. There is normal flow in the right and middle hepatic vein. There is inreased hepatic arterial flow. There is splenomegaly as well as large perisplenic varices. The gallbladder again contains a stone. There is no intra or extra hepatic biliary ductal dilatation. There are bilateral effusions, right greater than left. There is also moderate ascites. IMPRESSION: 1. No detectable portal flow, in this technically difficult study, consistent with thrombotic occlusion vs. extremely low velocity flow. 2. Cirrhotic liver with splenomegaly and varices. 2. Cholelithiasis. Brief Hospital Course: 57 yo male with a history of Hep B cirrhosis presents s/p seizure with ascites likely secondary to portal vein thrombosis. 1. Seizure: Likely secondary to hypoglycemia due to taking NPH and Lantus both mistakenly. He had another seizure en route to the ED after D50 administration and FS recorded as 200. Neurology was consulted, and they felt that this was possible given that CSF glucose lags behind plasma glucose. The patient's FS were monitored closely. Placed on seizure precautions. Initially, the patient was started on meningeal antibiotics; however, these were stopped after LP was negative. Neurology felt that anti-epileptic medications were not necessary given etiology of seizures was likely due to hypoglycemia. HSV PCR was negative and CSF cx preliminary read negative. 2. Hypoglycemia: Pt was taking incorrect insulin dose with both lantus and NPH. Restarted NPH at 12 units [**Hospital1 **] and RISS in the unit and increased to NPH 15 units [**Hospital1 **] on the floor. Sent home with new prescription for NPH 15 units in the am and 12 units at night. Explained he should throw away Lantus and not use it again. To follow-up with [**Last Name (un) **] as an outpatient for continued diabetes control and education. He has a Vietnamese speaking VNA. 3. Altered mental status: Likely post ictal. Monitored and improved with better glycemic control. 4. Hypotension: On initial admission, lactate elevated but improved with fluids. Was initially on Levophed but quickly weaned off. Hypotension not felt to be due to sepsis, but likely secondary to ativan. Nadir BP 80/42 in ED. UA negative. No fever. Mild hypothermia. Cultures all negative to date. No leukocytosis. Initially placed on vancomycin and cefepime and stopped after 48 hours because cultures negative. 5. Cirrhosis: Grade III varices on EGD [**8-4**]. Followed by hepatology while in ICU. PPI daily. Lactulose given. Nadolol re-started during ICU course once hypotension resolved. New complete portal vein thrombosis on abdominal U/S with ascites. 6. EKG changes: ruled out for myocardial infarction with cardiac enzymes. 7. Pneumonitis: Likely aspiration in the setting of seizure. No leukocytosis or fever. Briefly on antibiotics but remains afebrile 2 days after antibiotics stopped. Medications on Admission: Entecavir 0.5 mg po daily Furosemide 20 mg po daily Rifaximin 200 mg po tid Lactulose 15mL po tid Lisinopril 5 mg po daily Calcium Carbonate 500 mg po tid w/ meals Cholecalciferol (Vitamin D3) 800u po daily Nadolol 20 mg po daily Omeprazole 20 mg po daily Spironolactone 25 mg po daily Magnesium Oxide 400 mg po daily Humalog Mix 75-25. 30 units sc bid [**Month/Year (2) **] Medications: 1. Entecavir 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO three times a day. 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO once a day. 7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. MagOx 400 mg Tablet Sig: One (1) Tablet PO once a day. 11. Insulin Please take 15 units of NPH insulin before breakfast and 12 units of NPH insulin before dinner every day. 12. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: see instructions Subcutaneous twice a day: Take 15 units of NPH insulin before breakfast and 12 units of NPH insulin before dinner by subcutaneous injection. Disp:*qs one month* Refills:*2* [**Month/Year (2) **] Disposition: Home With Service Facility: [**Hospital **] Homecare [**Hospital **] Diagnosis: Primary: Seizure [**1-29**] hypoglycemia Aspiration pneumonitis Secondary: Hepatitis B Cirrhosis complicated by portal vein thrombosis Diabetes [**Month/Day (2) **] Condition: stable, blood sugars controlled [**Month/Day (2) **] Instructions: You were admitted to the hospital after a seizure. We felt that this was due to a dangerously low blood sugar, most likely from taking too much insulin. You were monitored closely in the ICU and you had no further seizures. You also had a lumbar puncture to rule out meningitis and this was negative. Your blood pressure was low in the ICU and you were given IVF to treat this. . We have made the following changes to your medications: 1. You should stop lantus 2. We have decreased your insulin to 15 units in the morning before breakfast and 12 units at night before dinner. 3. You should now take only NPH insulin. 4. You should stop taking your lisinopril blood pressure pill until you see your PCP. . If you experience dizziness, lightheadedness, fainting, chest pain, difficulty breathing or a seizure, please contact your doctor or go to the emergency room. . Please keep the appointments listed below. Followup Instructions: We have scheduled an appointment with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 66992**] for 1pm on monday [**6-25**]. Please keep a record of your blood sugars 3 times a day and bring this to your PCP. . Call [**Last Name (un) **] at [**Telephone/Fax (1) 58905**] to schedule an appointment to follow-up your diabetes. . Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2170-7-25**] 8:40 . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2170-9-5**] 3:00 . Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2170-11-15**] 2:00

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icd9cm

[ [ [] ] ]

[ "38.93", "03.31" ]

icd9pcs

[ [ [] ] ]

5075, 6368

292, 352

2643, 2643

10212, 10996

1902, 1963

7396, 9684

1978, 1978

9713, 10189

241, 254

380, 1396

2657, 5052

6383, 7370

1418, 1764

1780, 1886

20,252

101,600

17486+56863

Discharge summary

report+addendum

Admission Date: [**2157-2-14**] Discharge Date: [**2157-5-26**] Date of Birth: [**2084-7-29**] Sex: M Service: BLUE [**Doctor First Name 147**]. HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old male with a complicated past surgical history of appendectomy, multiple exploratory laparotomies for small bowel obstruction and lysis of adhesions and multiple ventral hernia repairs, the latest of which resulted in enterocutaneous fistula through a [**Doctor Last Name 4726**]-Tex/Marlex composite mesh. The patient was transferred from a hospital in [**Location (un) 7498**] complaining of enterocutaneous fistulae. PAST MEDICAL HISTORY: Significant for: 1. Coronary artery disease. 2. Atrial fibrillation. 3. Atrial flutter. 4. Severe chronic obstructive pulmonary disease. PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile at 97.9 degrees. The pulse was irregularly irregular at a rate of 71. Blood pressure 110/65. Respiratory rate of 18. Saturating at 95% on three liters nasal cannula. The patient was alert and oriented times three. Cardiovascular examination was significant for irregularly irregular rate. S1, S2. The lung examination revealed hoarse breath sounds with transmitted sounds and end expiratory wheezing. The abdominal examination had positive bowel sounds. A Vac dressing applied over two enterocutaneous fistulae in the lower quadrants and a third enterocutaneous fistula through the mesh in the right abdominal area. LABORATORY ON ADMISSION: White count 8.3, hemoglobin and hematocrit of 9.7/29.6, platelet count 429,000. Serum chemistries: Sodium 134, potassium 4.7, chloride 96, CO2 30, BUN 25, creatinine 0.5, glucose 88. Calcium 8.3, magnesium 1.9, phosphorus 4.7. AST and ALT 10 and 9 respectively. Alk phos was 211. Total bilirubin was 0.5. Amylase and lipase were 108 and 38. Albumin was 2.2. PT/PTT were 13.5 and 27.1 respectively with an INR of 1.2. HOSPITAL COURSE: A vacuum dressing was put over the abdominal wound site with enterocutaneous fistulae and dressing was changed regularly by the surgical team. The patient was made NPO and then initially started on TPN via PICC line that was placed [**2157-2-14**]. G-tube was changed [**2-15**] and patient was slowed started on J-tube feeding at one-half strength starting at 20 cc/hr and slowly increased to a goal rate of 100 cc. The patient was restarted at two-thirds strength at 20 cc and rate increased incrementally. Nutritional consult follow up was done to assess caloric count and to make sure that the patient was receiving adequate nutrition. The week before surgery the patient underwent abdominal chest wall preparation with Hibiclens everyday and was optimized for Operating Room on [**2157-4-26**]. On [**4-26**] the patient underwent two part surgery. The first part was exploratory laparotomy with removal of [**Doctor Last Name 4726**]-Tex and Marlex mesh, lysis of adhesions, enterectomy, enterostomy and feeding jejunostomy. During this surgery, 18 inches of small bowel starting three feet distally to the ligament of Treitz were removed because the segment _________ anastomosis of enterocutaneous fistulae. This first part of the surgery was done by Dr. [**Last Name (STitle) 957**] and the Blue Surgery team. The second part of the surgery was done by Dr. [**Last Name (STitle) **] and the Plastic Surgery team and the procedures included bilateral muscle flap component separation, abdominal wall reconstruction with left pedicle tensor fascia lata fascia and split thickness skin graft of approximately 440 cm squared. The patient underwent the two part surgery without any complication and postoperatively was transferred to the Trauma Surgical Intensive Care Unit intubated in stable condition. On postoperative day one, the patient was extubated without complications. The patient was restarted on tube feeds at one-half strength of 20 cc and it was advanced in rate. During his stay in the Surgical Intensive Care Unit the patient received appropriate antibiotics and was transferred to the floor on postoperative day six without any complications. While on the floor, the surgical wound had the vacuum dressing changed every other day by the Plastics Service. On postoperative day seven, the patient tolerated clear liquids and was advanced to a regular diet as tolerated with discontinuation of TPN and tube feed cycled only during the night. By discharge, the surgical wound has granulated beautifully but still requires vacuum dressing change every other day. The patient is eating regular diet with Boost t.i.d. in addition to two-thirds strength tube feed at 90 cc/hour overnight. I will now review the rest of the hospital course stay by system and highlight the most relevant events. 1. Cardiovascular system: The patient has a significant past medical history of coronary artery disease and atrial fibrillation and atrial flutter with occasional PVCs. The patient was put on telemetry and cardiologist consulted. On [**2-16**], transthoracic echocardiogram was done which revealed a normal wall thickness with a left ventricular cavity and left ventricular ejection fraction of greater than or equal to 40%. The right ventricle was noted to be dilated by the systolic right ventricular function was within normal limits. The patient was started on intravenous Lopressor for rate control and monitored on telemetry. Postoperatively, the patient had supraventricular tachycardia and Cardiology Service was consulted again and this was controlled with intravenous Lopressor, digoxin and amiodarone. The patient was diuresed with intravenous Lasix and did well. Towards the end of his hospital stay, the patient had an episode of bradycardia and this was resolved with discontinuation of amiodarone and decrease in the dose of Lopressor. 2. Respiratory system: The patient has a history of long-standing severe chronic obstructive pulmonary disease. The patient was continued on his preadmission medications which included fluticasone 110 mcg two puffs inhaler b.i.d., albuterol nebulizer one treatment q. 3h. p.r.n. and Atrovent nebulizer treatment one treatment q. 4h. p.r.n. as well as albuterol one to two puffs inhaler q. 6h. p.r.n. The patient was also continued on his p.o. prednisone 5 mg q. day. During his prolonged hospital stay, the patient has always had productive sputum and had transmitted sounds on lung examinations. The patient underwent chest PT. Chest x-ray on [**4-12**] showed questionable right lower lobe infiltrate, however, clinically patient did not develop any signs or symptoms of pneumonia. 3. Renal system: The patient's creatinine value was 0.5 on admission and throughout his prolonged hospital stay the creatinine values stayed within normal limits. 4. Genitourinary system: The patient had Foley catheter in postoperatively to prevent contamination of his skin graft donor site with urine. The Foley catheter was eventually discontinued with healing skin graft donor site and patient received terazosin q. hs. The tip of the glans of the penis had a small ulceration with Foley catheter use. With appropriate skin care provided, the ulceration has improved and Foley catheter was discontinued. 5. Hematology: On [**4-11**] to 27th, the patient received two units of packed red blood cells with a decrease in hematocrit. During his operation on [**4-26**] the patient also received three units of packed red blood cells and three units of fresh frozen plasma. Since his operation, his hematocrit has been stable at a level of 30.2 +/- 1. The patient is currently on iron sulfate 325 mg b.i.d. 6. Endocrine system: The patient was covered with regular insulin sliding scale but did not require much dosage. During his prolonged hospital stay, the patient received steroids, parenteral and p.o. forms, because of his history of severe chronic obstructive pulmonary disease and currently remains on prednisone 5 mg p.o. q. day. 7. Infectious Disease: On [**3-3**] patient's Kefzol was changed to penicillin for presumed local cellulitis around the abdominal wound site, however, patient remained afebrile. On [**3-21**] gentamicin was added to penicillin for persistent cellulitis around the surgical wound site. Postoperatively, patient was started on gentamicin and levofloxacin. Vancomycin was added to his gentamicin and levofloxacin when the tissue culture from [**4-26**] came back with Proteus, Pseudomonas and methicillin-resistant Staphylococcus aureus. Catheter tip culture from [**5-1**] also came back positive for MRSA and patient was continued on vancomycin, levofloxacin and gentamicin. On [**5-4**] the urine culture grew yeast, more than 100,000 colonies, and patient was started on fluconazole 400 mg. Subsequent urine culture was negative times two and fluconazole was discontinued. Levofloxacin, vancomycin, gentamicin and fluconazole are now currently discontinued. Patient is now only on Keflex 500 mg p.o. q.i.d. Erythema and induration around the G-tube site was noted and was treated with Neosporin topical antibiotic ointment and Betadine with dressing changes. During the early part of the patient's admission, the patient was also found to have an area that looked like a fungal infection over his gluteal regions and has been getting clotrimazole cream applied two times a day to the affected area. 8. Pain management: The patient was initially managed kept on morphine PCA and was switched over to p.o. morphine p.r.n. Neurontin p.o. was added because of patient's complaining of burning and cramping pain. Postoperatively, patient was initially sedated with propofol while in Surgical Intensive Care Unit. When he was awake, patient was using morphine sulfate PCA. On discharge to the floor patient received Roxicet 10 cc p.o. q. 4h. with morphine 2 mg IV q. 4h. p.r.n. for breakthrough pain. During Vac dressing changes, patient was premedicated with morphine 4 mg to 12 mg IV q.o.d. as needed in increments of 2 mg IV. 9. Neurology and Psychiatry: Patient remained alert and oriented times three without mental status changes. The patient is currently on Celexa and Paxil. Toward the end of his prolonged hospital stay, the patient complained of some moderate tremors of the upper and lower extremities and was evaluated by the Neurology consulting service. It was recommended that the patient discontinue Neurontin and mirtazapine and patient was started on quinine sulfate 300 mg p.o. t.i.d. for muscle relaxation. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: Discharged to [**Hospital 1514**] [**Hospital **] Hospital. DISCHARGE DIAGNOSES: 1. Enterocutaneous fistulae status post exploratory laparotomy, removal of [**Doctor Last Name 4726**]-Tex and Marlex mesh, lysis of adhesions, enterectomy, enterostomy and feeding jejunostomy, bilateral muscle flap component separation, abdominal wall reconstruction with left pedicle tensor fascia lata and split thickness skin graft. 2. Coronary artery disease. 3. Severe chronic obstructive pulmonary disease. 4. Atrial fibrillation. 5. Atrial flutter. DISCHARGE MEDICATIONS: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**] Dictated By:[**Last Name (NamePattern1) 10201**] MEDQUIST36 D: [**2157-5-25**] 23:09 T: [**2157-5-25**] 20:42 JOB#: [**Job Number 48834**] Name: [**Known lastname **], [**Known firstname 7540**] Unit No: [**Numeric Identifier 9067**] Admission Date: [**2157-2-14**] Discharge Date: [**2130-1-16**] Date of Birth: [**2084-7-29**] Sex: M Service: ADDENDUM TO DISCHARGE SUMMARY: DISCHARGE MEDICATIONS: 1. Fluticasone propiram 110 micrograms two puffs inhaled twice a day. 2. Nystatin Oral suspension, 5 cc p.o. q. six, swish and swallow. 3. Clotrimazole Cream applied topically twice a day to the gluteal region. 4. Albuterol nebulizer one treatment q. three hours p.r.n. 5. Atrovent one treatment nebulizer q. four hours p.r.n. 6. Celexa 20 mg p.o. q. day. 7. Paxil 20 mg p.o. q. a.m. 8. Miconazole powder 2%, one application topically p.r.n. 9. Roxicet 5 to 10 cc p.o. q. four hours. 10. Morphine sulfate 2 mg intravenous four q. hours p.r.n. for breakthrough pain. 11. Dulcolax 10 mg p.o. q. day p.r.n. constipation. 12. Zinc sulfate 220 mg p.o. q. day. 13. Digoxin 0.125 mg p.o. q. day. 14. Metoprolol 12.5 mg p.o. twice a day; please hold for systolic blood pressure less than 110 or heart rate less than 55. 15. Neosporin, one application topically twice a day with G-tube dressing changes. 16. ........iodine compress and ointment, one application topically twice a day to G-tube site after cleaning. 17. Ferrous sulfate 325 mg p.o. twice a day. 18. Prednisone 5 mg p.o. q. day. 19. Keflex 500 mg p.o. q. six hours. 20. Terazosin 2 mg p.o. q. h.s. 21. Glycerine suppository, one suppository per rectum p.r.n. constipation. 22. Albuterol one to two puffs by inhaler q. six hours p.r.n. 23. Morphine sulfate, 4 to 12 mg intravenous q.o.d. p.r.n. VAC dressing change. Give initial dose of 4 mg and give additional doses in increments of 2 mg as needed during dressing change. 24. Diphenhydramine 25 mg p.o. q. six hours p.r.n. 25. Quinine sulfate 325 mg p.o. three times a day. DISCHARGE INSTRUCTIONS: 1. The patient is to follow-up with the Plastic Service in two weeks. 2. The patient is to follow-up with Dr.[**Name (NI) 9068**] office; please call Dr.[**Name (NI) 9068**] office for an appointment. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 486**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2157-5-25**] 23:16 T: [**2157-5-26**] 00:13 JOB#: [**Job Number 9069**]

[ "682.2", "427.31", "996.52", "427.32", "496", "285.1", "998.6", "E878.6", "996.62" ]

icd9cm

[ [ [] ] ]

[ "54.72", "86.28", "99.15", "96.6", "97.02", "45.62", "86.69", "86.74", "54.59", "46.39", "38.93" ]

icd9pcs

[ [ [] ] ]

10680, 11143

11711, 13302

1967, 10555

13326, 13753

10570, 10659

195, 645

1522, 1949

668, 831

30,154

170,021

3730

Discharge summary

report

Admission Date: [**2178-4-17**] Discharge Date: [**2178-4-22**] Date of Birth: [**2106-2-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1042**] Chief Complaint: fevers Major Surgical or Invasive Procedure: None History of Present Illness: 72 yo male with HTN who arrived on the floor from the emergency department with respiratory distress. . He presented to the ED with fevers, chills and weakness for 48 hrs. Per ED notes, spike at home to 104. Of note, ha had a prostate biopsy 5 days prior to presentation and reported hematuria but no clots in the urine. He also reports 2 episodes of diarrhea over last couple of days. No sick contacts. Denied any cough, runny nose, headaches, abdominal pain. . In the ED, VS 102.7, hr 120, 153/91, RR 20, Sats 99% on RA. He was diaphoretic and febrile in the Ed. He received ceftriaxone 1gm (22:00), levofloxacine 500 iv x1 (2100). BP's into the 181/118. He received 10 mg IV diltiazem (00:10) . On arrival to the floor, T 101.8, patient found tachypneic 32-33, BP 180/114, tachycardic 130's, sats 97% 3 L. + wheezing. Per nursing report at some point his HR went into the 170's. He received atrovent nevs, albuterol, racemic epinephyrine, epi sub q, 25 mg IV benadryl, 125mg solumedrol, demerol and 650 tylenol after concern for allergic reaction. Initial ABG: 73.36/36/239, 2nd ABG 7.48/25/183. he never drop his BP while on the floor. Past Medical History: HTN s/p prostate biopsy secondary to abnormal exam Social History: Lives with his wife. Retired bus driver. + smoking. Alcohol + . Family History: non contributory Physical Exam: Vitals: T: 101.8 P 124: R:28 BP:149/97 SaO2: 100% NRB General: Awake, alert HEENT: dry oral mucose, ? thursh, Neck: no JVD. supple. Pulmonary: Lungs ocassional expiratory wheezing. Cardiac: RRR, nl. S1S2, tachycardic, holosystolic murmur to the apex Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: no edema. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Skin: no rashes or lesions noted. Neurologic: alert, oriented x 3. movilizing all extremities spontaneously Pertinent Results: [**2178-4-17**] 08:45PM WBC-11.6* RBC-4.41* HGB-13.4* HCT-39.2* MCV-89 MCH-30.5 MCHC-34.3 RDW-13.7 [**2178-4-17**] 08:45PM NEUTS-89.1* LYMPHS-6.9* MONOS-3.7 EOS-0.2 BASOS-0.1 [**2178-4-17**] 08:45PM PLT COUNT-286 [**2178-4-17**] 08:45PM GLUCOSE-154* UREA N-18 CREAT-1.5* SODIUM-135 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-23 ANION GAP-15 [**2178-4-17**] 11:08PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.024 [**2178-4-17**] 11:08PM URINE BLOOD-LGE NITRITE-POS PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-SM [**2178-4-17**] 11:08PM URINE RBC-21-50* WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-1 ECG [**4-17**] Sinus tachycardia. Non-specific ST-T wave changes. Consider ischemia. Compared to the previous tracing of [**2178-4-17**] no change. CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2178-4-18**] 10:55 AM CTA CHEST W&W/O C&RECONS, NON- Reason: please assess for PE [**Hospital 93**] MEDICAL CONDITION: 72 year old man with hx HTN, recent prostate bx here with fevers, SOB, tachycardia REASON FOR THIS EXAMINATION: please assess for PE CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Recent prostate biopsy here with fevers, shortness of breath, tachycardia, please assess for PE. COMPARISON: Chest x-ray of [**2178-4-18**]. TECHNIQUE: Multiple MDCT images were obtained before and after the administration of intravenous Optiray. No enteric contrast was administered and coronal and sagittal reformatted were than derived. FINDINGS: There is no CT evidence for pulmonary emboli. No aortic dissection is demonstrated and there is no evidence for intramural hematoma. There are vascular, including coronary, artery calcifications. There are calcified pleural plaques. Emphysematous changes are seen, and there is bibasilar dependent atelectasis with a small right pleural effusion. Heart size is normal. There is no abnormal bowing of intraventricular septum or enlargement of the right heart. Three hypodensities are seen in the liver, the largest measuring 1.2 cm in the dome of the liver and two in the in the left lobe of the liver, too small to characterize, likely cysts. The visualized portion of the spleen and right kidney appear normal. OSSEOUS STRUCTURES: Mild degenerative changes are seen at numerous levels in the spine with some symmetric sclerosis of the posterior elements superiorly. IMPRESSION: 1. No pulmonary embolus or aortic dissection. 2. Hepatic hypodense nodules of undetermined nature, for which ultrasound is recommended for characterization. ABDOMEN U.S. (COMPLETE STUDY) [**2178-4-20**] 3:56 PM ABDOMEN U.S. (COMPLETE STUDY) Reason: please further evaluate hypodensities in liver [**Hospital 93**] MEDICAL CONDITION: 72 year old man with SOB, recent prostate biopsy and now here with NSTEMI with liver densities on CT chest REASON FOR THIS EXAMINATION: please further evaluate hypodensities in liver HISTORY: 72-year-old male with recent prostate biopsy, now with hypodensities in the liver on CT chest. COMPARISON: CTA chest of [**2178-4-18**]. ABDOMINAL ULTRASOUND: Multiple cysts are seen within the liver, the largest one measuring 1.9 x 1.7 x 1.6 cm. These correspond to the hypodensities that were seen on the CT chest performed 2 days prior. Otherwise, the liver demonstrates normal echogenicity and no other focal lesions. Portal venous flow is normal and hepatopetal. The common duct is not dilated and measures 6 mm. The gallbladder appears normal without evidence of stones. The pancreatic tail is not well visualized due to overlying bowel gas; the visualized portions of pancreas appear normal. The spleen is not enlarged. The right kidney measures 12.0 cm and the left kidney measures 11.47 cm; there is no hydronephrosis, stones, or masses. There is no ascites. While the distalmost aorta is obscured by overlying bowel gas there is focal aneurysmal dilatation of the distal aorta measuring 3.3 cm, compared to the aorta directly above it which measures 2.2 cm. IMPRESSION: 1. Hypodense lesions on the CT chest correspond to hepatic cysts. Otherwise, liver appears normal. 2. Focal aneurysmal dilatation of distal aorta measuring 3.3 cm. Aortic bifurcantion not seen due to overlying bowel gas. Echo ([**4-20**]) The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is an inferobasal left ventricular aneurysm. There is moderate regional left ventricular systolic dysfunction with akinesis of the basal inferior and inferolateral segments, severe hypokinesis of the mid inferior and inferolateral segments and mild hypokinesis of all other segments. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The remaining left ventricular segments are hypokinetic. 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. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Global LV systolic dysfunction with the inferior wall being worst affected. Inferobasal aneurysm. Diastolic dysfunction. Mild mitral regurgitation. Brief Hospital Course: The patient was admitted to the MICU for respiratory distress which responded to stress dose steroids and inhaler therapy. During a period of high blood pressure and tachycardia, the patient was noted to have a mild NSTEMI which was medically managed. He was also noted to be in acute renal failure, which resonded to gentle hydration. He was also noted to have a pyuria and started empirically on cefepime and ciprofloxacin. He was subsequently transferred to the floor with reasonable control of blood pressure and heart rate. He was started on high dose simvastatin. Cardiology consult recommended 4 week outpatient follow up. His urine culture and sensitivities returned, and his antibiotic regimen was converted to sulfamethoxazole/trimethoprim twice daily for a total of 4 weeks given the reduced tissue penetration to the prostate of sulfa antibiotics. Outpatient follow up for his new diagnosis of prostate cancer was to be arranged by his spouse. On discharge, the patient was feeling at baseline without any significant symptoms. Medications on Admission: valsartan amlodipine Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO twice a day. Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*1* 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 6. Septra DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 4 weeks: For urinary tract infection. Disp:*56 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Prostate adenocarcinoma 2. Non-ST elevation myocardial infarction 3. Acute renal failure, resolved 4. Sepsis, resolved 5. Urinary tract infection following prostate biopsy 6. Hypertension 7. Hyperlipidemia Discharge Condition: Stable Discharge Instructions: Please contact your primary care physician if you develop shortness of breath, chest pain, palpitations, increasing edema in your legs, or difficulty urinating. Followup Instructions: 1. Please schedule a follow up appointment with Urology 2. Cardiology Clinic Monday [**5-18**] with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] at 2:20pm located on [**Hospital Ward Name 23**] 7 3. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14290**], OD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2178-7-22**] 1:00

[ "410.71", "E878.8", "995.92", "599.0", "272.4", "401.9", "584.9", "185", "998.59", "038.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9533, 9539

7782, 8827

322, 329

9792, 9801

2273, 3193

10010, 10390

1671, 1689

8898, 9510

4991, 5098

9560, 9771

8853, 8875

9825, 9987

1704, 2254

276, 284

5127, 7759

357, 1499

1521, 1574

1590, 1655

4,423

121,780

47696

Discharge summary

report

Admission Date: [**2139-9-1**] Discharge Date: [**2139-9-8**] Date of Birth: [**2084-3-23**] Sex: F Service: CARDIOTHORACIC Allergies: Vancomycin And Derivatives / Penicillins / Dilantin / Phenergan / Imipenem Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2139-9-2**] Mitral Valve Repair(28mm [**Company 1543**] Ring) History of Present Illness: Ms. [**Known lastname 100734**] is a 55 yo female with known mitral regurgitation following a bout of endocarditis in [**2122**]. That was complicated by embolic CVA and seizures. Over the last year, she has noted increasing dyspnea on exertion with walking 20ft and during flight of stairs. She has been followed closely with serial ECHO and underwent cardiac MRI in [**2139-1-13**] with confirmed severe MR with effective forward ejectin fraction of 25%. She has been admitted for preoperative cardiac catheterization followed by surgical intervention. Past Medical History: 1. History of Preeclampsia ('[**22**]) 2. SBE ('[**22**]) 3. CVA ('[**22**]) - residual left sided weakness, difficulty with decision making, ataxia, anosmia (improving), left arm parasthesias 4. Seizures (started '[**22**], last one 8 yrs ago) 5. Depression 6. Mitral regurg/congestive heart failure 7. C-Sx ('[**22**]) 8. s/p tubal ligation ('[**24**]) 9. Bifrontal craniotomy with revision ('[**37**]) Social History: Previously worked as nurse, at home x 15 yrs. Married one son, no smoking, drugs. Occ etoh. Family History: Mother w/[**Name (NI) **], father heart dx alive and, one sister. [**Name (NI) **] w/"brain tumor". Physical Exam: Vitals: 115/55, 58, 18 General: WDWN female in NAD HEENT: Oropharynx benign, EOMI Neck: Supple, no JVD Lungs: CTA bilaterally Heart: Regular rate and rhythm, [**4-19**] holosytolic murmur best heard at left lower sternal border Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, trace edema Pulses: 2+ distally Neuro: Alert and oriented, CN 2- 12 grossly intact, mild left sided weakness Pertinent Results: [**2139-9-1**] 08:10AM BLOOD WBC-4.9 RBC-4.16* Hgb-11.9* Hct-34.9* MCV-84 MCH-28.7 MCHC-34.2 RDW-13.4 Plt Ct-255 [**2139-9-1**] 08:10AM BLOOD PT-12.4 PTT-25.9 INR(PT)-1.0 [**2139-9-1**] 08:10AM BLOOD Glucose-103 UreaN-21* Creat-0.9 Na-140 K-4.4 Cl-104 HCO3-27 AnGap-13 [**2139-9-1**] 08:10AM BLOOD ALT-31 AST-23 LD(LDH)-220 AlkPhos-99 Amylase-81 TotBili-0.3 [**2139-9-1**] 08:10AM BLOOD Albumin-4.6 [**2139-9-1**] 03:08PM BLOOD %HbA1c-5.7 [**2139-9-1**] ECHO: The left atrium is markedly dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are severely thickened/deformed. There is moderate/severe mitral valve prolapse. There is partial mitral leaflet flail. There is moderate thickening of the mitral valve chordae. An eccentric jet of severe (4+) mitral regurgitation is seen. There is a small pericardial effusion. [**2139-9-1**] Cardiac Cath: 1. Selective coronary angiography of this right dominant system revealed no coronary artery disease. 2. Resting hemodynamics demonstrated normal systemic arterial pressures. LVEDP was measured when the JR4 catheter was inadvertently advanced into the LV. LVEDP was elevated at 22 mmHg, consistent with elevated left sided filling pressures. There was no transaortic gradient on pullback of catheter from LV to aorta. Chest X-Ray: [**Known lastname **],[**Known firstname 674**] [**Medical Record Number 100735**] F 55 [**2084-3-23**] Radiology Report CHEST (PA & LAT) Study Date of [**2139-9-6**] 6:23 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2139-9-6**] SCHED CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 100736**] Reason: ? effusion [**Month (only) **] hct [**Hospital 93**] MEDICAL CONDITION: 55 year old woman with s/p mv repair REASON FOR THIS EXAMINATION: ? effusion [**Month (only) **] hct Wet Read: DSsd SUN [**2139-9-6**] 6:42 PM Slightly decreased small bilateral pleural effusions. Unchanged bibasilar atelectasis. Final Report PA AND LATERAL CHEST INDICATION: 55-year-old woman status post mitral valve repair. COMPARISON: Multiple prior studies, most recent dated [**2139-9-4**]. FINDINGS: The degree of cardiomegaly and mediastinal widening is stable. Bilateral pleural effusions are slightly smaller. Bibasal atelectasis is present. Pulmonary vascularity is slightly increased, there is no frank pulmonary edema. Right IJ catheter ends in the right atrium. IMPRESSION: 1. Slight interval decrease in bilateral small pleural effusions. 2. Bibasal atelectasis. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Name (STitle) **] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] Approved: TUE [**2139-9-8**] 10:52 AM Head CT: [**Known lastname **],[**Known firstname 674**] [**Medical Record Number 100735**] F 55 [**2084-3-23**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2139-9-6**] 11:30 AM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2139-9-6**] SCHED CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 100737**] Reason: r/o bleed, ? acute changes with confusion [**Hospital 93**] MEDICAL CONDITION: 55 year old woman with s/p mv repair REASON FOR THIS EXAMINATION: r/o bleed, ? acute changes with confusion CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: PXDb SUN [**2139-9-6**] 1:52 PM No intra- or extra-axial hemorrhage, or acute major vascular territorial infarcts to explain patient's recent change in mental status. Stable bifrontal encephalomalacia. Final Report INDICATION: 55-year-old woman status post MV repair. Rule out bleed, acute changes with confusion. COMPARISON: [**2139-7-13**]. MR [**First Name8 (NamePattern2) 767**] [**2139-6-26**]. TECHNIQUE: Non-contrast head CT. FINDINGS: Unchanged appearance of extensive bifrontal encephalomalacia with volume loss and dilated lateral ventricular frontal horns, at site of extensive frontal craniotomy and cranioplasty. The previously noted small left parafalcine meningioma is not well visualized on non-contrast study; however, was better characterized on the MR [**First Name8 (NamePattern2) 767**] [**2139-6-26**]. There are no foci of intra- or extra-axial hemorrhage, mass effect, or shift of normally midline structures. There is no major vascular territorial infarct. Otherwise, the ventricles and sulci are normal in size and configuration and the [**Doctor Last Name 352**] and white matter differentiation is well preserved. A dense focus of high attenuation, probably calcification is noted in the right anterior temporal region (2A:18). Otherwise, the osseous and soft tissue structures are unremarkable. IMPRESSION: 1. No intra- or extra-axial hemorrhage, or acute major vascular territorial infarct. 2. Unchanged extensive bifrontal encephalomalacia, with volume loss and associated slight bilateral frontal [**Doctor Last Name 534**] dilation. 3. Previously noted left parafalcine meningioma is not well characterized on the current study; however, was recently well-seen on the MR study from [**6-26**], [**2139**] (MR). The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**] Approved: SUN [**2139-9-6**] 2:31 PM Imaging Lab TEE: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 674**] [**Hospital1 18**] [**Numeric Identifier 100738**]Portable TEE (Complete) Done [**2139-9-2**] at 11:31:52 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2084-3-23**] Age (years): 55 F Hgt (in): BP (mm Hg): 140/85 Wgt (lb): HR (bpm): 82 BSA (m2): Indication: Murmur. Shortness of breath. Valvular heart disease. ICD-9 Codes: 786.05, 424.0 Test Information Date/Time: [**2139-9-2**] at 11:31 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD Test Type: Portable TEE (Complete) 3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW06-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *6.2 cm <= 4.0 cm Left Atrium - Four Chamber Length: *9.4 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Aorta - Sinus Level: 2.1 cm <= 3.6 cm Aorta - Ascending: 2.2 cm <= 3.4 cm Aorta - Arch: 2.4 cm <= 3.0 cm Findings The anterior mitral leaflet is mildly thickened with some restricted motion. There is posterior leaflet flail located at P2 and P3 segments Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Marked LA enlargement. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal LV wall thickness. Normal LV cavity size. Normal regional LV systolic function. No LV mass/thrombus. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Simple atheroma in ascending aorta. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Partial mitral leaflet flail. Mitral leaflets fail to fully coapt. Eccentric MR jet. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is markedly dilated. No mass/thrombus is seen in the left atrium or left atrial appendage. Left ventricular wall thicknesses and cavity size are normal. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is partial mitral leaflet flail. The mitral valve leaflets do not fully coapt. An eccentric,anteriorly directed jet of Severe intensity is aslo viosualized. POST: 1. Preserved biventricular systolci function. 2. A bioprosthetic ring is seen in the mitralposition. Well seqated and mechanically stable. 3. Mean gradient 4.00 mm Hg. MVA = 2.5 cm2. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2139-9-7**] 15:54 Brief Hospital Course: Mrs. [**Known lastname 100734**] was admitted and underwent preoperative evaluation which included echocardiogram and catheterization. Please see result section for details. Preoperative evaluation was otherwise unremarkable and she was cleared for surgery. On [**9-2**], Dr. [**Last Name (STitle) **] performed a mitral valve repair. For surgical details, please see seperate dictated operative note. Following the operation, she was brought to the CVICU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. She was started on low dose beta blockade. She maintained stable hemodynamics and transferred to the SDU on postoperative day one. Subsequently, chest tubes and pacing wires were discontinued without incident. The pt made excellent progress with physical therapy, showing good strength and mobility before discharge. The pt did have an episode on the evening of POD 4 where she became agitated and paranoid. Psychiatry consult was obtained. The pt was treated with haldol. There was no recurrence. Neurology was asked to reconsult. Head CT did not reveal any acute hemorrhage or infarct. EEG was performed, given the patient's seizure history. Results are pending at the time of discharge. The remainder of the hospital course was uneventful. By the time of discharge the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. She was discharged to home on POD 6. Medications on Admission: Lipitor 10 qd, Celexa 40 qd, Digoxin, Lamictal 200 [**Hospital1 **], Gabapentin 300 [**Hospital1 **], Lisinopril 5 qd, Aspirin 81 qd Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 7. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: Please continue for full 7 days. Disp:*7 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Mitral Valve Repair Congestive Heart Failure(Chronic, Systolic) History of Mitral Valve Endocarditis - Mitral Regurgitation History of Embolic CVA Bifrontal Meningioma History of Seizures Depression Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [**Last Name (STitle) **] in [**4-18**] weeks, call for appt Dr. [**Last Name (STitle) 120**] in [**2-15**] weeks, call for appt Dr. [**Last Name (STitle) **] in [**2-15**] weeks, call for appt Completed by:[**2139-9-8**]

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icd9cm

[ [ [] ] ]

[ "38.93", "37.22", "88.56", "39.61", "99.04", "35.12" ]

icd9pcs

[ [ [] ] ]

15411, 15469

12456, 13940

359, 426

15712, 15719

2105, 4236

16055, 16283

1565, 1667

14123, 15388

5736, 5773

15490, 15691

13966, 14100

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1682, 2086

300, 321

5805, 11002

454, 1010

5310, 5696

1032, 1439

1455, 1549

23,390

153,893

23302+57345

Discharge summary

report+addendum

Admission Date: [**2144-2-7**] Discharge Date: [**2144-2-20**] Date of Birth: [**2076-7-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Acetaminophen / Percocet Attending:[**First Name3 (LF) 783**] Chief Complaint: transfer from OSH for SDH Major Surgical or Invasive Procedure: L subclavian line placement intubation History of Present Illness: 67 YO F with HTN, CAD, COPD, h/o craniotomy, duraplasty, and VP shunt for HTN encephalopathy who was initially presented [**2-7**] w/increased lethargy and found to have bilateral subdural hematomas secondary to fall (unclear etiology) and admitted to neurosurgery. Neurosurg recommended conservative therapy and watch patient with serial CT scans and held anticoagulation. Pt was loaded on dilantin for question of seizures. Patient became increasingly agitated and ativan/haldol was given, and subsequently she was intubated for MS changes and placed on propofol. Patient then became hypotensive and neosynephrine was started, although her BP meds were continued during this time. Sepsis was thought to be likely given fevers to 101.4. In setting of neo had elevation in troponin to. She only remained intubated for one day and was quickly weaned off of the neo after extubation. Pt had recent long admission in [**2143-10-25**] with right ischemic foot admitted to vascular for rAKA, found unresponsive and intubated w/MRI showed non-communicating hydrocephalous (htn encephalopathy). NSICU put craniotomy, VP shunt, and duraplastly. The course was prolonged with respiratory failure, pulmonary edema (reintubated X 3), klebsiella PNA, and NSTEMI but pt was eventually sent to rehab. Was readmitted [**1-9**] for revision R AKA which now shows dehiscence of medial aspect, no infection. Past Medical History: *htn *cad *copd *gout *anemia ,chronic *anxiety *nausea *s/p aorto-bifem *s/p fem-[**Doctor Last Name **] *s/p several digit amputations *stroke *anxiety *hx of flash pulmonary edema, with respiratiory failure , requiring endotracheal intubation x3 ,compensated [**11-15**]. *klebsella pneumonia secondary to aspiration treated [**11-15**] *hyperlipdemia *troponin leak related to rate related ischenia [**11-15**] *s/p ABF [**2-14**] *s/p fem-[**Doctor Last Name **] bpg [**2-14**] *s/p multiple digit amputations *s/p PEG placement [**11-15**] *s/p Rt. AKA [**11-15**] *s/p subocciptual crainotomy with partial C1 laminectomy and *cebellar left hemispherectomy with durgen duraplasty [**10-16**] *s/p left frontal VP shumt with med. pressure valve [**11-15**] *s/p rt. PICC [**11-15**] Social History: prior to [**2143-10-25**] pt lived at home with her husband. [**Name (NI) **] she used to smoke, but quit many years ago. denies EtOH or other drug use. Family History: unknown Physical Exam: Vitals: 97.5 110/70 76 20 100% 2L NC FS 114 wt 46.2 kg Gen: somnolent and difficult to arouse. HEENT: MMM with white covering on tongue and roof of mouth. PERRLA, EOMI. Neck: with extremely limited range of motion. Denies pain on passive rotation but only able to move neck approximately 10 degrees to either side. Flexion and extension extremely limited. CV: distant HS, difficult to appreciate with copious upper airway noise. Lungs: loud upper airway noise. Abd: PEG in place with no erythema or tenderness. soft, non-tender, non-distended. + well healed midline scar through midline below umbilicus. Ext: R leg s/p AKA with dressing c/d/i. L leg with no c/c/e. No pulses palpable in L foot, but is warm with some hair on dorsal aspect of foot. Neuro: awakens with repeated verbal stimulus. Opens eyes, PERRLA, EOMI, unable to shrug shoulders or turn head from side to side. palate elevates with tongue movements in tact. sensation grossly in tact. Motor: moves all extremities. Pertinent Results: CT spine: There is no obvious fracture or subluxation. Degenerative changes of the cervical spine are noted. Perhaps an MR examination would be helpful to examine for the presence of perivertebral edema. Head CT: Left subdural hematoma with mild midline shift. Echo (TTE): 1. The left atrium is mildly dilated. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets are mildly thickened. Mild to moderate ([**12-15**]+) aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 6.There is borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. MRI head: 1) No area of restricted diffusion is seen to suggest a recent infarct. There is an area of T2 shine through in the left parietal white matter, present on [**2144-1-6**]. 2) There is extensive left-sided subdural hematoma, which measures less than 1 cm in maximal thickness. The septum pellucidum is bowed slightly towards the right and the left lateral ventricle is smaller than the right, as was seen on the earlier CT. There is slight asymmetry of the medial temporal lobes and mid brain, although the ambient cistern remains patent. 3) There is a much smaller right-sided subdural collection, too small to be visualized on the CT. 4) The left frontal shunt catheter is again noted. 5) The posterior fossa postoperative changes and encephalomalacia in the left cerebellar hemisphere are again noted. 6) There are mild microvascular changes in the cerebral white matter. MRA head: There is segmental decreased flow in the siphons, which appears to be artifactual with good distal flow noted. The study is slightly limited by patient motion. Brief Hospital Course: ##MS changes: The patients MS drastically improved from admission to discharge. The alterations were thought to be likely [**1-15**] SDH's, also s/p intubation with sedation and use of psych meds of haldol, ativan, olanzapine, and lexapro. When all of these were discontinued and the pt no longer required sedation, her MS improved. Blood gases were normal and an LP ruled out infectious causes. She still remains A&O to person and place, but not to time. Her family states this is not far from her baseline. . ## SDH with ?seizures and ?CVA: the pt was monitored in the neuro ICU and managed conservatively. After serial CT's showed that the SDH was stable she was transferred to the floor and further head CT's also showed no change. She was also followed by neurology who recommended continuing dilantin for seizure ppx since her husband was not sure if he had witnessed her experiencing shaking in a seizure-like manner. Also, a seizure could have caused her original fall. An MRI was performed which was read by some to have a small CVA in watershed territories, although the final read does not call this. She will follow up with neurology and neurosurgery as an outpatient. . ##BP: has h/o HTN, but was hypotensive in unit in setting of ?sepsis. She was on neosynephrine for approx 24 hours, but then weaned easily and soon began having HTN again. Her BP meds were titrated for target sBP of 130-160 given recent SDH and questionable CVA. She will continue on Toprol XL and lisinopril and follow up with her PCP as an outpatient. . ## Fevers to 101.2 with elevated WBC: The patient was diagnosed with a vent-associated pna while in the MICU and treated with a 10 day course of IV Zosyn. Her cough improved and she remained afebrile once transferred to the floor. Sputum cx, Bcx and Ucx were negative. C.diff was also negative and WBC count trended down. . ## Cardiac: patient with elevated troponin in setting of neo use. She ruled in for an MI w/ trop positive. In past hospitalization troponin elevation felt secondary to demand and this was the case during this elevation as well. Aspirin held secondary to subdural, BB, statin, and ACEi were started. TTE showed a possible pericardial effusion, however, upon d/w cards, it was felt that a TEE not needed since this "fat pad vs. loculated pericardial effusion" was likely an artifact. The patient was diuresed gently to remove some excess fluid and sats improved. She was then euvolemic and had no problems with respiration or edema for the rest of her stay. She will follow up with her PCP and set up cards follow up as is deemed necessary. It is not likely that the pt would benefit in the short term from cath given that she does not do much activity and has no sx's of CP or other cardiac complaints. . ## pulmonary/ COPD: the patient's respiratory status improved with gentle diuresis, use of albuterol / fluticasone, and IV zosyn. At d/c she was sat'ing in the high 90's on RA with use of fluticasone standing and only prn albuterol. . ## Renal insufficiency - The pt experienced a brief elevation in her Cr to 1.6 following her episode of hypotension. This resolved back to her baseline of 0.6. The pt continued to make good urine. . R AKA wound: The patient was seen by vascular who felt that the pt will likely require another revision of her AKA in the near future. They felt that although the bone is partly exposed, this did not warrant additional antibiotics at this time. Santyll dressings will be continued and the pt will follow up with Dr. [**Last Name (STitle) 1391**] as an outpatient to discuss further revision. . ## FEN: The pt [**Last Name (STitle) 1834**] a formal speech and swallow study which cleared her for thin liquids and soft solids with supervision. They also recommended that the HOB be kept at at least 30 degrees with eating. She was continued with TF's via her PEG. Goal for rehab is to increase the amount taken po in hopes of decreasing TF requirements. Discharge Medications: 1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Three Hundred (300) mg PO DAILY (Daily). 5. Phenytoin 100 mg/4 mL Suspension Sig: Two Hundred (200) mg PO Q12H (every 12 hours). 6. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): apply to peroneal region. 7. Chlorhexidine Gluconate 0.12 % Liquid Sig: Fifteen (15) ML Mucous membrane TID (3 times a day). 8. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily): please apply to base of R AKA wound in morning and cover with wet to dry saline dressing. . 9. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)): may hold if TF residuals small and pt having good BM's. . 10. Lisinopril 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 2857**] - Twin Oaks - [**Location (un) 4047**] Discharge Diagnosis: SDH HTN NSTEMI COPD anemia R AKA wound small CVA Discharge Condition: stable Discharge Instructions: Please continue to take all medications as prescribed. If you start to develop more pain or have pus draining from your R wound, please call vascular right away. Continue with santyll dressing changes [**Hospital1 **] . Followup Instructions: Please follow up w Dr. [**Last Name (STitle) 1391**] in vascular in [**1-16**] weeks. Call for an appointment [**Telephone/Fax (1) 1393**]. Please follow up with Dr. [**Last Name (STitle) 23813**] in neurosurgery. Call [**Telephone/Fax (1) 1669**] to schedule an appointment in the next 2-4 weeks. Please discuss if you need to continue on dilantin at this time. Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 59840**] for an appointment in the next 2-3 weeks. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Name: [**Known lastname 10959**],[**Known firstname 1940**] Unit No: [**Numeric Identifier 10960**] Admission Date: [**2144-2-7**] Discharge Date: [**2144-2-20**] Date of Birth: [**2076-7-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Acetaminophen / Percocet Attending:[**First Name3 (LF) 758**] Addendum: Pt remained in house overnight while awaiting rehab bed. No new events or changes. Discharge Disposition: Extended Care Facility: [**Hospital3 7340**] - Twin Oaks - [**Location (un) 4186**] [**First Name11 (Name Pattern1) 27**] [**Last Name (NamePattern1) 28**] MD, [**MD Number(3) 765**] Completed by:[**2144-2-20**]

[ "997.69", "852.21", "593.9", "496", "518.81", "349.82", "410.71", "E888.9", "780.39", "285.9", "785.51", "486" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.6", "96.04", "03.31", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

12724, 12967

5881, 9836

345, 386

11291, 11299

3829, 4034

11567, 12701

2803, 2812

9859, 11090

11220, 11270

11323, 11544

2827, 3810

280, 307

414, 1806

4043, 5858

1828, 2617

2633, 2787

74,748

167,693

8538

Discharge summary

report

Admission Date: [**2197-10-18**] Discharge Date: [**2197-11-22**] Date of Birth: [**2132-4-19**] Sex: M Service: MEDICINE Allergies: Penicillins / Hydrocodone / Sulfa (Sulfonamide Antibiotics) / Haldol / Vicodin / Morphine / Atorvastatin / Statins-Hmg-Coa Reductase Inhibitors / Metoclopramide / Propofol Attending:[**First Name3 (LF) 2297**] Chief Complaint: Right lower extremity worsening ischemia and non-healing wounds. Major Surgical or Invasive Procedure: [**2197-10-23**] Right below knee amputation Intubation and mechanical ventilation Placement of left radial arterial line Direct Current Cardioversion History of Present Illness: 65M with multiple medical problems s/p L SFA to AT bypass on [**7-24**] that failed and thrombectomy of the graft at that time, which was also unsuccessful, requiring multiple toe amputations and most recently a left BKA now presenting from nursing home Academy Manor with worsening ischemia and non-healing wounds on the RLE. Apparently he was being treated with Vancomycin 750 q36hrs for his wound infections, but that was most recently switched to Linezolid as wound cultures came back with Vanc resistent enterococcus, as well as Morganella Morganii sp and Klebsiella. Past Medical History: #. H/o MRSA, VRE infections #. H/o ESBL in the urine in [**6-/2197**] #. Peripheral vascular disease #. Coronary artery disease: The patient reports a "massive heart attack" 16 years ago. No intervention at that time. He is recently s/p cardiac cath [**6-/2197**] with DES to Left circumflex, and POBA to D1 #. Chronic systolic heart failure: Ischemic cardiomyopathy with regional hypokinesis. EF=45%. Patient reports frequent admissions for HF and dependence on lasix. He has been chronically on oxygen, 2-3L for approximately 2 months, which has not been weaned secondary to frequent hospitalizations. #. Statin induced immune-mediated necrotizing myopathy - on Cellcept and prednisone, history of weakness requiring intubation s/p treatment with IVIG as well as Rituxan. #. Hypertension #. Gastro-esophageal reflux disease #. Hypothyroidism #. Diabetes mellitus type 2 #. Dyslipidemia #. chronic anemia PAST SURGIGAL HISTORY: #. Left superficial femoral artery to left anterior tibial bypass [**7-24**] #. Thrombectomy of graft [**8-23**], #. Multiple toe amps (1st toe Right foot, 1st/2nd/5th toe Left foot) #. Left BKA on [**8-15**], recently discharged Social History: Lives in a rehab facility. Has never smoked. At baseline the patient is quadriplegic, secondary to the necrotizing myopathy, although is able to feed himself if someone cuts up his food. Family History: non-contributory Physical Exam: On admission: Exam: 97.3 110 159/83 19 94/RA Gen: NAD Chest: decreased BS at bases bilaterally CV: RRR, -MRG Abd: soft/NT/ND, no pulsatile masses Ext: L BKA - with tiny pressure ulcer and mild drainage Right: Pulses: Fem [**Doctor Last Name **] DP PT R palp palp BKA---- L palp palp BKA---- At discharge: Pertinent Results: Micro: [**2197-10-19**], [**2197-11-1**] WOUND SWAB - pseudomonas. AMIKACIN-------------- 4 S CEFEPIME-------------- 8 S CEFTAZIDIME----------- 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 8 I PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ =>16 R . [**2197-10-25**] STOOL CDIFF - negative x 1. . Urine cxr [**2197-10-28**] KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 256 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- =>16 R . [**11-1**] urine cxr - GNRs . Images: [**2197-11-3**] R LE US - no abscess [**2197-10-27**] UE LENI- No evidence of deep vein thrombosis in the right arm. [**2197-10-27**] CT HEAD - No intracranial hemorrhage or other acute intracranial abnormality. [**2197-10-19**] R LE art ext (rest) study - There is significant outflow arterial insufficiency at the level of the distal popliteal or proximal tibial artery. . EKG: [**2197-10-25**] 14:00, NSR, LAD, ?q's inferiorly, no STE/STD. TWF V4-6, V1. . Path: Right lower extremity; below-the-knee amputation (A-J): Cutaneous ulceration, acute inflammation and necrosis. Calcified atherosclerosis. Histologically viable soft tissue margins. Bony margin, no diagnostic abnormality recognized. EEG: ([**11-22**]): This is an abnormal video EEG study due to periodic generalized sharp and slow wave discharges with bifrontal predominance at 1-1.5 Hz frequency. These findings are suggestive of cortical irritability and potential for epileptogenesis. However, no electrographic seizures were seen during this recording. This telemetry captured one pushbutton activation but did not contain an electrographic seizure. Brief views of the background rhythm show a disorganized mixed theta/delta activity consistent with a moderate to severe encephalopathy. No areas of focal slowing were seen in this recording although encephalopathies may obscure focal findings. ([**11-17**]): This 24-hour video EEG telemetry captured no pushbutton activations. No electrographic seizures or epileptiform discharges were seen. The background was very slow throughout the day's recording suggestive of a severe encephalopathy. ([**11-16**]): This is an abnormal video EEG study because of initial continuous periodic epileptiform discharges at 1.5-2 Hz consistent with non-convulsive status epilepticus. These abated after treatment with intravenous phenobarbital. After 7 p.m., there were no further definite electrographic seizures but periodic discharges occasionally recurred in brief runs at frequencies less than 1 Hz. Interictal background activity showed severe diffuse slowing and attenuation of faster frequencies consistent with a severe diffuse encephalopathy ([**11-13**]): This 24 hour video EEG telemetry demonstrated generalized and bifrontal, spike and sharp wave discharges that evolved into periods of sustained, rhythmic discharges, consistent with an underlying non-convulsive status epilepticus. There were no apparent clinical manisfestations on video associated with the status epilepticus. MRI Head: No acute intracranial abnormality present. Pooled nasopharyngeal secretions and under-pneumatized mastoid air cells bilaterally. Brief Hospital Course: Mr. [**Known lastname 30048**] is a 65 year old man, with h/o PVD, CAD, DM2, s/p remote L BKA, and statin-induced immune-mediated necrotizing myopathy, who presented on [**10-18**], with a right LE ulcer/osteomyelitis to the vascular service. He was started on IV linezolid, cipro, flagyl, and underwent right BKA on [**10-23**]. His course has since been complicated by a. fib with RVR s/p DCCVx1, hypotension, hypercarbic respiratory failure on [**10-27**], prompting intubation and pressor support, as well as status epilepticus. . Course on Vascular Service . Post-operatively, in the PACU, the patient had hypotension 96/40, with minimal oozing from wound; the patient recieved fluids and was transfused packed red cells, eventually started on Neo drip, with stabilization of BP, and was transferred back to [**Hospital Ward Name 121**] 5 VICU with Neo drip. Over the next day, the patient's blood pressure was stable, and the Neo drip was weaned off. He was also started Hydromorphone IV for breakthrough pain. His Tmax was 101.0, and his R LE wound swab grew Pseduomonas. On [**10-25**] @ 0847AM, the pt was noted to have A. FIB with RVR 160s, SBP 95/60s->60/40, prompting re-starting the neo gtt and transfer to CVICU with cardiology consultation. The pt received direct cardioversion x 1, and converted to NSR. He received IV amiodarone load x 24hrs, then coverted to oral dosing x 1 week. He was also started on heparin gtt, which was transitioned to oral comadin. Cardiac enzymes were obtained, and his troponin ranged from 0.40 to 0.53, with flat CK, MB peaked at 10. TTE was obtained without new focal wall motion abnormality. Cardiology did not think that the hypotension was [**12-19**] decreased EF. He was transferred back to the vascular floor service on [**10-26**]. . On arrival to the floor, he was described as "lethargic, easy to arouse." BP was 83/40, albumin hung, and BP increased. The pt was on 2L NC with O2sat 99%, although he was noted to be oliguric (180cc/24hr). . On [**10-27**], pt continued to be oliguric, with SBP in 80s, despite albumin and fluid boluses. He triggered for ongoing oliguria and increasing somnolence. He was placed on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 597**], [**First Name3 (LF) **] ABG was drawn (7.05/81/43 @ 4AM); he was re-started on neo gtt, and then intubated for respiratory distress (no O2 sats in chart, time 04:46AM on [**10-27**]). His CVICU course is not documented, but he received 2U PRBC (HCT 27->34->27). L UE LENI was obtained to r/o DVT. Repeat TTE ordered (EF more depressed), heparin gtt stopped. Cardiology was re-consulted given worsening EF. He has been off antibiotics since [**2197-10-24**]. . Course in MICU # Mental Status: Throughout the MICU course patient unresponsive thought to be secondary to anoxic brain injury. Found to be in non convulsive Status epilepticus which eventually resolved with AED however no improvement in mental status. MRI or LP without etiology for mental status changes. Eventually patient made CMO given extremely poor medical prognosis and very little hope of meaningful improvement in mental status. . # Hypercarbic respiratory failure - Although the details of the decompensation are unclear, the patient had a chronic metabolic alkalosis on admission--he has no known history of COPD or OSA, but likely due to hypoventilation, and resultant respiratory acidosis, caused by the necrotizing myopathy. His ABG (7.05/81/43) during the initial event was consistent with hypoventilation--likely contributors include myopathy (? exacerbation from being cellcept on admission to the vascular service), narcotic medications as well as aspiration (given known muscle weakness). His CXR and exam were additionally consistent with volume overload, without frank evidence of pneumonia. PE was thought to be less likely, given the pt's therapeutic INR and on heparin gtt. After admission to the MICU, the pt was treated with steroids and re-started on Cellcept (1000mg [**Hospital1 **]). Sedating medications were avoided. While intubated, the pt did best w. pH in 7.2-7.3 range and w. pCO2 50s. Although the pt was extubated on [**10-29**], he had to be re-intubated on [**11-1**] for recurrent hypercarbic respiratory failure (ABG 7.14/78/56/28). Neurology consultation was obtained, who recommended a 5 day course of IVIG, as this had alleviated the patient's muscle weakness in the past and facilitated extubation. Despite these efforts, he was unable to be weaned off of the ventilator and ultimately the decision was made for CMO and the patient was extubated. . # Hypotension - The patient had several episodes of hypotension while admitted, including post-operatively, in the setting of A.fib w. RVR, after diuresis, and while being treated with AEDs for status epilepticus (see below). He had no evidence of frank sepsis (lactate 0.7 and stable, leukocytosis improved initially without antibiotics, LFTs WNL, afebrile), although his right LE showed erythema and warmth c/w cellulitis as well as purulent drainage from the surgical wound. A wound culture grew Pseudomononas with sensitivities as noted above. During his MICU stay, the patient was treated with Vanc and Cefepime (plan for 3 week course, ending on [**2197-11-24**] and [**2197-11-21**], respectively). The pt's most prolonged period of hypotension occurred in the setting of AED titration (with Keppra, Dilantin, and Phenobarb). He had to be maintained on Levophed while these drugs were initiated and titrated. He was also started on stress-dose steroids (hydrocort 50mg Q6hr), given concern for hypoadrenalism [**12-19**] chronic steroid use. Hydrocort was weaned and patient was weaned from pressor support, however intermittently reguired pressor support throughout MICU course. Pressors were removed after patient made CMO. . # Status Epilepticus: After being re-intubated on [**11-1**], the pt's mental status did not seem to recover. Prior to (re-)intubation, his mental status had been waxing and [**Doctor Last Name 688**], but at times the pt was alert and able to follow commands. After intubation, he was very somnolent, unresponsive to all but painful stimuli. During the weekend of [**11-15**], the pt was noted to have myoclonic jerks of his extremities. Given this, an EEG was obtained, which showed runs of rhythmic activity suggestive of non-convulsive seizures (see report above). Per Neurology's recommendations, Keppra, then Dilantin and, lastly, Phenobarbital were started. Phenobarbital was bolused with the goal level of 25-30. Eventually status epilepticus resolved. Patient continued to be monitored during MICU course on continuous EEG video monitoring. Further during MICU course he underwent an LP (WBC 1, RBC 1, 0% polys, 52% lymphs) and an MRI brain (no epileptogenic focus), which were both essentially unrevealing of an etiology for the pt's seizures. CSF protein electrophoresis showed no oligoclonal banding. HSV, VZV, and [**Male First Name (un) 2326**] negative. . # Acidosis: The pt's bicarb gradually trended downwards in the 7 days between [**11-3**] to [**11-11**] (28 -> 15). Gap = 10, albumin = 2.1. Lactate WNL (1.2). This was likely a mixed acidosis??????with the pt's chronic respiratory acidosis, LE ischemia, septic physiology from his wound infection, and uremia [**12-19**] ARF (see below) all contributing. He was cont'd on Vanc/Cefepime, stress dose steroids, and weaned off of pressors. Renal was consulted, who initiated CVVH, with improvement in acidosis. Eventually hemodialysis was attempted. However prior to permanent HD line placement the patient was made CMO given very poor prognosis and likely anoxic brain injury and unlikely return of meaningful mental status. . # Acute renal failure: The pt had rising Cr (peak 1.6 on [**11-11**]) and decreasing urine output over [**11-7**] to [**11-11**]. Urine lytes showed FeNa = 2, which is non-specific but c/w ATN; rare Eos and also muddy brown casts in urine. Suspect ATN, given preceding hypotensive episodes. Renal was consulted, and initiated the pt on CVVH. Patient eventually underwent dialysis however given very poor prognosis permanent HD line was not placed and patient made CMO. . # PVD s/p R BKA, distant L BKA - His right LE wound cxr grew Pseudomonas ([**10-28**]), resistant to Meropenem, sensitive to Cefepime. Vascular surgery followed the patient and he was continued on aspirin and plavix. . # Atrial fibrillation - After transfer to the MICU, his rate controlled with amiodarone 200mg Qd s/p amiodarone loading (IV loading, then 400mg x 7 days) and metoprolol 12.5mg TID. . # CAD - Continue aspirin, plavix. . # Systolic CHF: Held diuresis now given hypotension s/p diuresis with lasix on [**11-2**]. Daily weights were followed. Eventually CVVH was started and patient was bridged to HD as above. Medications on Admission: Plavix 75 mg mg qd RISS Synthroid 88mcg QD lisinopril 5mg QD glucophage 500mg QD lopressor 25mg [**Hospital1 **] prednisone 5mg QD flomax 0.4mg QD effexor xr 75mg QD albuterol neb PRN ipratropium neb PRN prilosec 40mg QD Kdur 40mEq [**Hospital1 **] Vit B12 SQ QSun colace 100mg [**Hospital1 **] ferrous sulfate 325mg QD lasix 20mg QD calcium carbonate 500mg [**Hospital1 **] (cellcept 1000mg [**Hospital1 **] held for anemia) procrit Qweek At transfer to MICU: Warfarin 5 mg PO/NG HYDROmorphone (Dilaudid) 0.125 mg IV Q3H:PRN pain Furosemide 20 mg IV ONCE Acetaminophen 325-650 mg PO/NG Q6H:PRN pain or fever Insulin DRIP Ipratropium Bromide MDI 6 PUFF IH QID Albuterol Inhaler [**4-26**] PUFF IH Q6H 12 Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO effect Metoprolol Tartrate 6.25 mg PO/NG [**Hospital1 **] Amiodarone 400 mg PO/NG [**Hospital1 **] Duration: 7 Days [**10-27**] @ 0735 View Famotidine 20 mg PO/NG Q12H [**10-27**] @ 0735 View TraMADOL (Ultram) 50 mg PO Q6H:PRN pain [**10-27**] @ 0735 [**Name6 (MD) **] Warfarin MD to order daily dose PO/NG DAILY16 [**10-27**] @ 0735 View Gabapentin 600 mg PO/NG TID [**10-27**] @ 0735 View Aspirin 81 mg PO/NG DAILY [**10-27**] @ 0735 View Venlafaxine XR 75 mg PO DAILY [**10-27**] @ 0735 View Tamsulosin 0.4 mg PO HS [**10-27**] @ 0735 View PredniSONE 5 mg PO/NG DAILY [**10-27**] @ 0735 View Levothyroxine Sodium 88 mcg PO/NG DAILY [**10-27**] @ 0735 View Clopidogrel 75 mg PO/NG DAILY Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "V45.82", "287.5", "272.0", "440.24", "584.5", "997.62", "707.22", "344.00", "427.31", "403.91", "357.2", "414.8", "359.4", "428.0", "707.09", "E942.2", "008.45", "276.3", "041.7", "707.14", "530.81", "250.60", "V58.65", "244.9", "785.52", "730.07", "276.2", "995.92", "345.3", "038.9", "585.6", "707.15", "348.1", "428.23", "414.01", "285.9", "518.81" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "96.71", "38.95", "84.15", "03.31", "96.04", "99.14", "96.72", "39.95", "99.62" ]

icd9pcs

[ [ [] ] ]

16917, 16926

6545, 9270

500, 652

16977, 16986

3041, 6522

17042, 17052

2660, 2678

16885, 16894

16947, 16956

15410, 16862

17010, 17019

2693, 2693

3022, 3022

395, 462

680, 1255

2707, 3007

9285, 15384

1277, 2439

2455, 2644

73,454

109,469

39247

Discharge summary

report

Admission Date: [**2121-5-22**] Discharge Date: [**2121-5-26**] Date of Birth: [**2063-7-9**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1271**] Chief Complaint: Unresponsive Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 57 year old male found down unknown etiology but appears to have been assaulted who was trasnferred from outside hospital intubated with SDH. Per report patient was awake on arrival at OSH and decompensated and required intubation. On approach patient is intubate and sedated. He was moving all extremities with good strength per report. He required sedation to stay calm. Past Medical History: Hep C, EtOH abuse Social History: EtOH abuse Family History: Non-contributory Physical Exam: O: T:98 BP: 140 / 96 HR: 88 R 12 O2Sats 100% 40% FIO2 Gen: traumatic, multiple facial swelling, abrasions and rhinorrhea of blood, intubated and sedated/chemically paralyzed GCS 8T E:2M5V1T right pupil 1.0 and sluggishly reactive left canal with cerumen, no otorrhea bilaterally no battle sign MAEs bilaterally with purposeful movement off sedation. Very strong, difficult to hold down Toes downgoing bilaterally No clonus PHYSICAL EXAM UPON DISCHARGE: Pertinent Results: [**2121-5-22**] CXR: Endotracheal tube within the mid trachea. No obvious traumatic injury. Mild cardiomegaly. [**2121-5-22**] CT Head without Contrast: 11 mm right parieto-occipital subdural hematoma with minimal interval decrease in subfalcine herniation, now with 8-mm leftward shift. No frank evidence of transtentorial herniation. Please see CT of the facial bones report for details regarding multiple facial fractures. [**2121-5-22**] CT Torso: 1. No evidence of acute traumatic injury in the chest, abdomen, or pelvis 2. Nodular liver contour, porta hepatis lymph nodes and pericholecystic fluid suggest underlying chronic liver disease or cirrhosis. Correlation with LFTs and clinical history is recommended. 3. Subcentimeter hypodensities in the left kidney may represent small cysts or angiomyolipomas. 4. Probable small splenic hemangioma [**2121-5-22**] CT Max-Face: 1. Comminuted depressed fracture of the roof of the frontal sinus with blood in the frontal sinuses. 2. Hyperdense air-fluid levels in the maxillary sinuses bilaterally, right larger than left, suggesting blood. Probably nondisplaced fracture of the right maxillary sinus lateral wall. Difficult to exclude fracture of the bilateral maxillary sinus medial walls. [**2121-5-23**] CT Head without Contrast: stable Brief Hospital Course: Pt was admitted to the Neurosurgery service, ICU for close neurological observation. He was started on dilantin for seizure prophylaxsis, and blood pressure was kept < 140 systolic. Patient was stabilized and exubated. His c-spine was cleared. Seen by plastics for facial fractures; they placed 2 sutures on nose and recommended sinus precautions with augmentin x2 weeks. Repeat head CT on [**5-23**] revealed no interval change in hemorrhage. Patient was subsequently transfered to the floor. Throughout his hospitalization, patient was monitored for signs of EtOH withdrawal but did not require benzodiazepines. PT was consulted and patient was deemed appropriate for discharge home. A plan was put in place with social work for the patient to discharge safely to his mother's home. At the time of discharge he was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Nadolol 20 mg PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain/temp max 4g/24 hr 2. Amoxicillin-Clavulanic Acid 875 mg PO Q12H Duration: 14 Days First day = [**2121-5-22**] Last day = [**2121-6-4**] RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 Tablet(s) by mouth every 12 hours Disp #*20 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. Multivitamins 1 TAB PO DAILY 5. Phenytoin Sodium Extended 100 mg PO TID RX *Dilantin Extended 100 mg 1 Capsule(s) by mouth Three times daily Disp #*90 Capsule Refills:*1 6. Nadolol 20 mg PO DAILY 7. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain RX *oxycodone 5 mg [**11-18**] Tablet(s) by mouth every 4 hours as needed for pain Disp #*15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Right Subdural Hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Take your pain medicine as prescribed if needed. You do not need to take it if you do not have pain. ?????? 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. ?????? DO not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. until follow up. ?????? You have been prescribed Dilantin (Phenytoin), take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? Do not drive until your follow up appointment. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 4676**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury (TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**]. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2121-5-26**]

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icd9cm

[ [ [] ] ]

[ "96.71", "21.81" ]

icd9pcs

[ [ [] ] ]

4497, 4503

2689, 3607

320, 327

4571, 4571

1357, 2666

5592, 6345

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268, 282

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355, 746

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2765

Discharge summary

report

Admission Date: [**2173-2-25**] Discharge Date: [**2173-3-4**] Date of Birth: [**2106-8-23**] Sex: M Service: CARDIOTHORACIC Allergies: Naproxen Attending:[**First Name3 (LF) 922**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: s/p Coronary artery bypass graft (Left internal mammary artery > left anterior descending, saphenous vein graft > diagonal, saphenous vein graft > obtuse marginal 1, saphenous vein graft > obtuse marginal 2) [**2173-2-25**] History of Present Illness: 66 year old male with alzheimers dementia and history of coronary artery disease, silent myocardial infarctions with multiple interventions. Past Medical History: Coronary artery disease s/p CABG Hypercholesterolemia Hypertension Venous insufficiency GERD Mitral Regurgitation Dementia Depression Obstruction sleep apnea Pseudogout Hyperuricemia Arthritis Social History: Retired Lives with spouse who is primary caretaker [**Name (NI) 1139**] 50 pack year history quit 25 years ago Alcohol rare Family History: Father deceased at 54 yo from myocardial infarction Physical Exam: General Comfortable HR 59, RR 19, b/p 173/94 rt, 183/88 lt Skin unremarkable HEENT unremarkable Neck Supple full ROM Chest Lungs CTA bilateral Heart RRR Abdomen soft, nondistended, nontender, + bowel sounds Extremeties warm well perfused Varicosities none Neuro grossly intact Pulses palpable Pertinent Results: [**2173-3-3**] 04:15PM BLOOD WBC-8.7 RBC-3.56* Hgb-10.5* Hct-28.7* MCV-81* MCH-29.5 MCHC-36.6* RDW-15.1 Plt Ct-241 [**2173-2-25**] 12:19PM BLOOD WBC-13.6*# RBC-3.49*# Hgb-10.0*# Hct-28.0* MCV-80* MCH-28.6 MCHC-35.7* RDW-14.1 Plt Ct-160 [**2173-3-3**] 04:15PM BLOOD Plt Ct-241 [**2173-3-1**] 12:01AM BLOOD PT-14.0* PTT-32.4 INR(PT)-1.2* [**2173-2-25**] 12:19PM BLOOD Plt Ct-160 [**2173-2-25**] 12:02PM BLOOD PT-35.8* PTT-150* INR(PT)-3.80* [**2173-2-25**] 12:02PM BLOOD Fibrino-52.5* [**2173-3-3**] 11:10AM BLOOD Glucose-79 UreaN-19 Creat-0.9 Na-143 K-4.4 Cl-111* HCO3-26 AnGap-10 [**2173-2-25**] 01:03PM BLOOD UreaN-13 Creat-0.8 Cl-115* HCO3-24 [**2173-3-1**] 12:01AM BLOOD ALT-21 AST-30 AlkPhos-41 TotBili-1.6* [**2173-2-26**] 05:41PM BLOOD ALT-15 AST-28 LD(LDH)-269* AlkPhos-35* TotBili-0.5 [**2173-3-1**] 09:29AM BLOOD Glucose-96 K-3.9 [**Known lastname 13640**],[**Known firstname **] SR [**Medical Record Number 13641**] M 66 [**2106-8-23**] Radiology Report CHEST (PA & LAT) Study Date of [**2173-3-2**] 10:40 AM [**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2173-3-2**] SCHED CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 13642**] Reason: evaluate for effusion [**Hospital 93**] MEDICAL CONDITION: 66 year old man with s/p CABG - hx alzeiheimers with confusion please limit time in radiology REASON FOR THIS EXAMINATION: evaluate for effusion Provisional Findings Impression: ARHb [**First Name8 (NamePattern2) **] [**2173-3-2**] 12:38 PM Left lower lung opacity demonstrates interval improvement which may represent atelectasis. Small bilateral pleural effusions. Final Report INDICATION: History of Alzheimer's with confusion. COMPARISON: CXR, [**2173-2-25**]. FRONTAL AND LATERAL CHEST: Patient is status post CABG and median sternotomy. The cardiomediastinal silhouette appears unchanged. The pulmonary vascularity appears stable. Left lower lung opacity, likely representing atelectasis, demonstrates mild improvement with small bilateral pleural effusions noted. The right lung appears clear and there is no pneumothorax. IMPRESSION: Improved left lower lung opacity with small bilateral pleural effusions. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**] DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: WED [**2173-3-3**] 9:20 AM [**Known lastname 13640**],[**Known firstname **] SR [**Medical Record Number 13641**] M 66 [**2106-8-23**] Cardiology Report ECG Study Date of [**2173-3-2**] 10:59:26 AM Sinus rhythm Prolonged QT interval T wave abnormalities Since previous tracing of [**2173-2-25**], ST segment elevation in the lateral leads are less Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 70 140 104 458/475 28 8 61 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 13640**], [**Known firstname **] SR [**Hospital1 18**] [**Numeric Identifier 13643**] (Complete) Done [**2173-2-25**] at 9:08:48 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2106-8-23**] Age (years): 66 M Hgt (in): 70 BP (mm Hg): 140/70 Wgt (lb): 220 HR (bpm): 72 BSA (m2): 2.18 m2 Indication: Chest pain. Coronary artery disease. Left ventricular function. Right ventricular function. Valvular heart disease. ICD-9 Codes: 440.0, 413.9, 414.8, 424.0 Test Information Date/Time: [**2173-2-25**] at 09:08 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW01-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: *3.9 cm <= 3.6 cm Aorta - Sinotubular Ridge: *3.2 cm <= 3.0 cm Aorta - Ascending: *3.7 cm <= 3.4 cm Aorta - Arch: 3.0 cm <= 3.0 cm Aorta - Descending Thoracic: *2.9 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.17 Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Lipomatous hypertrophy of the interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH with normal cavity size and global systolic function (LVEF>55%). Normal regional LV systolic function. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. Normal aortic arch diameter. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Myxomatous mitral valve leaflets. Mild MVP. Eccentric MR jet. Mild to moderate ([**2-5**]+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: No PS. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are myxomatous. There is mild mitral valve prolapse of the P2 region. An eccentric, posteriorly directed jet of Mild to moderate ([**2-5**]+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results on Mr [**Known lastname **], P at 8AM before incision. Post-Bypass: Preserved biventricular systolic function. Normal LVEF 55%, Intact thoracic aorta. Mild to moderate MR> I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2173-2-25**] 16:13 Brief Hospital Course: Admitted same day as surgery and underwent coronary artery bypass graft surgery. Received cefazolin for perioperative antibiotics. See operative report for further details. He was transferred to the intensive care unit for hemodynamic monitoring. In the first twenty four hours he was weaned from sedation, awoke with confusion but has baseline dementia, and was extubated without complications. He remained in the intensive care unit on nitroglycerin drip and management of confusion receiving haldol. With his confusion at times he became aggressive with staff. On post operative day four he was transferred to the floor for the remainder of his care. Physical therapy worked with him on strength and mobility. He continued to progress but remained on haldol due to confusion although no aggressive behavior toward staff. He was confused with environment, getting in and out of bed frequently, forgetting were things were in the room which may be due to the unfamiliar environment. He was ready for discharge home on post operative day seven with services. Sternal incision clean no erythema no drainage Left leg EVH sites no erythema, no drainage Lower extemeties with +1 edema which is progressively decreasing Plan to follow up with Dr [**Last Name (STitle) 1683**] on [**3-10**], he has been prescribed haldol for 1mg at bedtime with repeat dose of 0.5mg once if needed, wife has been instructed to call Dr [**Last Name (STitle) 1683**] with any concerns about confusion, agitation, and aggression. Spoke with Dr [**Last Name (STitle) 1683**] and she will monitor him and manage the haldol dosing, prescription given for only 20 tablets of 0.5mg. Social work meet with Wife [**Location (un) **] Elder services and Alzheimers association were contact[**Name (NI) **] on Mr [**Name (NI) **] behalf. Medications on Admission: Atenolol 50 mg daily Lipitor 70 mg daily Citalopram 60mg daily Plavix 75mg daily Colchicine 0.6 mg daily Donepezil 10 mg daily Zetia 10 mg daily Felodipine 10 mg daily Fluticasone 50 mcg 2 sprays each nostril daily HCTZ 25 mg daily Lisinopril 20 mg daily Prilosec 20 mg daily Aspirin 325 mg daily Tylenol 1000mg twice a day NTG SL prn 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. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily): to each nostril. Disp:*qs qs* Refills:*0* 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 7. Haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO at bedtime: 1 mg at bedtime, if needed may repeat with 0.5mg one time no more than 1.5 mg in 24 hours. Disp:*20 Tablet(s)* Refills:*0* 8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Donepezil 10 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*0* 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO once a day: total dose 60mg . Disp:*90 Tablet(s)* Refills:*0* 12. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*0* 14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) for 5 days. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary artery disease s/p CABG Acute Delirium Hypercholesterolemia Hypertension Venous insufficiency GERD Mitral Regurgitation Dementia Depression Obstruction sleep apnea Pseudogout Hyperuricemia Arthritis Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule all appointments Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**3-9**] weeks Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse ([**Telephone/Fax (1) 3071**]) Provider: [**Name10 (NameIs) 13644**],NURSE [**First Name (Titles) 13644**] [**Last Name (Titles) **] Date/Time:[**2173-3-4**] 2:15 Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB) Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2173-3-10**] 11:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2173-3-17**] 2:00 Completed by:[**2173-3-4**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

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26103

Discharge summary

report

Admission Date: [**2154-7-15**] Discharge Date: [**2154-7-19**] Date of Birth: [**2092-10-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: mental status and vision changes Major Surgical or Invasive Procedure: cardiac catheterization on [**7-16**] History of Present Illness: 61 yo F with CAD s/p MI, DM, PVD, RCA stenosis, and CRI who was admitted for elective cardiac catheterization and transferred post-cath for mental status and vision changes. The patient was referred for cardiac catheterization after abnormal stress testing prior to planned carotid endarterectomy. She was admitted yesterday for post-cath hydration. She received [**Month/Year (2) **], plavix, heparin bolus, and integrillin during the procedure. Cardiac cath showed CO 4.67, CI 2.50, PCW 12, PA 24/13, RV 25/5. Cath showed 80% occlusion of LAD, s/p stent in LIMA - LAD. . Post cath she was noted to be confused and complained of new loss of vision. The Stroke service was urgently consulted. Integrillin gtt was stopped. Head CT showed a lesion concerning for R occipital CVA. She underwent MRI/MRA demonstrating patency of the arterial circulation. . On exam she denies vision changes (diplopia, eye pain, photophobia). She has no memory of the morning's events (cath, CT or MRI, vision problems). She reports nausea and frontal headache. She denies chest pain, SOB, abdominal pain. Past Medical History: PMH: HTN, CAD, s/p MI '[**34**], NIDDM, hypothyroidism PSH: CABG with harvest B saphenous veins Social History: previous smoker / quit 10 years ago no alcohol lives with husband Family History: Father, brother died of MI at age 47 Mother MI in 70s Sister died of MI at age 39. Physical Exam: Vitals: 98.6F HR 75 BP 149/79 RR 10 97 RA weight 84 kg Gen: awake, oriented x 2, pleasant, c/o mild headache. exam limited due to patient laying flat post-cath HEENT: PERRL/EOMI, anicteric sclera. OP clear, MMM Neck: supple, 2+ carotid pulses, no carotid bruits appreciated. unable to assess JVD. CV: RRR, distant S1, S2. Pulm: clear anteriorly Abd: +BS, soft, ND/NT Ext: warm, 1+ DP/PT b/t. L toes with erythema, no skin breaks, mild tenderness to palpation. no edema b/t, no calf tenderness. R groin without hematoma, 1+ femoral pulse. Neuro: A & O x 2, CN II-XII grossly intact, except for inferior field defect to Left eye. mild agnosia. 4+ strength in UE/LE. 3+reflexes in LUE, nl in RUE and LLE (unable to assess RLE due to post-cath monitoring). sensation intact. neg Romberg. down-going Babinskis b/t. Pertinent Results: [**2154-7-15**] 09:21PM PT-11.3 PTT-26.9 INR(PT)-1.0 [**2154-7-15**] 09:21PM PLT COUNT-226 [**2154-7-15**] 09:21PM WBC-7.9 RBC-4.02* HGB-12.7 HCT-35.9* MCV-89 MCH-31.6 MCHC-35.3* RDW-13.1 [**2154-7-15**] 09:21PM CALCIUM-9.6 PHOSPHATE-3.3 MAGNESIUM-2.3 [**2154-7-15**] 09:21PM GLUCOSE-135* UREA N-31* CREAT-1.5* SODIUM-142 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16 EKG: NSR, rate 80. nl intervals. Q waves in III, aVF, slight L axis. Poor R-wave progression . Cardiac Cath [**7-16**]: CO 4.67, CI 2.50, PCW 12, PA 24/13, RV 25/5. 80% occlusion of LAD, s/p stent in LIMA -> LAD. . CT Head [**7-16**]: Findings suggestive of ischemic event involving the right occipital lobe with perfusion in that area. There is also possibly involvement of the left occipital lobe. old lacune disease. . echo: per report, moderate depression of LV fx, distal septal inferior hypokinesis. . Brief Hospital Course: A/P: 61 yo F with CAD s/p MI, DM, PVD, RCA stenosis, and CRI who was transferred post-elective cath for mental status and vision changes, now s/p R post occipital stroke. The following issues were investigated during this hospitalization: . # CVA: Likely thromboembolic in setting of cardiac catheterization and not thought to be due to ICA stenosis. Since she had already received [**Last Name (LF) 13860**], [**First Name3 (LF) **], Plavix during her catheterization, tPA administration was thought to be too risky (and perhaps not needed). Integrillin was stopped on transfer to the CCU and the stroke/neurology team continued to follow her progress. Initially, she was disoriented and had a left inferior field vision cut. Otherwise, her vision was intact. She was also febrile to 101.9. Blood and urine cultures show no growth to date and CXR was unremarkable. She was given Tylenol and started on empiric treatment with Levaquin, mostly for PNA and UTI organisms, since fever can worsen a stroke. She continued to be afebrile 2 days after her initial fever and since cultures showed no growth, Levaquin was d/c'd. A SBP goal of 140-180 was set by the stroke team to provide adequate perfusion of the brain in the setting of a stroke. However, despite fluid boluses and holding anti-hypertensive medications, her SBP never went above 130. Pt was only able to tolerate Trendelenberg for a few hours before becoming nauseous and vomiting. No other interventions were made. An EEG showed no seizure activity. Pt's orientation and memory slowly improved and she was d/c'd with Aspirin and Plavix. Per PT and OT consults, patient will need 24 hour supervision at home, which her husband is able and willing to provide. . # CVS: Patient had an abnormal outpatient stress Echo and was referred to [**Hospital1 18**] for a cardiac catheterization which revealed an 80% occlusion of LAD. She received a stent in LIMA -> LAD. While in the unit, she had an echo which showed a normal EF. She was discharged on [**Hospital1 **], Plavix and Lipitor. Her beta-blocker and ace-inhibitor were held since her blood pressure seemed to be well-controlled and since the recommendations of the stroke team was to allow for better perfusion of her brain with a higher BP. She was d/c'd on her outpatient beta-blocker dose. . # PVD:`Pt. has a history of 80-90% RCA stenosis for which she has already been evaluated as an outpatient. [**Hospital1 **] surgery was aware that the patient was in-house. They recommend that the patient continue with the current plan of follow-up as an outpatient and eventual carotid endarterectomy. . # DM: During this hospitalization, patient's Metformin was held because of concern for lacic acidosis in the setting of CRI and being post-cath. Her FS were well-controlled on a regular insulin finger stick. HbA1C is 7. On discharge, she was sent out on her outpatient doses of Glipizide and Glucophage. . # CRI: Patient's creatinine was maintained at baseline during this hospitalization and was not an active issue. . # Hypothyroidism: Pt. was maintained on outpatient dose of Synthroid Medications on Admission: Clopidogrel 75 mg qday ecAspirin 325 mg qday Coreg 3.125 [**Hospital1 **] Fosinopril 10 mg qday Glucophage 1,000 mg po bid Synthroid 125 mcg PO qday Glipizide 10 mg [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Fosinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Right Occipital Stroke Coronary Artery Disease Diabetes Mellitus Carotid stenosis Peripheral [**Hospital1 **] disease Discharge Condition: Stable Discharge Instructions: Please call your physician or call 911 if you experience a change in vision, severe headache, slurred speech or sudden weakness, chest pain, shortness of breath, fevers, numbness, weakness, leg pain, leg/foot ulcers or other concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) 17562**], [**Name11 (NameIs) 487**] MD Date/Time: [**2154-7-29**] 9:30 AM. You will need to get a referral from Dr. [**Last Name (STitle) 17562**] for your appointment with neurology on [**8-13**]. Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time: [**2154-7-31**] 1:45 Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2154-7-31**] 3:40 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone: [**Telephone/Fax (1) 2394**] [**2154-7-31**] AT 1:00 PM Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **], MD Neurology Phone: ([**Telephone/Fax (1) 7394**] Time/Date: [**2154-8-13**] at 1:30 PM on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 516**] of [**Hospital1 69**]

[ "434.11", "585.9", "250.00", "414.02", "414.01", "433.10", "413.9", "403.91", "244.9" ]

icd9cm

[ [ [] ] ]

[ "00.40", "88.53", "00.66", "00.45", "37.22", "88.56", "36.07" ]

icd9pcs

[ [ [] ] ]

7578, 7584

3607, 6711

349, 389

7746, 7755

2686, 3584

8050, 9033

1736, 1820

6943, 7555

7605, 7725

6737, 6920

7779, 8027

1835, 2667

276, 311

417, 1513

1535, 1636

1652, 1720

24,636

191,383

44102

Discharge summary

report

Admission Date: [**2155-6-20**] Discharge Date: [**2155-7-4**] Date of Birth: [**2104-4-11**] Sex: F Service: CHIEF COMPLAINT: Ovarian cancer. HISTORY OF PRESENT ILLNESS: Fifty-year-old woman with a history of metastatic ovarian cancer recently finished her third cycle of chemotherapy, came to the Emergency Room secondary to progressive abdominal pain and distention, unable to tolerate po's with bilious vomiting x3. PAST MEDICAL HISTORY: 1. Ovarian cancer papillary serous. 2. Small bowel obstruction status post lysis of adhesions and hemicolectomy, ileostomy. 3. Hydronephrosis. 4. Enterocutaneous fistula. MEDICATIONS: 1. Zofran. 2. Ativan. 3. OxyContin. 4. Dilaudid. 5. Klonopin. 6. Serax. ALLERGIES: No known drug allergies. FAMILY HISTORY: Positive for cancer. SOCIAL HISTORY: Negative for tobacco or alcohol. PHYSICAL EXAMINATION: Temperature 98.2, blood pressure 130/80, heart rate 78, respiratory rate 20, and sating 98% on room air. In general, in no acute distress. Oropharynx clear. Nasogastric tube in place. Lungs are clear to auscultation bilaterally. Heart: Regular, rate, and rhythm, no murmurs, rubs, or gallops. Abdomen: Normoactive bowel sounds, soft, nontender, nondistended, positive colostomy fistula, no clubbing, cyanosis, or edema. LABORATORIES: White count 10.5, hematocrit 31, platelets 250. Sodium 137, potassium 3.7, chloride 100, bicarb 25, BUN 21, creatinine 0.8, glucose 88. Abdominal film consistent with air fluid levels, small bowel obstruction without dilatation. HOSPITAL COURSE: 1. Hematologic issues: The patient is status post treatment with carboplatin. She underwent treatment with Neulasta while hospitalized. Patient's further chemotherapy regimen was considered, however, given her complicated hospital course and generalized decline, decision was made to discontinue further chemotherapy and move to comfort measures. 2. Small bowel obstruction: Patient was evaluated by surgical team. Nasogastric tube was placed for decompression. Patient's symptoms persisted and a palliative G tube was placed. 3. Nutrition: Patient was maintained on total parenteral nutrition, which she will continue as an outpatient. 4. Pain control: Initially with Dilaudid PCA and eventually transferred to IV Morphine at the time of discharge. 5. Neurologic: Patient had frequent episodes of delirium, initially felt likely secondary to pain medications. Patient's neurologic status, however, continued to decline despite holding her narcotic medication. She received Haldol for agitation. Subsequently the patient developed a dystonic reaction to Haldol requiring intubation. The patient was successfully extubated and mental status was returned to baseline at time of discharge. DISCHARGE DIAGNOSIS: Ovarian cancer. DISCHARGE PLAN: Home with hospice. Comfort medications. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 16520**] Dictated By:[**Last Name (NamePattern1) 7485**] MEDQUIST36 D: [**2155-8-3**] 14:06 T: [**2155-8-7**] 06:49 JOB#: [**Job Number 94671**]

[ "507.0", "518.82", "198.89", "560.89", "197.8", "197.7", "197.6", "V10.43" ]

icd9cm

[ [ [] ] ]

[ "99.15", "03.31", "96.04", "96.71", "38.93", "43.11" ]

icd9pcs

[ [ [] ] ]

775, 797

2790, 2807

1564, 2768

871, 1547

144, 161

190, 440

2824, 3107

462, 758

814, 848

7,212

122,310

19787+57088

Discharge summary

report+addendum

Admission Date: [**2185-10-24**] Discharge Date: [**2185-11-8**] Date of Birth: [**2109-6-11**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 76 year old male with a history of Type 2 diabetes, hypertension and hypercholesterolemia who developed a sharp right-sided chest pain on the morning of admission, associated with shortness of breath, diaphoresis and nausea. This resolved within four minutes and he went to the [**Country **] Planes DA [**Hospital **] Care Center where he got p.o. Lopressor and Aspirin. He was then transferred to [**Hospital6 256**] for further workup. PAST MEDICAL HISTORY: Past medical history includes diabetes Type 2, hypertension, hyperlipidemia and coronary artery disease. He has a history of old myocardial infarction by electrocardiogram. SOCIAL HISTORY: He lives with his wife, he does not smoke, he does not drink. He is a retired gas station owner. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Atenolol 50 mg p.o. q.d.; Aspirin 325 mg p.o. q.d. which he has stopped because of he did have some black tarry stools. PHYSICAL EXAMINATION: Vital signs heartrate 79, blood pressure 126/72, respirations 25, oxygen saturation 98% on room air. His general examination showed him to be in no acute distress. He is alert and oriented times three. His head, eyes, ears, nose and throat showed extraocular movements intact, pupils equal, round and reactive to light, his pharynx is clear. His neck is supple, no jugulovenous distension and no bruits. Heart examination shows regular rate and rhythm without murmur, rub or gallop. His lungs are clear to auscultation bilaterally. His abdomen is soft, nontender, nondistended with positive bowel sounds. Extremities shows no cyanosis, clubbing or edema. Neurologically he is grossly intact with no focal deficits. LABORATORY DATA: His laboratory data on admission includes a white count of 10.1, hematocrit 42%, platelet count of 220,000 and sodium 140, potassium 3.9, chloride 105, carbon dioxide 27, BUN 13, creatinine .7 and glucose of 160. His chest x-ray showed prominent right impaired hyaline consistent with clotting of his pulmonary vessels. He has an elevated right hemidiaphragm. HOSPITAL COURSE: On admission he was seen by Cardiology who recommended exercise tolerance Sestamibi scan. This scan was performed which showed moderate irreversible defect, distal anterior wall of apex and septum and also has a moderate partially reversible defect in the inferior wall with global hypokinesis and an ejection fraction of 37%. He was then referred for cardiac catheterization which was performed on [**2185-10-26**] and showed 100% occlusion of his left anterior descending, 100% occlusion of his mid right coronary artery, left circumflex was okay with an ejection fraction of 30%. The patient was then referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] for coronary artery bypass graft. On [**2185-10-27**], the patient underwent coronary artery bypass grafting times two with the left internal mammary artery to the left anterior descending artery and saphenous vein graft to the posterior descending artery. The surgery was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 16398**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as nurse practitioner. The surgery was performed under general endotracheal anesthesia with cardiopulmonary bypass time about 60 minutes and a crossclamp time of 38 minutes. The patient tolerated the procedure well and was transferred to the Cardiac Surgery Recovery Unit in normal sinus rhythm on Neo-Synephrine and Propofol drips with atrial and ventricular pacing wires, one mediastinal and one left pleural chest tube. After arrival in the Surgical Intensive Care Unit the patient was noted to have ventricular tachycardia which deteriorated into ventricular fibrillation with hypotension. He was defibrillated times one with 200 joules and he returned to [**Location 213**] sinus rhythm. He then had subsequent transesophageal echocardiogram and electrocardiogram which were done with no significant changes. On postoperative day #1 he was still on Propofol drip which was weaned and when the patient awoke he was very lethargic and restless, following commands. He became hypotensive and his Neo drip was titrated. He also had his external pacer rate increased and again he became hypotensive. He had been transfused 1 unit of packed red blood cells in the morning for a hematocrit of 21.6% and was given an additional unit of packed red blood cells. He was started on Epinephrine drip but then became tachycardiac, so he was subsequently started on Milrinone drip and Epinephrine was weaned off. His chest x-ray the morning of postoperative day #1 showed left lower lung collapse and therefore he received therapeutic bronchoscopy where a large greenish mucous plug was removed. He was suctioned for a scant amount of thick secretions. Also the patient was started on Precedex secondary to agitation and this was titrated to good effect. He was also on Amiodarone drip secondary to his dysrhythmia and subsequently had no further ectopy. By postoperative day #3 he received an additional bronchoscopy for secretions and therapeutic need in an attempt to extubate. He Precedex was weaned and he was extubated on postoperative day #3. At that point his Milrinone was able to be weaned with a good cardiac output of greater than 6. On the over night period of postoperative day #3, he did have some rapid atrial fibrillation to 130s. He received additional Amiodarone and was started on beta blocker. After multiple doses of intravenous Lopressor and increasing his p.o. Lopressor up to 50 mg he converted to normal sinus rhythm. By postoperative day #6 he still had some mild confusion but he was ready for transfer to the floor. He continued in normal sinus rhythm with some premature atrial contractions and was continued on Levaquin for his sputum. When the patient was transferred to the floor, later that afternoon he became agitated and wanted to leave. He dressed himself and headed for the door but then was able to receive Haldol 2 mg intramuscularly, calmed down and returned to his bed. Following that incident his confusion improved daily until the time of discharge where he is alert and oriented times three. On postoperative day #8 it was noted that his blood sugars have been elevated and he has been receiving sliding scale insulin frequently each day. A [**Hospital1 **] consult was obtained and he was eventually started on Glyburide 5 mg p.o. q. day. The sliding scale insulin did keep him in good control but this was not a good option for him upon discharge to home. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 53473**] MEDQUIST36 D: [**2185-11-8**] 11:05 T: [**2185-11-8**] 11:20 JOB#: [**Job Number 53474**] Name: [**Known lastname 9952**], [**Known firstname **] Unit No: [**Numeric Identifier 9953**] Admission Date: [**2185-10-24**] Discharge Date: [**2185-11-8**] Date of Birth: Sex: Service: ADDENDUM HOSPITAL COURSE: On postoperative day #3, the patient was weaned and extubated. His Milrinone was then able to be shut off, and cardiac output was maintained at greater than 6. He at that point was on Amiodarone drip for his postoperative ventricular tachycardia/ventricular fibrillation and had not had any further ectopy. He was weaned off the ..................., and by postoperative day #4, was alert and oriented. He was noted to be in rapid atrial fibrillation on postoperative day #4, with a rate in the 130s. He received an extra bolus of intravenous Amiodarone and also was started on Lopressor 12.5 b.i.d. By later in the day, he continued to be in atrial fibrillation and received extra intravenous doses and Lopressor and was increased to 25 ................... b.i.d. At that point, he converted to normal sinus rhythm. He did continue to have some confusion and was hallucinating at some point throughout the day. He remained in the Intensive Care Unit for a couple of more days. On postoperative day #6, he was transferred to the Surgical Floor. On that afternoon, he became more confused and combative. He dressed himself and began to approach the exit. He was restrained and brought back to his room and given Haldol 2 mg IM which calmed him, and he was able to get to bed and rest for some time. Since that point up through the time of discharge, his confusion and agitation have steadily improved, and he is no longer receiving Haldol. By postoperative day #8, it was noted that he was receiving coverage for sliding scale Insulin multiple times a day. He did receive [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 616**] consult who recommended continuing the sliding scale and eventually recommended to start him on Glyburide 5 mg p.o. q.d. He did receive ................... glucose management and recording his fingerstick blood sugars at home. A prescription was given for a glucometer. Over the next several days, he continued to work with Physical Therapy and was progressing in ambulation and was felt to be ready for discharge home on postoperative day #12. He will have visiting nurse services at home to aid with his medication management and help him with his glucose monitoring. His discharge exam shows him to be afebrile with a heart rate of 80, blood pressure 139/61, respirations 20, oxygen saturation 95% on room air. He was alert and oriented times three in no apparent distress. His lungs are clear to auscultation bilaterally. His heart is regular, rate and rhythm with no murmur. His abdomen is soft, nontender and nondistended. His extremities were without edema, and his wounds are clean, dry, and intact. Sternum is stable. Discharge white count is 13.3, hematocrit 33%, platelet count 509,000. His discharge chemistry shows a sodium of 136, potassium 4.5, chloride 102, CO2 25, BUN 14, creatinine 0.8, blood glucose 144. Chest x-ray showed small bilateral effusions, left greater than right. DISCHARGE DIAGNOSIS: 1. Coronary artery bypass grafting times two. 2. Diabetes mellitus type 2. 3. Hypertension. 4. Hypercholesterolemia. DISCHARGE MEDICATIONS: Aspirin 325 mg p.o. q.d., Amiodarone 400 mg p.o. q.d. x 10 days, then 200 mg p.o. q.d., Atenolol 75 mg p.o. q.d., Lasix 20 mg p.o. b.i.d. x 10 days, Potassium Chloride 20 mEq p.o. b.i.d. x 10 days, Glyburide 5 mg p.o. q.d., Protonix 40 mg p.o. q.d., Dulcolax 5 mg p.o. q.h.s. p.r.n., Magnesium Hydroxide 30 cc p.o. q.h.s. p.r.n. FOLLOW-UP: He should follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], in [**12-9**] weeks. He should follow-up with a cardiologist recommended to him or with Dr. [**Last Name (STitle) 690**] in [**1-10**] weeks and with Dr. [**Last Name (STitle) 71**] in six weeks. It was also strongly recommended that he be followed for at least teaching purposes regarding his diabetes and glucose management at the [**Last Name (un) 616**], although the patient is refusing this at this time. Hopefully he will be able to receive good teaching at an outside facility. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-358 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2185-11-8**] 11:43 T: [**2185-11-8**] 12:44 JOB#: [**Job Number 9954**]

[ "401.9", "250.00", "518.0", "458.29", "411.1", "427.41", "934.1", "507.0", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.61", "99.62", "99.04", "36.11", "96.05", "36.15", "88.53", "37.22", "88.56", "89.68" ]

icd9pcs

[ [ [] ] ]

10629, 11793

10483, 10605

1023, 1144

7499, 10462

1167, 2271

185, 644

667, 842

859, 996

7,192

142,374

24528

Discharge summary

report

Admission Date: [**2152-3-18**] Discharge Date: [**2152-3-22**] Date of Birth: [**2075-5-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: weakness, SOB Major Surgical or Invasive Procedure: EGD s/p clip placed in second part of duodenum colonoscopy s/p polyp removal in hepatic flexure paracentesis s/p removal 7L fluid History of Present Illness: A 76-year-old male with history of hypertension, AFIB, CAD, cardiomyopathy, valvular heart disease, CHF, hypothyroidism, renal insufficiency, GI bleed, colon polyps, arthritis, and anemia presents with 2 weeks of weakness, fatigue, SOB and chest pain. Pt was recently d/c'd from [**Hospital1 18**] on [**2152-3-5**] for increased ascites where he had an 11 liter paracentesis. He states that since his discharge he has had increased fatigue, SOB, weakness and upper chest pain. Has never had these symptoms in the past. He felt that he was "having a heart attack and dying." His chest pain began day PTA, radiated to neck, lasted a few minutes, had associated SOB. Relieved with ice. Feels that his abd girth has increased but he is not uncomfortable and has had no abd pain. Pt was seen in clinic by PCP [**Last Name (NamePattern4) **] [**2152-3-15**] and continued on Lasix and aldactone regimen. BP at that time was 85/37. . ROS positive for dizziness, constipation, one episode of vomiting at dentist's office yesterday. Denies F/C/night sweats. Denies diarrhea, abd pain, dysuria. Has not noted blood in stool or change in color. . In ED, found to have HCT 14, most recent HCT 27 on [**2152-3-5**]. GUAIAC positive but no melena. ECHO done for hypotension and no pericardial effusion seen. . Pt was noted to have guaiac positive stools on recent admission in [**2-3**], when he had Hct of 21.6. Was advised to get an outpt colonoscopy, but has not yet rec'd this. Past Medical History: 1. HTN 2. CAD -- s/p 3v-cabg 3. CHF -- Systolic and diastolic 4. AFib -- off warfarin 5. GIB -- H/o colon polyps, EGD with vascular ectasia (cauterized) 6. Ascites -- Secondary to Right-sided CHF 7. CRI -- Baseline cr ~ 1.3 8. Anemia 9. Hypothyroidism s/p goiter excision at age 30 10. S/p left TKR Social History: Pt lives with wife in [**Name (NI) 3146**], moved here from [**Country 3397**]. He smoked about 1ppd x 40yrs, quit 15 yrs ago. No significant alcohol use. Family History: Mother with hypertension. Physical Exam: EXAM: T 97.6, HR 70, BP 85/38, RR 22, O2sat=96% on RA GEN: Alert and oriented, pale-appearing. HEENT: Supple neck, distended EJs. CV: distant Irreg, irreg. LUNGS: Bibasliar crackles R>L, wheezes. BACK: No CVAT ABD: Soft, Nontender. Reducible umbilical hernia. EXT: [**1-31**]+ pitting bilateral lower extremity edema to the distal thighs. Pertinent Results: Cspy results: polyps in the distal sigmoid colon not removed; ulceration, erythema and congestion in the hepatic flexure and ascending colon concerning for ischemia; polyp in the hepatic flexure removed; stool in the cecum, ascending colon and hepatic flexure limiting the views of the mucosa. . EGD results: polyps in the first part of the duodenum and second part of the duodenum; angioectasias in the second part of the duodenum - likely etiology of iron deficiency anemia and guaiac positive stool. Clip placed. [**2152-3-18**] 02:55AM BLOOD WBC-10.7 RBC-1.51*# Hgb-4.1*# Hct-14.0*# MCV-93 MCH-27.4 MCHC-29.4* RDW-20.9* Plt Ct-336 [**2152-3-22**] 12:55PM BLOOD Hct-30.8* [**2152-3-18**] 02:55AM BLOOD Neuts-88.6* Bands-0 Lymphs-7.0* Monos-3.6 Eos-0.7 Baso-0.2 [**2152-3-18**] 02:55AM BLOOD PT-13.7* PTT-29.4 INR(PT)-1.2* [**2152-3-22**] 08:50AM BLOOD PT-13.3* PTT-31.0 INR(PT)-1.2* [**2152-3-18**] 02:55AM BLOOD Glucose-113* UreaN-74* Creat-1.9* Na-129* K-4.9 Cl-95* HCO3-20* AnGap-19 [**2152-3-22**] 06:10AM BLOOD UreaN-21* Creat-1.1 Na-131* K-3.4 Cl-97 HCO3-26 AnGap-11 [**2152-3-18**] 02:55AM BLOOD ALT-9 AST-17 LD(LDH)-202 CK(CPK)-46 AlkPhos-63 Amylase-134* TotBili-0.7 [**2152-3-18**] 02:55AM BLOOD Lipase-129* [**2152-3-18**] 02:55AM BLOOD cTropnT-<0.01 [**2152-3-19**] 04:39AM BLOOD CK-MB-4 cTropnT-0.03* [**2152-3-18**] 02:55AM BLOOD Albumin-3.0* Calcium-7.5* Phos-6.3*# Mg-2.5 Iron-11* [**2152-3-20**] 05:11AM BLOOD Calcium-7.2* Phos-3.7 Mg-2.1 [**2152-3-18**] 02:55AM BLOOD calTIBC-437 VitB12-596 Folate-12.7 Hapto-109 Ferritn-19* TRF-336 [**2152-3-18**] 02:55AM BLOOD TSH-25* [**2152-3-18**] 02:55AM BLOOD T4-3.3* [**2152-3-19**] 11:37PM BLOOD Na-130* K-3.3* Cl-95* Brief Hospital Course: 76yo man with likely recurrent GI bleed causing profound anemia which resolved after receiving transfusions and GI intervention. Anemia: Hct at admission was 14 with associated symptoms such as SOB, CP, weakness; his Hct increased appropriately after receiving transfusions. He was guaiac positive in the ED, and given his history of GI bleeds, most likely source of blood loss was from his GI tract. He was monitored in the ICU for possible hemodynamic instability while awaiting EGD and colonoscopy to evaluate the source of his bleeding. EGD demonstrated angioectasias in the 2nd part of the duodenum which was the likely source of blood loss - a clip was placed in this region. On the colonoscopy, an area of ulceration, erythema and congestion was seen in the hepatic flexure and ascending colon which was concerning for ischemia. Following these procedures, his blood counts remained stable, and he was discharged to home with an increased dose of protonix and instructions to discontinue aspirin until instructed otherwise by his PCP. CV: a) CAD: h/o 3VD; He was ruled out by enzymes given his complaint of chest pain. He was transfused with pRBC to maintain Hct>27. It was recommended that he avoid ASA secondary to bleeding; his BB and ACEI were also held given his low blood pressure and active GIB. b) Afib: Continued Amiodarone, follow QT intervals with serial EKGs; held anti-coag given active bleeding c) CHF/hypotension: Pt has been evaluated in the past for TVR though he was not felt to be a candidate given comorbidities. Restarted outpatient diuretics once Hct and BP were stable. d) PPx: as above, and continued statin Abdominal ascites: This was evaluated in the past and was felt to be secondary to R-sided CHF from 4+TR rather than cirrhosis. He received an uncomplicated paracentesis during which 7 liters of fluid were removed - this was mainly performed for the patient's comfort. Standing doses of spironolactone and lasix were restarted prior to discharge. He remained hemodynamically stable, and there was no evidence of fluid reaccumulation following the procedure. ARF on CKD: His renal failure was most ikely attributable to poor forward flow. This was improved with IVF and blood transfusions - creatinine trended towards his baseline of 1.3. This remained stable as we avoided overdiuresis or nephrotoxic medications. Hypothyroidism: Continued outpatient dose of levothyroxine Access: 3 peripheral IVs FEN: Advanced diet slowly following GI procedures, and he was given lasix as needed with his transfusions. PPx: He was given pneumoboots and PPI [**Hospital1 **] for prophylaxis. Communication: patient and wife Code: FULL Medications on Admission: 1. Aspirin 325 mg TabletQD 2. Amiodarone 200 mg QD 3. Pantoprazole 40 mg Tablet, QD 4. Atorvastatin 20 mg QD 5. Tamsulosin 0.4 mg Capsule, Sust. Release PO HS 6. Ferrous Sulfate 325 QD 7. Spironolactone 25 mg QD 8. Lasix 80 mg Tablet QPM. 9. Lasix 80 mg Tablet QAM. 10. Colace 100 mg Capsule [**Hospital1 **] 11. Oxygen-Air Delivery Systems 2L continous Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Capsule(s) 6. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: GI bleed - likely from angioectasias in duodenum iron deficiency anemia ascites [**3-2**] R heart failure . Secondary CAD HTN CHF - Systolic and diastolic AFib - off warfarin CRI - Baseline cr 1.3 Hypothyroidism s/p goiter excision at age 30 Discharge Condition: good; Hct stable between 28-31 w/ no further episodes of bleeding Discharge Instructions: Please call Dr. [**Last Name (STitle) **] or go to the ED if you notice black or tarry stool, feel dizzy, have shortness of breath, chest pain, fainting, nausea, vomiting or any other symptoms that are concerning to you. . Please note the following changes to your medications: - spironolactone 50mg daily (increased from 25mg) - pantoprazole 40mg TWICE a day (increased from once daily) - DO NOT TAKE ASPIRIN * Take other medications as your were prior to admission . You should keep the appointments that have been scheduled for you - the details are provided below. Followup Instructions: Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 9612**] MEDICINE (PRIVATE) Date/Time:[**2152-3-30**] 10:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2152-4-10**] 3:45 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2152-6-14**]

[ "280.0", "398.91", "585.9", "276.50", "789.5", "537.83", "427.31", "211.3", "276.1", "211.2", "401.9", "414.00", "244.0", "V43.65", "397.0", "584.9" ]

icd9cm

[ [ [] ] ]

[ "45.25", "54.91", "44.43", "99.04" ]

icd9pcs

[ [ [] ] ]

8398, 8404

4579, 7258

328, 460

8699, 8767

2873, 4556

9384, 9821

2471, 2498

7663, 8375

8425, 8678

7284, 7640

8791, 9040

2513, 2854

9069, 9361

275, 290

488, 1959

1981, 2282

2298, 2455

85

112,077

10928

Discharge summary

report

Admission Date: [**2167-7-25**] Discharge Date: [**2167-7-30**] Date of Birth: [**2090-9-18**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2279**] Chief Complaint: Weakness/fever Major Surgical or Invasive Procedure: None History of Present Illness: 76 yo Male with hx of AVR, CAD s/p CABG, MDS- pancyopenia, non-hodgkins lymphoma, and Parkinson's who was relaeased from the hospital 2 months ago for a pneumonia. He brought in from his ECF because of fever to 105 and new weakness, and sob. He says he has had a cough and SOB for the last few weeks. Today he was unable to get up and go to the bathroom. He denies any fevers prior to today. He denies any pains including chest and abdominal pain. In the ED a CXR showed possible RLL PNA versus atelectasis. His UA was neg, he got 3 sets of blood cultures. He was given Vanc/zosyn/azithro in the ED for emperic coverage of a HCAP, tylenol 325 after 650 earlier in the day for his fever and 4L of IVF. His EKG showed sinus tachycardia in the ED. On arrival to the MICU, in rigors, not febrile at this time, has cough, no pain. Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. AS s/p porcine Aortic Valve Replacement ([**2162-3-3**]) 2. CAD s/p CABG x 2 (LIMA to LAD, SVG to OM [**2162-3-3**]) 3. CKD 4. Depression / anxiety, currently treated only with diazepam qhs. Previously on Effexor and benzo and Seroquel (stopped in [**2157**] due to EPS/?PD) 5. hyperlipidemia on crestor 6. Hypothyrodism 7. Tremor 8. Gait disorder, thought by Dr. [**Last Name (STitle) **] to be primarily due to posterior column dysfunction 9. BPH s/p TURP, no longer on Flomax; nocturia x hourly 10. non-Hodgkin's Lymphoma s/p chemo/BMT @OSH was in remission until current thrombocytonia 11. OSA on prior sleep study; pt refuses CPAP; wife says no snoring. M-III to M-IV airway, with extra neck soft tissues. Social History: Married, kids in CA (just visited, as above), lives with wife. Retired from cigarette sales ~15y ago.Chronic/progressive health problems as above. Smoked heavily in military ~50y ago, but quit cigs and now smokes occasional cigars "do not inhale" for many years. Says 1-2 beers per night, but formerly drank heavily (up to ~15 years ago when he retired). Denies any h/o illicit drug use or supplements. Family History: Non-contributory Physical Exam: Admission Exam: Vitals: T: 98.6 BP: 166/87 P: 136 R: 39 O2: 99 General: Alert, rigors HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Tachycardic, crisp S1, s2, no rubs, gallops Lungs: Scattered wheezes Abdomen: soft, non-tender, non-distended, bowel sounds present GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Discharge exam: Pertinent Results: [**2167-7-25**] 04:50PM WBC-6.9# RBC-3.59* HGB-10.4* HCT-32.3* MCV-90# MCH-29.1# MCHC-32.2 RDW-22.5* [**2167-7-25**] 04:50PM NEUTS-57 BANDS-4 LYMPHS-23 MONOS-11 EOS-0 BASOS-0 ATYPS-4* METAS-0 MYELOS-0 BLASTS-1* NUC RBCS-1* [**2167-7-25**] 04:50PM HYPOCHROM-1+ ANISOCYT-3+ POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [**2167-7-25**] 04:50PM PLT SMR-VERY LOW PLT COUNT-31* [**2167-7-25**] 04:50PM PT-13.6* PTT-28.1 INR(PT)-1.3* [**2167-7-25**] 04:50PM CALCIUM-8.7 PHOSPHATE-1.2*# MAGNESIUM-1.8 [**2167-7-25**] 04:50PM CK-MB-1 cTropnT-<0.01 [**2167-7-25**] 04:50PM CK(CPK)-71 [**2167-7-25**] 04:50PM GLUCOSE-113* UREA N-22* CREAT-1.4* SODIUM-133 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-23 ANION GAP-14 [**2167-7-25**] 05:04PM LACTATE-0.9 [**2167-7-25**] 06:30PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-<1 [**2167-7-25**] 06:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2167-7-25**] 06:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2167-7-25**] 06:30PM URINE UHOLD-HOLD [**2167-7-25**] 06:30PM URINE HOURS-RANDOM CXR [**7-25**] PA and lateral The patient is status post median sternotomy for CABG. Heart remains mildly enlarged with left ventricular predominance. The patient is status post aortic valve replacement. The mediastinal contours are unchanged, with mild calcification of the aortic knob again demonstrated as well as a mildly tortuous course of the thoracic aorta. The pulmonary vascularity is not engorged. Streaky opacities in the lung bases are nonspecific, possibly reflecting atelectasis though infection cannot be excluded. No pleural effusion or pneumothorax is visualized. There are no acute osseous abnormalities. IMPRESSION: Streaky bibasilar opacities, which could reflect atelectasis though infection cannot be completely excluded. Brief Hospital Course: 76 yo Male with hx of AVR, CAD s/p CABG, MDS- pancyopenia, non-hodgkins lymphoma, and Parkinson's who was relaeased from the hospital 2 months ago for a pneumonia who returns with a HCAP and new a. fib w/ rvr. Was treated in the ICU and transferred to the floor to complete 10 day course of antibiotics. 1) HCAP pneumonia/sepsis- Pt initially sirs criteria, and presented with dry cough x2 weeks, new weakness, and his CXR was concerning for a new RLL inflitate. With the pt's history of Parkinson's disease, was at risk for aspiration due to dysphagia, and thus cause recurrent pneumonia. Pt's fever curve improved with vancomycin, cefepime and azithromycin for a 10 day course (through [**2167-8-6**]). Blood cultures were negative. Pt's dry cough did not improve with cough syrup, tessalon perles and nebulizer treatments and thus had an ENT consult which found mild irritation of vocal cords most likely related to acid reflux or viral infection. Laryngoscopy did not show vocal cord paralysis and structurally normal. Cough mildly improved while on the floor, but still with significant cough at discharge. He was started on prednisone 40 mg PO daily for a 4 day total course to end on [**2167-8-2**]. 2) New Atrial fib w/ rvr in 120s likely due to stress of increasing cardic output in septic picture. Other concerns included his thyroid medicine and new ischemia but TSH normal and cardiac enzymes were negative. Pt was rate controlled with metoprolol 50mg TID and was successfully converted to NS rhythm. Echo was done which showed LVEF>55%, no thrombus. Pt's CHADS2 score at 1. Aspirin was held due to thrombocytopenia. Metoprolol was discontinued given his reactive airways and wheezing. On stopping, patient tended to be borderline tachyardia with intermittent atrial fibrillation and bigeminal PACs. When his pulmonary symptoms resolve, metoprolol should be considered if his tachycardia/afib persists at rehab. 3) Parkinson's disease: Was continued on home pramipexole during course and was evaluated by speech and swallow for dysphagia; pt was cleared for regular solid PO intake. 4) MDS/Non-Hodgkin's lymphoma: s/p chemo and BMT, chronic thrombocytopenia. Pt had no bleeding issues. Patient required transfusion of 1 unit of platelets prior to PICC line placement but otherwised remained above transfusion threshold without evidence of bleeding. 5) Hyperlipidemia: Rosuvastatin was continued throughout course. 6) BPH: Tamsulosin was continued throughout course. 7) Depression/Anxiety: Stable, PRN diazepam. Was requiring approximately one additional dose of diazepam daily. 8) Hypothyroid: continue home Levothyroxine Sodium 50 mcg PO DAILY. TSH normal. 9) Left ear ceurmen: Stable. 10) Constipation: Continued Lactulose, Polyethylene Glycol, Docusate Sodium 100 mg PO BID, and Senna 1 TAB PO BID. # Transitional issues: - Consider starting patient on metoprolol for new atrial fibrillation, was started in house, then discontinued given reactive airways. Should be restarted if he continues to have tachycardia/afib once pulm symptoms resolve. - Patient should continue full treatment for HCAP with vancomycin 1g IV Q12 and Cefepime 2 g IV Q12H through is PICC line, both through [**2167-8-6**]. - PICC line okay to use by nursing staff at rehab. CXR confirmed placement on [**7-29**] and has been used here. - Patient started on prednisone 40 mg PO daily for reactive airways, which should continue through [**8-2**]. - Patient started on high dose PPI while in house given ENT evaluation of laryngeal inflammation from possible reflux. This should be discussed with PCP and [**Name9 (PRE) 31042**] in 2 weeks. Continued high dose PPI has multiple risks and these should be weighed. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Record. 1. Diazepam 5 mg PO DAILY:PRN anxiety 2. Lactulose 15 mL PO DAILY constipation 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. Acetaminophen 325-650 mg PO Q4H:PRN pain/fever 6. Codeine Sulfate 15-30 mg PO Q4H cough 7. Guaifenesin-Dextromethorphan 15 mL PO Q4H:PRN cough 8. Benzonatate 200 mg PO TID:PRN cough 9. Docusate Sodium 100 mg PO BID 10. Senna 1 TAB PO BID 11. pramipexole *NF* 0.5 mg Oral TID Parkinson's 12. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 13. Levofloxacin 500 mg PO Q24H PNA Duration: 13 Days 14. Levothyroxine Sodium 50 mcg PO DAILY 15. Tamsulosin 0.4 mg PO HS BPH 16. Carbamide Peroxide 6.5% 5 DROP AD QHS Duration: 4 Days Left ear at bedtime 17. Rosuvastatin Calcium 10 mg PO DAILY Discharge Medications: 1. Carbamide Peroxide 6.5% 5 DROP AD QHS Duration: 4 Days Left ear at bedtime 2. Acetaminophen 325-650 mg PO Q4H:PRN pain/fever 3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 4. Benzonatate 200 mg PO TID:PRN cough 5. Codeine Sulfate 15-30 mg PO Q4H cough 6. Diazepam 5 mg PO DAILY:PRN anxiety 7. Docusate Sodium 100 mg PO BID 8. Guaifenesin-Dextromethorphan 15 mL PO Q4H:PRN cough 9. Lactulose 15 mL PO DAILY constipation 10. Levothyroxine Sodium 50 mcg PO DAILY 11. Ondansetron 4 mg PO Q8H:PRN nausea 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. pramipexole *NF* 0.5 mg Oral TID Parkinson's 14. Rosuvastatin Calcium 10 mg PO DAILY 15. Senna 1 TAB PO BID 16. Tamsulosin 0.4 mg PO HS BPH 17. CefePIME 2 g IV Q12H Continue through [**8-6**]. 18. Vancomycin 1000 mg IV Q 12H Continue through [**8-6**]. 19. PredniSONE 40 mg PO DAILY Duration: 3 Days Continue through [**8-2**]. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Living Discharge Diagnosis: Primary: Health care associated pneumonia New atrial fibrillation Secondary: Myelodysplastic syndrome Thrombocytopenia Discharge Condition: Patient is afebrile with stable vitals. Satting mid 90s on RA. He is in and out of a fib and borderline tachycardic in the 90s-100s. Lung exam with inspiratory and expiratory wheezing and transmitted upper airway sounds, breathing is nonlabored. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - With walker or aid. Discharge Instructions: Dear Mr. [**Known lastname 35501**], You were admitted to the [**Hospital1 69**] for symptoms concerning for pneumonia. We treated your pneumonia with antibiotics and your fevers resolved. You will need to continue taking antibiotics at the rehab facility. A PICC line was placed in your left arm and it's placement was confirmed with an x-ray, so your antibiotics can be given at rehab. You were also started on steroids (prednisone) for a total of 5 days to help with your breathing. It was a pleasure taking care of you at the [**Hospital1 18**]. Followup Instructions: Department: CARDIAC SERVICES When: THURSDAY [**2167-8-6**] at 3:20 PM With: [**First Name8 (NamePattern2) **] [**Known firstname **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage We are working on a follow up appt with Dr. [**Last Name (STitle) 35507**] at [**Hospital 10596**]. You will be called at home/rehab with the appointment. If you have not heard or have questions, please call ([**Telephone/Fax (1) 35513**]. Department: DERMATOLOGY When: MONDAY [**2167-8-17**] at 9:30 AM With: [**Doctor Last Name 3833**] [**Telephone/Fax (1) 1971**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: THURSDAY [**2167-10-15**] at 2:20 PM With: [**First Name8 (NamePattern2) **] [**Known firstname **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: WEDNESDAY [**2167-11-25**] at 9:00 AM With: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**] Completed by:[**2167-7-30**]

[ "585.3", "788.43", "427.31", "486", "V10.79", "272.4", "327.23", "332.0", "038.9", "V43.3", "305.1", "995.91", "244.9", "V45.81", "V42.81", "414.00", "238.75", "600.01", "300.4" ]

icd9cm

[ [ [] ] ]

[ "38.97", "31.42" ]

icd9pcs

[ [ [] ] ]

10792, 10933

5253, 8079

320, 326

11097, 11346

3303, 5230

12081, 13761

2762, 2780

9875, 10769

10954, 11076

8995, 9852

11504, 12058

2795, 3267

3284, 3284

1203, 1588

265, 282

354, 1184

11361, 11480

8102, 8969

1610, 2326

2342, 2746

26,637

199,511

2244+55369

Discharge summary

report+addendum

Admission Date: [**2179-8-20**] Discharge Date: [**2179-9-3**] Date of Birth: [**2111-1-6**] Sex: F HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old woman with multiple medical problems, status post a prolonged hospitalization, discharged on [**2179-8-5**] for recurrent infection of sacral decubitus with osteomyelitis. The complete an 8-week course). The patient returned to the Emergency Department on the day of admission with a change in mental status. She had decreased alertness, decreased ability to converse, and decreased oral intake. The patient also complained of increased pain in her right foot requiring higher doses of In the Emergency Department, the patient's oxygen saturation pressure dropped to 69/34. The patient was intubated, started on pressors, and transferred to the Medical Intensive Care Unit. In the Medical Intensive Care Unit, she was stabilized, extubated, and weaned off pressors. She was transferred to the floor for a workup of her various medical problems. PAST MEDICAL HISTORY: 1. End-stage renal disease; previously on hemodialysis with poor access, now on peritoneal dialysis since [**2178-7-17**]. 2. Myopathy, status post deltoid muscle biopsy of unknown etiology. 3. Peripheral vascular disease, status post left below-knee amputation and multiple finger amputations; admitted on Coumadin and Lovenox. 4. Systemic lupus erythematosus. 5. Osteomyelitis; sacral decubitus ulcer, past methicillin-resistant Staphylococcus aureus positive. 6. Hypertension. 7. Gout. 8. B-cell non-Hodgkin lymphoma of the ribs, skull, and pelvis; status post palliative radiation therapy; diagnosed in [**2177-5-17**] sacral mass poorly differentiated malignant tumor with sclerosis, CD20 positive; consistent with large B cell lymphoma. 9. Hypohomocystinemia. 10. Nephrolithiasis. 11. Bilateral bibasilar nodules on chest CT; the patient declined a workup. 12. Chronic anemia secondary to chronic renal insufficiency. 13. Echocardiogram in [**2178-6-16**] demonstrated mild left ventricular hypertrophy, left ventricular ejection fraction of greater than 55%, normal right ventricle, and trace tricuspid regurgitation. A repeat echocardiogram in [**2179-6-16**] was suboptimal but demonstrated a left ventricular ejection fraction of 60% and mitral regurgitation. 14. Introsusception. 15. Cholecystectomy. 16. Appendectomy. ALLERGIES: ASPIRIN. MEDICATIONS ON ADMISSION: 1. Potassium chloride 40 mEq p.o. q.d. 2. Vitamin C 500 g p.o. q.d. 3. Neurontin 100 mg p.o. t.i.d. 4. Folic acid 1 mg p.o. every week. 5. Nephrocaps one tablet p.o. q.d. 6. Allopurinol 100 mg p.o. q.d. 7. Elavil 25 mg p.o. q.h.s. 8. Zinc sulfate 220 mg p.o. q.d. 9. Midodrine 2.5 mg p.o. t.i.d. 10. Renagel 800 mg p.o. t.i.d. 11. Hectorol 2.5 mcg p.o. on Monday, Wednesday and Friday. 12. Dilaudid 2 mg to 4 mg p.o. q.4-6h. as needed. 13. Keflex 500 mg p.o. q.d. (until [**9-28**]). 14. Flagyl 500 mg p.o. q.12h. (until [**9-28**]). 15. Lovenox 30 mg subcutaneously q.12h. 16. Coumadin 2 mg p.o. q.h.s. (on hold). 17. Colace 100 mg p.o. b.i.d. 18. Senna two tablets p.o. q.h.s. 19. Epogen 10,000 units twice per week. 20. Levofloxacin 250 mg p.o. q.48h. (until [**9-28**]). PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed the patient was hypothermic at 95.6. Her blood pressure on transfer to the floor was 106/54, pulse was 88, oxygen saturation was 100% on 1 liter. The patient was an obese elderly woman sleeping, and quite difficult to arouse. She had distant regular heart sounds. The chest was clear, but the patient was unable to cooperate with the examination. The patient had 2+ edema in her lower extremity with a left below-knee amputation. She was quite somnolent and unable to cooperate with the neurologic examination. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories included a [**Known lastname **] blood cell count of 19.3, hematocrit of 27.1. INR was 1.9, PTT was 48.6. Sodium was 142, potassium was 3.3, blood urea nitrogen was 15, creatinine was 5.4. An arterial blood gas was done [**8-23**] which showed a pH of 7.31, PCO2 of 42, and a PO2 of 141. Clostridium difficile was negative on [**8-24**]. ADMISSION DIAGNOSES: 1. Change in mental status. 2. Osteomyelitis. 3. Hypotension. HOSPITAL COURSE: 1. CHANGE IN MENTAL STATUS: The etiology is now thought to likely have been multifactorial secondary to an infection, increased use of analgesics, and possible dehydration. On admission, a head CT was negative. On [**8-26**] a head magnetic resonance imaging was negative for cerebrovascular accident or bacterial abscess. A CT angiogram was done to rule out pulmonary embolism. A CT-guided cisternal puncture was performed. Cerebrospinal fluid demonstrated no growth on culture, and no polymorphonuclear leukocytes or microorganisms. Gram stain revealed a glucose of 73, protein was 22, [**Known lastname **] blood cells of 4. The fluid was clear and colorless. The patient's mental status gradually improved over her admission. On the day of discharge she was alert, and lucid, and conversant. 2. OSTEOMYELITIS/SACRAL DECUBITUS ULCER: On this re-admission, the patient's osteomyelitis and sacral decubitus ulcer were found to be no worse . However, her coverage was changed to Zosyn and vancomycin. Infectious Disease was consulted and followed the patient throughout the course of her stay. The patient's [**Known lastname **] blood cell count on admission was 15 and went up to 20.1 the following day. It had gradually decreased to 17.8 on the day prior to discharge. Plastic Surgery also saw the wound and determined that a flap was not an appropriate choice for the patient because she would have to remain off the flap for an extended period of time in order for it to heal appropriately. The wound was maintained with wet-to-dry dressing changes three times per day. A magnetic resonance imaging of the lower spine on [**8-22**] showed no abscesses and no progression of the infection. A peripherally inserted central catheter line was placed in the patient's arm on [**8-31**] for intravenous antibiotic use on discharge. 3. WEAKNESS: The patient has had generalized weakness for some time. She had a deltoid muscle biopsy in the past. Neurology was consulted and confirmed that the patient had myopathy by reviewing electromyogram and deltoid biopsy studies; but the attested the cause was still unknown. It was most likely due to chronic illness and/or inflammation. Lambert-Eaton syndrome was also on the differential and could be worked up as an outpatient once the patient is stronger. 4. END-STAGE RENAL DISEASE: The patient came in on q.i.d. peritoneal dialysis, and this regimen was continued during her hospital stay. The Renal team was consulted and oversaw the patient's treatment, which was stable and uneventful. 5. HYPOTENSION/ADRENAL INSUFFICIENCY: The patient was hypotensive both in the Emergency Department and once on the floor. Both times causing the patient to be transferred to the Intensive Care Unit. In addition, she was hypothermic throughout her hospital stay. An a.m. cortisol was checked which was low at 12. A cosyntropin stimulation test was done with 250 mcg of cosyntropin; subsequent cortisol levels were 10, 13, and 15. In light of the patient's positive clinical history, a diagnosis of adrenal insufficiency was made, and the patient was started on a stress-dose of hydrocortisone. The Endocrine team was consulted and followed the patient. On the day of discharge, the patient received 25 mg of prednisone p.o. q.d. She will undergo a gradual taper over the subsequent week. 6. OBSTRUCTIVE SLEEP APNEA: Initially, the patient was placed on BiPAP at night and was comfortable with that regimen. After approximately one week, the patient refused her BiPAP machine. She did not desaturate during the night. 7. ANEMIA: The patient's anemia is most likely secondary to her end-stage renal disease as well as anemia of chronic disease. The patient has had one or two positive stool guaiacs which could represent a very slow gastrointestinal ooze. The patient was continued on her Epogen twice weekly. Hematocrit on admission was 30.5. On a nadir during this hospitalization, it was 25.1. The patient was transfused 2 units of packed red blood cells. 8. FOOT PAIN: The patient complained of increasing pain around her foot ulcers. On [**8-23**], a foot x-ray was done which was negative for osteomyelitis. The pain was treated with a number of analgesics. Addendum: Subsequent to [**9-3**] date for above dictation, pt's overall condition conitnued to deteriorate (details of subsequent hosp to be dicatated as addendum. Pt and family ultimately did not want extaordinary measures performed and decision made for comfort care only. Pt expired a few days after that on [**2179-9-20**]. [**Name6 (MD) 306**] [**Name8 (MD) **], M.D. Dictated By:[**Last Name (NamePattern1) 11873**] MEDQUIST36 D: [**2179-9-2**] 15:14 T: [**2179-9-2**] 15:29 JOB#: [**Job Number 11874**] Name: [**Known lastname **], [**Known firstname 1683**] Unit No: [**Numeric Identifier 1684**] Admission Date: [**2179-8-20**] Discharge Date: [**2179-9-11**] Date of Birth: [**2111-1-6**] Sex: F Service: WBC fluctuation. The patient's [**Known lastname **] blood cell count has been fluctuating between 16.8 and 24.4 throughout her hospital stay. C. diff was negative despite the patient's rigorous antibiotic regimen. The patient was not experiencing any change in fever or her symptoms. The patient pulled her own PICC line and it was replaced on [**2179-9-8**] with much difficulty by interventional radiology. Thyroid dysfunction. The patient's TSH was measured to be 11. However, anti TPO and anti TBG antibodies were both measured to be negative, suggestive of a euthyroid fixed syndrome. Therefore, the patient will not receive any thyroid treatment in-house. Her thyroid function will be rechecked for possible resolution with her follow-up with the endocrinologist after discharge. DISCHARGE MEDICATIONS: 1. Prednisone 10 mg p.o. q.d. 2. Amitriptyline 25 mg p.o. q. h.s. 3. Enoxaparin subcutaneous q.12h. 4. DC Coumadin. The rest of the patient's medications are as listed in the discharge summary dated [**2179-9-3**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1752**], M.D. [**MD Number(1) 1689**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2179-9-11**] 13:13 T: [**2179-9-20**] 18:07 JOB#: [**Job Number 1753**]

[ "707.0", "255.4", "440.24", "518.81", "730.28", "458.9", "585", "285.21", "038.8" ]

icd9cm

[ [ [] ] ]

[ "01.01", "96.04", "54.98", "84.15", "96.70", "38.93", "86.22" ]

icd9pcs

[ [ [] ] ]

10199, 10682

2454, 4245

4350, 4364

4266, 4332

144, 1026

4380, 10176

1049, 2427

22,386

146,328

2196

Discharge summary

report

Admission Date: [**2126-6-30**] Discharge Date: [**2126-7-5**] Date of Birth: [**2051-11-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1055**] Chief Complaint: Dizziness, polyuria, polydipsia Major Surgical or Invasive Procedure: None History of Present Illness: 74 yr old male with hx of 2-vessel CAD s/p stent in [**2123**], HTN, high cholesterol who presents with 2 weeks of dizziness, blurry vision, polydipsia, polyuria and found to have a blood glucose of 1100, anion gap of 17. Initially, pt complained of exterional chest pain and dyspnea but when asked later, he reported only a few seconds of chest pain 1.5 weeks ago that resolved with one SL NTG. Pt states that he presented to the ED today at his son's urging and because he was starting to feel weak. Pt denies abd pain, dysuria, fevers, chills, cough, rhinorrhea, sore throat. He states that he has never had problems with high sugar, no hx of alcohol abuse but one sister does have diabetes. In the ED, he received 2L of NS and 1L of NS with 40mEq of KCl. He also received 10U of insulin x 1 and was started on an insulin drip. Given his initial presentation with chest pain, cardiac enzymes were drawn and troponin was slightly elevated at 0.03. Pt was admitted to the MICU for insulin drip. Past Medical History: 1. CAD, 2-vessel disease s/p stenting of pLAD and diag 2. Hypertension. 3. Hypercholesterolemia. 4. Epigastric hernia; status post repair in [**2117-3-29**]. Social History: Tobacco history revealed six to eight cigarettes per day times five years; quit 30 yrs ago. Occasional social alcohol use. No other drugs. Family History: Mother died of unknown causes. Father died of heart disease at the age of 86. He had heart disease for approximately 15 years at that point. Sister with diabetes Physical Exam: temp 98.5, BP 129/72, HR 89, R 22, O2 95% on 3L Gen: NAD, AO x 3 HEENT: PERRL, EOMI, MM slightly dry; on limited fundoscopic exam, no hemorrhages noted Neck: supple, no bruits CV: RRR, no g/m/r Chest: bibasilar crackles Abd: +BS, soft, NT, palpable mass beneath umbilicus the is more pronouced when pt bears down Ext: no edema, 1+ DP, sensation intact Neuro: CN 2-12 intact, [**4-2**] strenght in upper ext, [**3-2**] strenght in lower ext (though may be [**1-30**] poor cooperation), nl sensation, finger-nose-finger slow but accurate; gait not assessed Pertinent Results: [**2126-6-30**] 03:40PM GLUCOSE-1159* UREA N-54* CREAT-2.5*# SODIUM-126* POTASSIUM-6.6* CHLORIDE-87* TOTAL CO2-22 ANION GAP-24* [**2126-6-30**] 04:15PM PT-12.0 PTT-24.6 INR(PT)-1.0 [**2126-6-30**] 03:40PM cTropnT-0.03* [**2126-6-30**] 03:40PM CK-MB-6 [**2126-6-30**] 03:40PM WBC-9.9 RBC-5.14 HGB-16.1 HCT-50.9 MCV-99* MCH-31.3 MCHC-31.6 RDW-13.2 Brief Hospital Course: 1. Hyperglycemia: Prior to his arrival for this hospitalization, the patient did not carry the diagnosis of diabetes mellitus type 2. His admission blood glucose was over 1100. He was deemed to be in a hyperosmotic, nonketotic metabolic acidosis. His symptoms were most assuredly due to this diagnosis. He was started on an insulin drip per protocol, and was admitted to the medical ICU for management of his fluid status, electrolytes, and blood sugar. The MICU gained rapid control of his blood sugars, and he was transferred to the medical service for titration of insulin and disposition. The department of Endocrinology from [**Last Name (un) **] Diabetes Center was consulted and made recommendations for insulin administration. The patient was placed on Lantus insulin at bedtime, with a sliding scale of humalog insulin at mealtime. Adequate control of sugars was achieved, but the patient had a great deal of difficulty comprehending the diabetes teaching. He was mom[**Name (NI) 11711**] discharged from the hospital to [**Last Name (un) **] Diabetes Center for an outpatient diabetes teaching session, but was unable to self-administer. Ultimately, the patient's son came to a family meeting and it was decided that he would have to perform the insulin injections for the patient. The patient was discharged to his son's care, and instructions were given for follow-up at the [**Last Name (un) **] Diabetes Center. In discussion with the endocrinology fellow, a specific doctor and nurse were recommended for follow-up because of the patient's spanish-only requirements. [**Last Name (un) **] will coordinate further evaulation for podiatry and ophthalmology. 2. Acute Renal Failure: Per records, the patient has a baseline Cr of 1.1-1.4, but he came to the hospital with a Cr of 2.5. This was deemed to be almost certainly due to prerenal azotemia. With resolution of his hyperosmotic, hyperglycemic state, his renal function improved to a Cr of 1.3. No further intervention or diagnostics were deemed necessary by the primary team. 3. Hypertension: The patient came to the hospital on an ACE-I and HCTZ. Both medications were deemed appropriate, but both were held due to the patient's acute renal insufficiency. Once the Cr dropped to an acceptable level, his ACE-I was re-started. The HCTZ remained held, and should be re-started once as an outpatient once full renal recovery has occurred, and where good BP monitoring can be achieved on a long-term basis. 4. Hypercholesterolemia: Lipitor was continued throughout the hospitalization. 5. CAD: The patient's DM represents a CAD risk equivalent. His elevated A1C level suggests that he has had occult DM for some time. His ACE-I was restarted as noted for renal protection and cardiac benefits. The patient was also scheduled for an outpatient [**Last Name (un) **] test to evaluate his cardiac function. 6. FEN: The patient was initially fluid repleted and placed on an insulin drip in the MICU. On the floor these interventions were discontinued. The patient was placed on a diabetic diet, and was counseled on dietary requirements. 7. Prophylaxis: The patient was placed on a PPI for his hospital stay. He was given subcutaneous heparin for DVT prophylaxis. 8. Code status: full code Medications on Admission: ASA 81mg qd Flonase HCTZ 25mg qd Lipitor 20mg qd Lisinopril 5mg qd Lopressor 50mg [**Hospital1 **] NTG prn Ranitidine 150mg [**Hospital1 **] Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nitroglycerin 2.5 mg Capsule, Sustained Release Sig: [**12-30**] Capsule, Sustained Releases PO every four (4) hours as needed for chest pain. 7. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. Disp:*qs qs* Refills:*2* 8. Insulin Syringes (Disposable) Syringe Sig: One (1) 12u Miscell. at bedtime: Use syringe for Glargine (Lantus) insulin administration. Disp:*90 * Refills:*2* 9. Lancets Misc Sig: At mealtime 1 Miscell. QAC QHS. Disp:*qs qs* Refills:*2* 10. test strips Sig: One (1) strip QAC QHS. Disp:*qs qs* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Type 2 Diabetes Coronary Artery disease Hypertension Hyperlipidemia Acute renal failure-resolved Discharge Condition: Stable, ambulating without assist. Discharge Instructions: If you experience return of frequent urination, blurry vision, dizziness, chest pain, shortness of breath, fevers, chills, nausea, or vomiting, contact your physician or return to the Emergency Room. Followup Instructions: On Monday, call [**Last Name (un) **] Diabetes Center, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2384**] for an appointment. She speaks spanish. Pt can also have an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11712**], the educator [**Known firstname **] worked with at [**Last Name (un) **] on [**2126-7-3**]. [**Doctor Last Name **] also speaks spanish. [**Doctor Last Name **] Test scheduled for [**2126-8-8**] at 1PM. See instructions below. Provider: [**Name Initial (NameIs) 10081**]/EXERCISE LAB Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 1566**] Date/Time:[**2126-8-8**] 1:00 Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Hospital1 7975**] INTERNAL MEDICINE Where: [**Hospital1 7975**] INTERNAL MEDICINE Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2126-8-29**] 9:45 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2126-9-4**] 2:30 Completed by:[**2126-7-6**]

[ "276.7", "414.01", "276.1", "112.0", "250.20", "401.9", "E932.3", "V45.82", "250.80", "584.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7340, 7398

2867, 6166

347, 354

7538, 7574

2487, 2844

7822, 8955

1733, 1896

6358, 7317

7419, 7517

6192, 6335

7598, 7799

1911, 2468

276, 309

382, 1379

1401, 1561

1577, 1717

21,150

108,957

43656+58645+58646+58647+58648

Discharge summary

report+addendum+addendum+addendum+addendum

Admission Date: [**2145-8-9**] Discharge Date: [**2145-8-16**] Date of Birth: [**2087-8-18**] Sex: M Service: Medicine - [**Location (un) **] HISTORY OF PRESENT ILLNESS: The patient is a 57 year old quadriplegic male who was recently discharged from [**Hospital6 1760**] with the diagnosis of pseudomonal infection of PICC line who now returns back with magnetic resonance imaging scan findings consistent with an abscess at the T4-5 level. This is Mr. [**Known lastname 93873**] third admission over one month period. He was first admitted first on [**2145-7-4**] with a chief complaint of fevers and chills and symptoms of urinary tract infections that persisted despite treatment with Ciprofloxacin. He was found to have Methicillin-sensitive Staphylococcus aureus bacteremia and T4, T5, T8 and T9 diskitis. The patient was subsequently treated with ultrasound and sent home with a PICC line. He rejoined on [**8-2**] with similar symptoms and was found to have infection of the PICC line and urinary tract infection. Both PICC line catheter tip and urinary cultures grew Pseudomonas which was treated with Cefepime. At that time Oxacillin was discontinued. Prior to his discharge, during this admission, he received magnetic resonance imaging scan of his spine. After discharge results of the magnetic resonance imaging scan became available and the patient was readmitted to the hospital on [**8-9**], with magnetic resonance imaging scan findings consistent with T4 and T5, epidural abscess. The patient was contact[**Name (NI) **] prior to this admission by his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and after consultation with Dr. [**Last Name (STitle) 1338**] from Neurosurgery he was admitted to [**Location (un) **] Medicine for the workup of possible abscess. PAST MEDICAL HISTORY: Past medical history includes 1. Quadriplegic times 30 years secondary to a water skiing accident; 2. Neurogenic bladder; 3. Anxiety; 4. Osteoporosis; 5. History of pneumonias; 6. Anemia; 7. Hemorrhoids. MEDICATIONS ON ADMISSION: Cefepime 1 gm q. 12 hours; Buspirone 30 mg p.o. once a day; Loxitane, Ditropan, Dulcolax, Colace, Lomotil, Ativan. ALLERGIES: The patient has allergy to Bactrim, Erythromycin and Zoloft. SOCIAL HISTORY: Quit smoking 30 years ago. He is married, former accountant. FAMILY HISTORY: Non-contributory. PHYSICAL EXAMINATION: Temperature 99.3, heartrate 97, blood pressure 107/73, respirations 20. Oxygen saturation is 97% on room air. General, in no acute distress, oriented times three. Head, eyes, ears, nose and throat, extraocular movements intact. Pupils equal, round, and reactive to light and accommodation bilaterally. Oropharynx clear. No jugulovenous distension noted. Cardiovascular examination, regular rhythm and rate, no murmurs. Normal S1 and S2, point of maximal impulse not displaced. Pulmonary, clear to auscultation bilaterally. Abdomen, firm, nontender, nondistended, positive bowel sounds. Extremities, no edema. 2+ Pulses in all four extremities. LABORATORY DATA: Sodium 129, potassium 3.7, chloride 93, bicarbonate 23, BUN 14, creatinine 0.4, glucose 99. White blood cell count 10.6 with 88.6 neutrophils and 6.2 lymphocytes. Hematocrit 31.3 and platelets 395. Chest x-ray showed increased left lower lobe opacity with air bronchograms concerning for worsening pneumonia. It also showed small left pleural effusion. HOSPITAL COURSE: Mr. [**Known lastname 3803**] was admitted to the floor for further workup of possible epidural abscess at the T4-5 level. He received computerized tomography scan guided biopsy the next day after admission. The biopsy was significant for large amounts of pus-looking fluid, however, gram stain was negative and cultures were pending at the time of this dictation. He Cefepime was discontinued and the patient was started on Levofloxacin and Oxacillin to cover for possible Staphylococcal infection of his spine. Secondary to spinal cord damage, the patient could not feel pain, however, continued to sweat profusely which according to the patient is the only manifestation of his pain symptoms. He was treated for sweats with pain medications, specifically Percocet and Demerol were given on a prn basis with good response. On [**8-13**], the debridement of T4, T5 spine was done by Dr. [**Last Name (STitle) 1338**]. Transpedicular decompression of T4, T5 segments was also performed at this time with minimal blood loss and no complications. There was an extensive depth infected appearing tissue in the epidural space of T4 and 5 disc. The specimens were taken during the surgery and sent to Pathology and all specimen results were pending at the time of this dictation. There was no gross pus found in surgery. The drain was placed on the left in the T4-T5 disc space. The patient returned to the floor on [**8-13**] and continued to have sweats, but was afebrile and otherwise reported feeling better. His hematocrits went down to 26.6 after the surgery, however, it went back up to 29.6 on [**8-15**]. Therefore no blood transfusion was given. At the time of this dictation, the patient was anticipated to be discharged on [**8-16**] to home on Oxacillin and Levofloxacin. The plan for antibiotic coverage was to continue Levofloxacin for 14 days after discharge and Oxacillin for at least six more weeks. Reimaging of the spine with magnetic resonance imaging scan was also planned in about two weeks after discharge. DISCHARGE MEDICATIONS: He was anticipated to go home on the following medications- 1. Oxycodone 5 mg p.o. q. 4-6 hours as needed for seats 2. Oxacillin 2 gm intravenously every 4 hours 3. Levofloxacin 500 mg p.o. q. day 4. Cefadyl 10 mg p.r. q.d. as needed 5. Docusate sodium 100 mg p.o. b.i.d. prn 6. Lorazepam 0.5 mg p.o. h.s. prn 7. Oxybutynin 5 mg p.o. b.i.d. 8. Loxitane 20 mg p.o. b.i.d. 9. Buspirone 10 mg p.o. t.i.d. 10. Metoprolol 25 mg p.o. b.i.d. 11. Simethicone 80 mg p.o. q.i.d. prn 12. Diphenoxylate/Atropine 2 tablets p.o. q. 6 prn DISCHARGE INSTRUCTIONS: He was anticipated to be discharged home on a regular diet. Follow up to be arranged by the patient with Dr. [**Last Name (STitle) **] and Infectious Disease. [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**MD Number(1) 200**] Dictated By:[**Name8 (MD) 93874**] MEDQUIST36 D: [**2145-8-15**] 10:41 T: [**2145-8-15**] 15:14 JOB#: [**Job Number 93875**] Name: [**Known lastname 14843**], [**Known firstname 33**] Unit No: [**Numeric Identifier 14844**] Admission Date: [**2145-8-9**] Discharge Date: [**2145-8-18**] Date of Birth: [**2087-8-18**] Sex: M Service: ADDITION TO HOSPITAL COURSE: As noted in previous Discharge Summary the patient's hematocrit had gone down to 0.6 postop and rose back to 29 with no blood transfusion. Subsequently, the patient's course he developed left pleural effusion that was recently tapped using ultrasound guidance. Approximately 50 cc of aspirate were removed, no further fluid removed secondary to loculation. These fluids were sent to the laboratory for analysis, notable for protein ratio of pleural to serum greater than 0.5, pH 7.52, ratio of LDH in the pleural space versus serum was 0.7 most consistent with an exophytic process. The patient was discharged to home to be followed by home health aid care where imaging of the spine with magnetic resonance scan is also planned as per the original [**2145-8-16**] discharge on the following medications. DISCHARGE MEDICATIONS: Oxycodone Sustained Release 30 mg p.o. q.12h. Oxycodone 5 mg p.o. q.4-6h. p.r.n. for breakthrough pain manifested in this patient. Antibiotics consist of Oxacillin 2 mg intravenous q.4h. for the next 42 days. Levofloxacin 500 mg p.o. q. day. Flagyl 500 mg p.o. t.i.d. Docusate sodium 100 mg p.o. b.i.d. p.r.n. Lorazepam 0.5 mg p.o. q. h.s. p.r.n. Oxybutynin 5 mg p.o. b.i.d. Fluoxetine hydrochloride 3 mg p.o. b.i.d. Buspirone 10 mg p.o. t.i.d. Metoprolol 25 mg p.o. b.i.d. Simethicone 80 mg p.o. q.i.d. Lomotil 2 tabs p.o. q.6h. p.r.n. diarrhea. Diphenoxylate two tabs p.o. q.6h. p.r.n. DISCHARGE INSTRUCTIONS: The patient can be discharged home with a regular diet with home health care. Follow-up will be arranged with the patient with Dr. [**Last Name (STitle) 1801**] and Infectious Disease. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1802**], M.D. [**MD Number(1) 1803**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2145-8-18**] 20:09 T: [**2145-8-24**] 10:59 JOB#: [**Job Number 14845**] Name: [**Known lastname 14843**], [**Known firstname 33**] Unit No: [**Numeric Identifier 14844**] Admission Date: [**2145-8-9**] Discharge Date: [**2145-9-13**] Date of Birth: [**2087-8-18**] Sex: M Service: Medicine [**Location (un) **] Firm NOTE: This is an addendum to the discharge addendum dated [**2145-8-18**]. The patient is to be discharged home with home care services. The patient's initial discharge was planned for [**2145-8-18**], however his course was complicated by a bacterial infection for which he was being treated with intravenous oxacillin as well as po Levaquin and po metronidazole until a definitive organism grew out in culture. No definitive organisms grew out of blood cultures or sputum cultures, however native blood cultures were positive for a yeast. The patient was then empirically started on amphotericin intravenous. However, after two days of treatment of amphotericin, a definitive diagnosis of [**Female First Name (un) 1441**] parapsilosis was found in blood cultures drawn through the patient's PICC line. Therefore, the amphotericin was switched to po fluconazole and with establishment of secondary peripheral line, the PICC was removed by interventional radiology, further complicating the patient's hospitalization, however, the patient began to develop a pleural effusion as stated in the previous addendum to the original discharge summary. Attempt was made with ultrasound guided thoracentesis to completely drain the effusion, however this was only successful for a diagnostic rather than inferior therapeutic tap. Interventional pulmonology was consulted once again and a more definitive tap which removed successfully approximately 1.4 liters of pleural fluid resulted, however the patient's pleural effusion began returning within a matter of days and so it was determined to place a chest tube. Chest tube was placed and negative pressure -20 cm of water was established. The patient's initial chest tube produced an amount of fluid approximately 1 liter plus over the first 24 hours, however by the end of the week, the output had dropped to about 100 cubic centimeters overnight, so it was decided by pulmonary and interventional pulmonology to discontinue the chest tube. Unfortunately, with discontinuation of the chest tube and follow up with multiple chest x-rays, it was noticed that the patient's left lung field had again started to become opacified on chest film. The patient also began to notice some mild shortness of breath even though this O2 saturations held steady in the 95% to 97% range on room air. Therefore, the patient's discharge was delayed once again. The plan now is to do a diagnostic tap of the left lung and still tack into the pleural space to generate scar formation of the visceral and parietal pleura before considering sending the patient home. The discharge date therefore is [**Last Name (LF) 228**], [**9-13**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1802**], M.D. [**MD Number(1) 1803**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2145-9-11**] 14:56 T: [**2145-9-14**] 11:11 JOB#: [**Job Number 14846**] Name: [**Known lastname 14843**], [**Known firstname 33**] Unit No: [**Numeric Identifier 14844**] Admission Date: Discharge Date: Date of Birth: [**2087-8-18**] Sex: M Service: The patient had reaccumulation of the left pleural effusion with increasing shortness of breath. On [**9-14**], he was thoracentesed 750 cc of pleural fluid were drained. On [**9-15**] he was bronched to investigate the persistent left lower lobe collapse without any finding. He was also pleurodesed on the following day, the 29th. The patient had no breath sounds on the left lung on examination, and a chest x-ray was obtained showing whiteout of the left lung. The chest tube was flushed without much relief in the shortness of breath. A chest CT scan was obtained showing mucus plugging. He was bronched on [**9-17**] during which the mucus plug was suctioned with improvement. However, in the pleural suite after the bronchoscopy, patient acutely desaturated due to copious secretions. From [**9-17**] to [**9-25**], patient was in the Medical Intensive Care Unit for respiratory distress requiring intubation x2. The patient required daily bronchoscopies in the unit for aspiration of copious secretions. An additional chest tube was placed for drainage of effusion. Patient was also started on levofloxacin for tracheobronchitis and received a seven day course. On the [**9-25**], the patient was transferred out of the unit and was improving clinically with resolving bronchitis, but persistent whiteout of the left lung. On the 9th, repeat chest CT scan showed increased effusion and collapse of the lower lobes. He was bronched again, and on bronchoscopy, there was edema of the airway with some external compressions seen of unknown cause. The patient continued to sat well while in the mid 90s on [**2-23**] liters of O2 via the nasal cannula. The patient was eventually weaned off of oxygen and continued to improve respiratory wise with chest PT, albuterol, and Atrovent nebulizers. In terms of ID issues, again the patient was treated with intravenous levofloxacin for seven days for tracheobronchitis. He completed his six week course of oxacillin for a diskitis/osteomyelitis. He however, on the [**9-28**] spiked a temperature of 100.7 with a white count of 20 and was started on Zosyn for a wound culture growing Pseudomonas as well as a urine culture growing out VRE. The wound culture was in an old chest tube site. On examination it was slightly erythematous with slight pus. It improved however, during the rest of the hospital course and healed well. The patient responded to Zosyn with decrease in his white count and staying afebrile since that spoke. Infectious Disease was reconsulted for patient's various infectious disease issues. A repeat spinal MRI was obtained after the completion of the course of oxacillin and ID recommended an additional three week course of IV oxacillin. Patient was restarted on IV oxacillin after the completion of the seven days of Zosyn on [**10-6**] to continue at home for a full three week additional course. Patient is to followup with Dr. [**Last Name (STitle) 113**] as well as Infectious Disease Clinic to monitor his response to the additional course of intravenous oxacillin and to obtain a spinal MRI on [**10-27**] which has been ordered. Patient continued to get physical therapy throughout the hospital course. In terms of GI issues, he continued to have intermittent diarrhea and constipation which he reports to be his baseline at home. Clostridium difficile were all negative. Stool cultures were all negative. He was given Colace, Senna, and Fleets prn, as well as Lomotil prn for diarrhea. The patient was discharged in good condition to home with VNA services on the following medications: Fluoxetine 20 mg po bid, buspirone 10 mg po tid, calcium carbonate 500 mg po tid with meals, Fleet enema one application q day prn constipation, Compazine 10 mg po q6 hours prn nausea, olanzapine 2.5 mg po q hs prn insomnia can repeat in one hour if persistent insomnia, Colace 100 mg po bid prn constipation, Senna 1-2 tablets po q day prn constipation, magnesium oxide 400 mg po bid, albuterol MDI 1-2 puffs q6 hours prn wheezing, ipratropium MDI two puffs qid prn wheezing, oxacillin 2 grams q4 hours x3 weeks IV, Lomotil 1-2 tablets q6-8 hours prn diarrhea. The patient is to receive chest PT at home from VNA. He is to followup with Dr. [**Last Name (STitle) 113**] after receiving his final MRI as well as Infectious Disease on [**10-21**] at 9:30 am. He is also asked to call Dr. [**Last Name (STitle) 14847**] for follow-up appointment. His MRI was ordered and scheduled for [**10-27**]. The patient was asked to call to confirm the time. DISCHARGE DIAGNOSES: Diskitis, spinal abscess, persistent left pleural effusion, lung collapse, hypoxic respiratory failure. [**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D. [**MD Number(1) 352**] Dictated By:[**Name8 (MD) 8213**] MEDQUIST36 D: [**2145-10-6**] 14:00 T: [**2145-10-7**] 05:55 JOB#: [**Job Number **] Name: [**Known lastname 14843**], [**Known firstname 33**] Unit No: [**Numeric Identifier 14844**] Admission Date: Discharge Date: [**2145-10-7**] Date of Birth: [**2087-8-18**] Sex: M Service: Mr. [**Known lastname **] is also to followup with Dr. [**Name (NI) 781**] in [**2-21**] weeks for a CXR and office visit. He will call for an appointment. DR.[**Last Name (LF) **],[**First Name3 (LF) 77**] 12-838 Dictated By:[**Name8 (MD) 8213**] MEDQUIST36 D: [**2145-10-7**] 06:27 T: [**2145-10-7**] 06:59 JOB#: [**Job Number **]

[ "996.62", "599.0", "324.1", "998.59", "344.00", "511.9", "518.5", "518.0", "112.5" ]

icd9cm

[ [ [] ] ]

[ "34.04", "33.24", "34.91", "34.92", "33.23", "80.51", "38.93", "03.4" ]

icd9pcs

[ [ [] ] ]

2395, 2414

16757, 17690

7641, 8230

2108, 2298

6808, 7618

8255, 16735

2437, 3469

192, 1849

1872, 2081

2315, 2378

6,894

151,434

16730

Discharge summary

report

Admission Date: [**2193-12-23**] Discharge Date: [**2193-12-31**] Date of Birth: [**2138-4-23**] Sex: M Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: This 55 year-old gentelman with a known history of peripheral vascular disease who is status post a left carotid endarterectomy in [**2193-9-17**] who was found to have a myocardial infarction intraoperatively. He subsequently underwent cardiac catheterization on [**2193-9-19**], which revealed three vessel coronary artery disease with 100% occluded left anterior descending coronary artery, 99% left circumflex and a 100% occluded right coronary artery. His ejection fraction at the time of catheterization was 25%. He was referred in for a coronary artery bypass graft surgery to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. PAST MEDICAL HISTORY: 1. Peripheral vascular disease. 2. Coronary artery disease. 3. Peripheral neuropathy. 4. Status post left carotid endarterectomy [**2193-9-17**]. 5. Right carotid stenosis. 6. Status post myocardial infarction with a history of several silent myocardial infarctions. 7. Bronchitis and pneumonia with mental status changes at his [**2193-9-17**] hospitalization. MEDICATIONS ON ADMISSION: 1. Aspirin. 2. Toprol. 3. Lipitor. 4. Trazodone. 5. Pletal. 6. Combivent. 7. Percocet prn. 8. Colace. 9. Thiamine. The patient did not have his dosages with him at the time. PHYSICAL EXAMINATION: He was in sinus rhythm in the 70s with a pressure of 115/82 on the right and 146/82 on the left. He was 6'0" at 153 pounds. He had venostasis changes in bilateral lower extremities right worse then left. He appeared to be well hydrated. He had no thyromegaly or JVD. No tracheal deviation and no carotid bruits. His left carotid endarterectomy scar appeared to be healing well. His lungs were clear bilaterally with breath sounds decreased mid and lower right chest without any wheezing or rhonchi. Heart was regular rate and rhythm with S1 and S2. No murmurs or rubs. His abdominal examination was benign. His extremities were warm. He had point tenderness on both feet with venostasis color changes in bilateral lower extremities. He also had varicosities in his right leg. His neurological examination was grossly intact. He had some difficulty walking due to his peripheral vascular disease and uses a cane. He had good capillary refill in both legs with no calf tenderness. The patient was noted to be right handed and had poor collateral ulnar flows demonstrated right ____________ mammography. His electrocardiogram showed normal sinus rhythm with lateral ST and T wave changes. The patient had a chest CT without contrast done on [**12-19**] preoperatively for a right apical opacity on his preop chest x-ray. Of note, was emphysema and two small calcified nodules in the right lung apex. In addition, there was another noncalcified nodule in the periphery of the left upper lobe. In addition, bilateral proximal renal artery calcifications were seen as well as a hyperdense liver and evidence of emphysema. PREOPERATIVE LABORATORY: White blood cell count of 9.1, hematocrit 42.8, PT 12.4, PTT 29.4, platelets count 239,000, INR 1.0, sodium 139, K 4.0, chloride 98, CO2 28, BUN 14, creatinine 0.8 with a blood sugar of 72 and anion gap of 17, ALT 19, AST 21, LDH 197, alkaline phosphatase 66 and total bili of 0.6. Preoperative chest x-ray prior to his chest CT showed linear opacities previously noted peripherally in the right upper lobe. In addition, coronary artery calcifications were noted as well as degenerative changes of the spine. Please refer to this chest CT done in early [**Month (only) 404**]. HOSPITAL COURSE: On [**12-23**] the patient underwent a coronary artery bypass grafting times three by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] with a left internal mammary coronary artery to the left anterior descending coronary artery, vein graft to obtuse marginal and vein graft to the posterior descending coronary artery. The patient was transferred to the cardiothoracic ICU on a neo-synephrine drip at 1 microgram per kilogram per minute, Propofol drip at 30. Later that afternoon the patient was reopened for bleeding by Dr. [**Last Name (STitle) 70**]. There was some bleeding from the left internal mammary harvest site as well as right sternum with a generalized ooze. On postoperative day one the patient had been extubated. He had no dopplerable peripheral pulses. The patient desated slightly on a 60% face maxed, but improved to 96%. He had coarse breath sounds bilaterally. His sternum was stable. His postop hematocrit was 26.5. His BUN was 7, creatinine 0.6 and a potassium of 4.2. He was receiving Percocet prn and Ativan for presumed ETOH withdraw. He was on no drips at the time. He was seen by psychiatry for follow up who recommended giving him Ativan as well as thiamine and folate. On postoperative day two he was a bit agitated overnight and was treated by additional Ativan prn as well as Haldol. He was somewhat hypertensive and tachycardic in the morning with a heart rate of 112 and a blood pressure of 151/78, but he was alert, but unable to follow commands and trying to pull his oxygen mask off. His hematocrit on that morning was 31.4. His other laboratories were unremarkable. The diagnosis was just delirium and acute agitation to be treated with continuing Haldol and Ativan. On postoperative day two he was transfused 2 units of packed red blood cells. His Swan was discontinued. His Ativan was decreased per psychiatry. His neo was weaned off. His Lopresor was added in. He was in sinus rhythm at 102 with a blood pressure of 157/76. His sternum was stable. His hematocrit was 29.5. He continued with advancing his diet and pulmonary toilet. Postoperative day three he was started on an alcohol drip and was restarted on Captopril added into his Lopresor and he started receiving some tube feeds, completed his perioperative antibiotics. Later that day his alcohol drip was held and then restarted at approximately one third of the dose. He was seen by clinical nutrition for assessment of his appropriate tube feeds. He was also seen by physical therapy and continued to be followed by psychiatry. On postoperative day four he received Lasix and Diamox. His alcohol drip was being held. He was in sinus rhythm in the 90s with a good blood pressure sating 96% on 4 liters nasal cannula. His hematocrit stabilized at 30.2 and he continued to have his blood pressure medications adjusted with Captopril and Lopressor for tighter blood pressure control. On postoperative day five his alcohol drip was back on. He was tachycardic in the low 100s, sating 94% on room air. His hematocrit rose to 33.4. His other laboratories were unremarkable. His Lopressor was increased to bring his heart rate down. His diet was advanced. On postoperative day six he continued on his alcohol drip in sinus rhythm. His hematocrit continued to improve to 37.0, as he continued to stabilize on the unit on his alcohol drip. On the [**12-29**] he was transferred to the floor. His Foley, wires and chest tubes had been discontinued in the Intensive Care Unit. He was alert, oriented and cooperative. Pedal pulses were being monitored carefully for peripheral circulation. He was sating 97% on room air. His breath sounds were clear. On postoperative day seven he had no issues overnight and he was ambulating on his own without any difficulty except he was interrupted by some claudication pain in his legs, which was his baseline. His lungs were clear. Sternal incision was healing nicely. His abdominal examination was unremarkable. He had minimal lower extremity edema. He was doing well and almost ready for discharge pending his final physical therapy evaluation with the plan that he will be able to go home. He was seen by case management and followed up by the clinical nutrition team. He remained in sinus rhythm with no ectopy and was ambulating on his own with a cane. On [**12-31**] he was discharged to home with instructions to return on [**1-7**] for an incision check and to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] in approximately two to four weeks in the office. He was also instructed to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47320**] his cardiologist in approximately one week and Dr. [**First Name (STitle) **] [**Name (STitle) **] in approximately one to two weeks his primary care physician. DISCHARGE DIAGNOSES: 1. Coronary artery bypass grafting times three. 2. Coronary artery disease. 3. Peripheral vascular disease with peripheral neuropathy. 4. Status post left carotid endarterectomy. 5. Right carotid disease. 6. Status post myocardial infarctions. 7. Status post bronchitis. 8. Status post alcohol withdraw during this hospitalization. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q.d. 2. Ranitidine 150 mg po b.i.d. 3. Multivitamins one capsule po q.d. 4. Thiamine 100 mg po q.d. 5. Folic acid 1 mg po q.d. 6. Metoprolol 125 mg po b.i.d. 7. Captopril 6.25 mg po t.i.d. 8. Ibuprofen 400 mg po prn q 6 hours. 9. Trazodone 100 mg po q.h.s. prn insomnia. 10. Tylenol 650 mg po prn q 4 hours. DISCHARGE CONDITION: The patient was discharged to home in stable condition on [**2193-12-31**]. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 76**] MEDQUIST36 D: [**2194-4-8**] 11:27 T: [**2194-4-8**] 11:37 JOB#: [**Job Number 47321**]

[ "443.9", "305.00", "998.11", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9371, 9728

8645, 8986

9009, 9349

1259, 1444

3730, 8624

1467, 3712

178, 841

863, 1233

1,326

123,263

54295

Discharge summary

report

Admission Date: [**2132-9-17**] Discharge Date: [**2132-10-8**] Service: [**Hospital Unit Name 111234**] OF PRESENT ILLNESS: This is an 83-year-old woman with a history of multiple medical problems significant for atrial fibrillation, MVR with leak, and hemolysis, who was admitted on [**2132-9-17**], for red urine. She was on the floor on the day of admission to the MICU on [**10-2**], acidosis with increased lactate. The patient complained of abdominal pain on the morning of admission and had some abdominal pain the day prior to admission, although much increased. Evaluation by CT showed increased dilation of the common bile duct, no bowel edema, and no pancreatic process. The [**Hospital Unit Name 153**] tachypneic, cyanotic, but with stable blood pressure and heart rate of 75. Arterial blood gases showed metabolic acidosis and lactate of 11. The immediate concern was for an intra-abdominal process, and the patient was transferred to MICU and electively intubated for management of acidosis. Review of the chart revealed that she presented on [**2132-9-17**], with chills and malaise and was treated for hypertensive urgency, with headache and hematuria. She was also noted to have a left shift on white count, with 1 band. Levaquin was started on [**9-18**] for urinary tract infection. Bandemia was ultimately diagnosed with hemolytic anemia. Echocardiogram confirmed perivalvular leak. The plan was initiated for mitral valve replacement, and the patient was treated with transfusions. She was seen by Cardiology on [**2132-9-28**], after she fell out of bed. The patient reportedly received vitamin K, and Heparin was discontinued pending negative head CT for bleed. On [**9-28**] through [**10-2**], she had increased white blood cell count with left shift despite Levofloxacin and Flagyl. Infectious Disease was consulted and recommended abdominal CT and recommended changing to Ampicillin, Levofloxacin, and Flagyl for further evaluation of abdomen. On [**2132-10-2**], on the day of MICU admission, she complained of diffuse abdominal pain. ALLERGIES: BETA-BLOCKERS, DEMEROL, MORPHINE, SULFATE (P.O., NOT IV), CARDIZEM. MEDICATIONS ON TRANSFER: Lanoxin 0.125 mg p.o. q.d., Nitropaste q.6 hours, Coumadin 2 mg p.o. q.h.s., Zantac 150 mg p.o. b.i.d., Prednisone which was stopped after diagnosis of hemolytic anemia was made thought to be autoimmune, Iron Sulfate 325 p.o. t.i.d., Folate 1 mg p.o. q.d., Toprol XL 50 mg p.o. q.d., Flagyl 500 mg p.o. t.i.d., started [**9-28**], Levofloxacin 250 mg p.o. q.d., started [**9-28**], Norvasc 5 mg p.o. q.d., Neutra-Phos 2 tab p.o. q.d., Ampicillin 500 IV q.6, Flagyl 500 mg IV t.i.d., that had been written but neither of which had been given. PAST MEDICAL HISTORY: Congestive heart failure. Gastroesophageal reflux disease. Hypertension. Status post pacer for tachy-brady syndrome. Abdominal pain. Status post cholecystectomy. Atypical chest pain. Cerebrovascular accident. Rheumatic heart disease. SOCIAL HISTORY: The patient is retired and active. No alcohol or tobacco. She is a linguist. PHYSICAL EXAMINATION: Vital signs: On admission blood pressure was 140-210/70-108, 99% on 2 L. I&Os: 850 in/600 out. On the day of admission she was 450 with incontinence of urine. General: She was awake and arousable. HEENT: Pupils equal, round and reactive to light. Extraocular movements intact. Normocephalic, atraumatic. Lungs: Clear to auscultation bilaterally. Heart: Regular, rate and rhythm. There was a 2 out of 6 systolic ejection murmur at the left lower sternal border. Abdomen: Left lower quadrant tender, in addition to the periumbilical area. Rectal: Negative. Extremities: Cyanotic and with mottled extremities. There was 1+ dorsalis pedis edema. She was moving all extremities. LABORATORY DATA: White count 11.5, hematocrit 32.4, differential showing [**2-2**] bands; CHEM7 with a sodium of 144, potassium 5.4, chloride 106, bicarb 24, BUN 41, creatinine 1.5, glucose 90; INR 1.3, PTT 83.9 on [**2132-10-1**]; repeat pending; urinalysis with large blood, 500 protein, 34 white cells, no red cells; LFTs with an ALT of 49, AST 160, alkaline phosphatase 98, LDH 4460, amylase 370, total bilirubin 3.0; Digoxin 0.9; ABG 7.34, 27, 379 on 100%, lactate 10.5; urine microbiology on urine culture showed staph 10-100,000 colonies on [**9-30**]. Blood cultures on [**2132-9-29**], were negative times two, Monospot negative on [**9-28**]. CT of the abdomen showed increased dilation of common bile duct, no stranding, no edema, no evidence of bowel ischemia. On [**2132-9-26**], transesophageal echocardiogram showed perivalvular mitral leak and 3+ tricuspid regurgitation. HOSPITAL COURSE: The patient as noted above was found to have abdominal pain and a significant metabolic lactic acidosis, and there was immediate concern for an intra-abdominal process. She was intubated and brought to the Intensive Care Unit. The initial impression of the team at that time was that she might have been suffering from ischemic bowel, although there was no clear precipitant of hypotension prior to the episode, although the patient was somewhat hypertensive. She was started on Ampicillin, Levofloxacin, and Flagyl, given Gentamicin times one, and had an immediate evaluation by Gastroenterology and Surgery. In addition, a Swan was placed. Surgery evaluation revealed that there was clear evidence of an intra-abdominal bowel ischemia. There was enough suspicion that she was taken for exploratory laparotomy which revealed evidence of globally diminished blood flow to her bowel but no frank bowel necrosis, and her abdomen was closed. Swan numbers initially showed decreased cardiac output and increased SVR, unpressable, that was not completely compatible with sepsis, but the cardiac output improved by using Nitrate to reduce afterload. It was thought that the patient may have a component of heart failure. At that time, there was no evidence of myocardial ischemia or myocardial infarction causing her decreased cardiac output. By MICU day #2, she remained stable on a ventilator and had some resolution of her acidosis. There was a concern raised for cholangitis, but the overall impression was that she was being covered for same, and she was too unstable to undergo ERCP at this time. Ampicillin, Levofloxacin, and Flagyl were continued. Swan numbers again initially showed a wedge of 15, and low cardiac output, question secondary to her valvular disease, question of low cardiac output as cause for global bowel ischemia; however, her cardiac output improved dramatically, and acidosis resolve somewhat on Nipride drip, and she was titrated on IV Enalapril and Hydralazine. She had a hematocrit drop to 22 and was transfused 2 U. The patient was extubated on [**2132-6-3**]. By [**2132-10-5**], she remained hemodynamically stable and not intubated. GI was following and felt that she had probably mesenteric ischemia of unclear etiology. They did not feel that cholangitis was a significant component of her presentation. They also felt that the increase in her bilirubin could be secondary to ischemic hepatitis. They recommended to continue antibiotics. On the morning of [**2132-10-6**], however, she developed abdominal pain, very similar to her initial presentation, after receiving 10 mg of Hydralazine, and a drop in her blood pressure. The thought of the team at this point was that she had a very tenuous hemodynamic status, and that where she was hypertensive on admission with bowel ischemia, she now had an episode of hypotension which may have precipitated additional ischemia. The patient also developed worsening respiratory distress and acidosis and required intubation on [**2132-10-6**]. Overall, the initial episode of bowel ischemia was note related to increased afterload and decreased cardiac output; however now, there was a question of hypotension which may have contributed. She received intravenous fluids to support a blood pressure to 130-150 range, and pressors were avoided. Ventricular tachycardia was noted, and CKs were cycled which were negative times two; however, the third CK did have a positive MB, with a question related to her stress of her hypotension. Of note, the patient was anticoagulated on Heparin, but dropped this course for her valve. Increased white blood cell count was noted with a left shift, and there was a question of translocation of bacteria through ischemic bowel. Ampicillin, Ceftriaxone, Levofloxacin, and Flagyl were continued. Because of the decrease in her platelets, the patient was changed from Heparin to Lepirudin with careful dosing after discussion with pharmacy. On [**2132-10-7**], the patient had decreased urine output. Swan numbers at that time showed again a decreased cardiac output at 2.99 with a wedge of 17, cardiac index of 2, SVR of 1043. At this time, she required Levophed as a pressor for presumed septic physiology, and her creatinine started to rise to 2.2. Overall it was felt that the patient was exhibiting a combination of both septic and cardiogenic shock. Surgery had been following the patient, and on [**2133-10-7**], felt that the patient was in a difficult situation with a history of ischemic bowel noted on laparotomy, now with increased lactic acid, decreased blood pressure despite aggressive fluid resuscitation and pressor support. At that time, they agreed with fluid resuscitation, and cardiac optimization as the team was presently implementing. They questioned bowel ischemia secondary to low-flow state or possibly a focal obstruction. On [**2132-10-7**], the MICU Team had an extensive discussion with the patient's daughter and son, and given her overall grave prognosis, it was decided to change her code status to DNR, but with a plan to continue pressors and antibiotics, and review her condition the following day. On [**2132-10-7**], the patient was noted to have a Digoxin that was somewhat high at 4.8; however, this medication had been discontinued on her admission to the MICU, likely related to her renal failure. This was discussed with the toxicologist on call, and there was no indication of acute digoxin toxicity requiring therapy. By [**2132-10-8**], the patient continued on Levophed with decreased blood pressure, maintained a moderate metabolic acidosis, and continued to have Swan numbers that were consistent with both cardiogenic and septic shock. On [**2132-10-8**], a family meeting was held, and after discussion with the patient's daughter and son, and given her overall grave condition and poor prognosis despite aggressive medical care, they elected to pursue comfort measures only at that time and asked the team to proceed with no further treatment prolonging her dying process, thus no antibiotics, no pressors, and no fluids were given at this time, and sedation was provided for the patient's comfort. The patient became hypotensive with nonmeasurable blood pressure at 6:45 p.m. At 7 p.m., the patient had pacer spikes without effect and then ventricular contractions. The ventilator was turned off, and there were no spontaneous respirations and no heart rate. The patient was pronounced dead at 7 p.m., and the family was informed of her death. The attending was notified. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. [**MD Number(1) 3091**] Dictated By:[**Name8 (MD) 37298**] MEDQUIST36 D: [**2133-6-17**] 14:58 T: [**2133-6-24**] 13:25 JOB#: [**Job Number **]

[ "557.1", "283.19", "584.9", "038.9", "785.59", "518.81", "996.02", "276.2", "599.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "88.72", "89.64", "54.11", "38.91", "42.23", "96.72", "54.51" ]

icd9pcs

[ [ [] ] ]

4735, 11579

3129, 4717

2201, 2744

2767, 3009

3026, 3106

32,746

175,949

44041

Discharge summary

report

Admission Date: [**2191-2-2**] Discharge Date: [**2191-2-3**] Service: MEDICINE Allergies: Sulfasalazine / Percocet Attending:[**First Name3 (LF) 5608**] Chief Complaint: AMS Major Surgical or Invasive Procedure: none History of Present Illness: 85 year old male with h/o Pagets, CRI, CAD, DM, HTN, CAD presented from nursing home with concern for tibial plateau fracture seen on xray at the nursing home. He was transferring with assistance from the nurses and fell on his knee. He was given Percocet 5/325 and ativan 0.5 mg this morning to help him tolerate ambulance transfer which confused him. . In the ED, films were done and showed no evidence of fracture. Then patient desaturated to 70% while sleeping; (per son he is on oxygen at home only at night); pt placed on NRB and sats came up to 100%; stayed in 90s off of the NRB. Labwork and EKG ordered as well as CXR. Then desated to 70s again while lying flat in bed again. CXR showed large left sided pleural effusion (has this in past and drained before). EKG wnl. ABG done b/c became more somnolent pH 7.21/76/104 and was then gave patient nebulizers, azithromycin, 125mg Solumerol. Labs WBC 11.1 with 89%Neutrophils. Repeat gas: ph:7.00 pCO2:141 pO2:79 HCO3:37. Discussion was held with the family given the patients desire for DNR/DNI and the decision was made to do trial of BIPAP to see if his respiratory status could improve. On BIPAP in the ED, his repeat ABG demonstrated persistant hypercarbic respiratory failure. The patient was then admitted to the MICU for further care. . Currently the patient is non-responsive on BIPAP, thus further history is unable to be obtained. Past Medical History: Paget's disease Chronic kidney disease (most recent Cr 2.5, GFR 28 [**2191-1-28**], Cr sometimes up to high 3's) Prostate CA CHF Dementia, early PLeural effusions DM 2 Anemia of chronic disease COPD Social History: Patient lives at [**Hospital **] [**Hospital **] Nursing Home. Wife was in the ICU. No smoking, EtoH or IVDU. Has local sons. Family History: NC Physical Exam: Admission: GENERAL: patient is somnolent, nonresponsive HEENT: Pupils are equal, reactive, MMM CARDIAC: RRR no murmurs LUNG: Difficult to assess, chest wall rises, minimal air movement ABDOMEN: Soft, NT, ND EXT: Warm, perfused, no edema NEURO: Not alert or responsive. Pertinent Results: [**2191-2-2**] 03:10PM BLOOD WBC-11.1* RBC-4.18* Hgb-11.2* Hct-37.4* MCV-90 MCH-26.9* MCHC-30.0* RDW-16.2* Plt Ct-294 [**2191-2-2**] 08:42PM BLOOD WBC-19.2*# Hct-37.9* [**2191-2-2**] 03:10PM BLOOD Neuts-89.3* Lymphs-4.9* Monos-4.1 Eos-1.1 Baso-0.6 [**2191-2-2**] 03:10PM BLOOD Glucose-170* UreaN-40* Creat-2.7* Na-144 K-4.6 Cl-102 HCO3-30 AnGap-17 [**2191-2-2**] 08:42PM BLOOD Glucose-316* UreaN-42* Creat-3.1* Na-141 K-5.9* Cl-102 HCO3-27 AnGap-18 [**2191-2-2**] 08:42PM BLOOD Calcium-9.2 Phos-7.3*# Mg-2.3 [**2191-2-2**] 08:42PM BLOOD CK-MB-NotDone cTropnT-0.16* [**2191-2-2**] 03:59PM BLOOD pO2-104 pCO2-76* pH-7.21* calTCO2-32* Base XS-0 Intubat-NOT INTUBA Comment-NON-REBREA [**2191-2-3**] 06:19AM BLOOD Type-[**Last Name (un) **] pO2-209* pCO2-243* pH-6.77* calTCO2-40* Base XS--6 Comment-GREEN TOP [**2191-2-2**] 08:56PM BLOOD Lactate-1.6 [**2191-2-3**] 06:19AM BLOOD Lactate-4.0* Knee Plain Films: IMPRESSION: 1. No acute fracture is seen. If clinical concern persists, consider CT or MRI to evaluate for occult fracture. 2. Moderate to large right suprapatellar joint effusion. 3. Bilateral degenerative changes at the knees with joint space narrowing as well as diffuse osteopenia. CXR: IMPRESSION: 1. Interval worsening with now moderate left-sided pleural effusion. Stable left basilar opacification, likely representing collapse and effusion, though underlying infection is not excluded. Note that patient has had persistent collapse since remote examinations dating back to [**2185**]. Correlate with any history of bronchoscopy. 2. Mild interstitial pulmonary edema. 3. Known Paget's involving the right shoulder. Brief Hospital Course: 85 yo M with MMP admitted with hypercarbic hypoxic respiratory failure. Admitted to ICU for trial of BIPAP as patient is DNR/DNI. # Hypercarbic and Hypoxic Respiratory Failure: Patient presented from his nursing home with concern for tibial plateau fracture seen on xray at the nursing home. He was transferring with assistance from the nurses and fell on his knee. He was given Percocet 5/325 and ativan 0.5 mg to help him tolerate ambulance transfer which confused him. In the ED, films were done and showed no evidence of fracture. He was evaluated by ortho and placed in a knee immobilzer. Then patient desaturated to 70% while sleeping; (per son he is on oxygen at home only at night). He was placed on NRB and O2 saturations came up to 100% and remained in the 90s off of the NRB. A CXR showed a large left sided pleural effusion. His EKG was wnl. His initial ABG was 7.21/76/104 and was then given nebulizers, azithromycin, 125mg Solumerol. A repeat gas: showed ph:7.00 pCO2:141 pO2:79 HCO3:37. Discussion was held with the family given the patients desire for DNR/DNI and the decision was made to do trial of BIPAP to see if his respiratory status could improve. On BIPAP in the ED, his repeat ABG demonstrated persistant hypercarbic respiratory failure. The patient continued to worsen and reamined non-responsive. He had worsening hypercarbic respiratory failure without improvement on BiPAP. After a discussion with the family his BiPAP was removed and the patient passed with the family at the bedside. The Medical Examiner and family decline autopsy. Medications on Admission: Glipizide 5mg [**Hospital1 **] Ativan 0.5mg qhs Zocor 20mg daily Ocuvite Casodex 50mg daily Plavix 75mg daily Omeprazole 20mg Tiotropium Fluticasone [**Hospital1 **] Spiriva Insulin regular prn Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Hypercapneic respiratory failure Discharge Condition: death Discharge Instructions: n/a Followup Instructions: n/a Completed by:[**2191-2-3**]

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icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

5877, 5886

4026, 5603

234, 240

5962, 5969

2369, 4003

6021, 6054

2055, 2059

5848, 5854

5907, 5941

5629, 5825

5993, 5998

2074, 2350

191, 196

268, 1671

1693, 1894

1911, 2039

74,514

124,945

44954

Discharge summary

report

Admission Date: [**2156-10-18**] Discharge Date: [**2156-10-25**] Date of Birth: [**2100-10-6**] Sex: F Service: MEDICINE Allergies: Amoxicillin / Bactrim Attending:[**First Name3 (LF) 38277**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Cardiopulmonary Resuscitation Cardiac Catheterization with Placement of 2 Drug Eluting Stents Intubation with Mechanical Ventilation Central Venous Catheterization Attempted IR guided AV Graft Thrombectomy Tunneled Line Placement History of Present Illness: Please see admission note for full details. In brief this a 56 year old female h/o ESRD on HD (MWF), DM2, who was admitted with acute respiratory failure, s/p 2 PEA arrests in the ED and with acute MI s/p DES X2. She was in her usual state of health until monday morning [**2156-10-18**] when on her way to dialysis she had acute onset dyspnea. EMS was called and transferred her to [**Hospital1 18**] ED. She was noted to be hypoxic to the 60's. When she was laid flat for intubation she had PEA arrest. CPR was initiated for 3 minutes and patient was given epi and calcium chloride, with spontaneous return of circulation. She was given lasix and prior to transfer to MICU, she became bradycardic and PEA arrested again. CPR was initiated for 4 minutes and she was given Epi and atropine. She then awoke and was following commands and therefore cooling protocol was not performed. The patient was planned for emergent dialysis however her RUE AVG was noted to be thrombosed and therefore a temporary dialysis line had to be placed. A left IJ line was attempted with difficulty and U/S confirmed the presence of a left IJ clot. Also on [**2156-10-18**] EKG was performed which was remarkable for atrial fibrillation, ventricular rate 155bpm, STE in III, STD in V4-6. CKMB was elevated up to peak of 86, troponin was also elevated and has not yet peaked. Cardiology was consulted who recommended cardiac catheterization. Proximal and mid LAD stenoses were noted and were treated with DES x2. She was also started on heparin, given ASA 325 and started on Atorvastatin, and plavix was continued (home med). On [**2156-10-19**] (post cath), she was extubated and was following commands. She was then transferred to the cardiology service on [**2156-10-20**] for further management of acute MI. Past Medical History: - ESRD on dialysis MWF, s/p thrombectomy and revisions in [**2-13**] - DM2, c/b retinopathy, neuropathy - HTN - Hyperlipidemia - Peripheral arterial disease - smoking - retinopathy - neuropathy - asthma - nephrotic syndrome - anemia - morbid obesity Social History: Lives with family in [**Location (un) 86**], good support. Tobacco: [**12-7**] ppd x 40 yrs ETOH: denies Family History: brother, sister had [**Name2 (NI) **] in their late 50s. Two brothers on dialysis with HTN, Mother with HTN. Physical Exam: Admission Physical Exam: Vitals: T: 97.8 BP: 127/60 P: 104 R: 25 O2: 100% General: intubated, sedated, follows commands HEENT: Sclera anicteric, intubated Neck: supple, no LAD Lungs: crackles b/l throughout anteriorly CV: sinus tachy, S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild distension, bowel sounds present GU: foley Ext: warm, L BKA, R foot amputation, RUE fistula no thrill Neuro: intubated, sedated, moving all extremities Pertinent Results: Admission labs: [**2156-10-18**] 06:10AM GLUCOSE-240* UREA N-76* CREAT-9.4*# SODIUM-136 POTASSIUM-5.5* CHLORIDE-97 TOTAL CO2-20* ANION GAP-25* [**2156-10-18**] 06:10AM estGFR-Using this [**2156-10-18**] 06:10AM cTropnT-0.10* [**2156-10-18**] 06:10AM proBNP-[**Numeric Identifier 96135**]* [**2156-10-18**] 06:10AM CALCIUM-14.8* PHOSPHATE-10.0*# MAGNESIUM-2.7* [**2156-10-18**] 06:10AM PT-11.6 PTT-20.6* INR(PT)-1.0 [**2156-10-18**] 06:19AM TYPE-[**Last Name (un) **] PO2-78* PCO2-78* PH-7.07* TOTAL CO2-24 BASE XS--9 COMMENTS-GREEN TOP [**2156-10-18**] 06:19AM GLUCOSE-230* LACTATE-4.2* NA+-137 K+-5.2* CL--100 [**2156-10-18**] 06:20AM URINE BLOOD-SM NITRITE-NEG PROTEIN-300 GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD [**2156-10-18**] 06:20AM URINE RBC-3* WBC-32* BACTERIA-FEW YEAST-NONE EPI-<1 TRANS EPI-<1 [**2156-10-18**] 06:20AM URINE HYALINE-1* Cardiac enzymes: [**2156-10-18**] 06:10AM BLOOD proBNP-[**Numeric Identifier 96135**]* [**2156-10-18**] 06:10AM BLOOD cTropnT-0.10* [**2156-10-18**] 11:29AM BLOOD CK-MB-49* MB Indx-5.9 cTropnT-1.02* [**2156-10-18**] 04:52PM BLOOD CK-MB-86* MB Indx-6.5* cTropnT-2.44* [**2156-10-19**] 12:50AM BLOOD CK-MB-49* MB Indx-4.7 cTropnT-3.91* [**2156-10-19**] 07:14AM BLOOD CK-MB-27* MB Indx-3.6 cTropnT-3.88* [**2156-10-19**] 05:07PM BLOOD CK-MB-17* [**2156-10-20**] 03:50AM BLOOD CK-MB-15* MB Indx-3.3 cTropnT-4.57* [**2156-10-21**] 06:20AM BLOOD CK(CPK)-262* [**2156-10-25**] 04:56AM BLOOD CK(CPK)-71 [**2156-10-21**] 06:20AM BLOOD CK-MB-7 cTropnT-5.35* [**2156-10-22**] 02:55PM BLOOD CK-MB-4 cTropnT-7.98* [**2156-10-25**] 04:56AM BLOOD CK-MB-3 cTropnT-8.43* Discharge Labs [**2156-10-25**] 04:56AM BLOOD WBC-7.1 RBC-2.75* Hgb-8.7* Hct-27.0* MCV-98 MCH-31.5 MCHC-32.1 RDW-14.5 Plt Ct-239 [**2156-10-25**] 08:00AM BLOOD PT-11.4 PTT-24.7 INR(PT)-0.9 [**2156-10-25**] 04:56AM BLOOD Glucose-112* UreaN-43* Creat-8.9*# Na-139 K-4.7 Cl-97 HCO3-31 AnGap-16 [**2156-10-24**] 10:08AM BLOOD Calcium-9.7 Phos-5.2*# Mg-2.2 Other Studies: TTE [**2156-10-18**]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the inferior wall and septum and distal inferior dyskinesis. There is mild-moderate hypokinesis of the remaining segments (LVEF = 30 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal. with mild global free wall hypokinesis. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with extensive regional and global systolic dysfunction c/w multivessel CAD or other diffuse process. Compared with the prior study (images reviewed) of [**2155-12-25**], the abnormalities are new and c/w interim ischemia/infarction. TTE [**2156-10-22**]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior akinesis and mid to distal anteroseptal hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2156-10-18**], left ventricular systolic function is now improved (particularly anteroseptal and apical motion). Admission CXR: IMPRESSION: 1. Endotracheal tube 5.5 cm above the carina in standard position. 2. New moderately severe pulmonary edema. 3. Increased cardiomegaly, now moderately severe. 4. Stable foreign body (uncertain etiology) overlying the right medial lung base. [**10-18**] ECG: Probable sinus tachycardia with premature atrial contractions. Anterolateral ST segment depressions which may be due to ischemia. Possible ST segment elevation, one millimeter in leads III and aVF. Cannot exclude ongoing inferior wall myocardial infarction. Q wave in lead III and non-diagnostic Q wave in leads aVF which may be due to prior inferior wall myocardial infarction. Compared to the previous tracing of [**2156-8-27**] ST segment elevations in lead III and aVF are new. Lateral ST segment depressions are also new. The rate is faster. Clinical correlation is suggested. [**2156-10-24**]: Left Upper Extremity Doppler U/S Occlusive thrombus within the caudal portion of the left internal jugular vein, as seen previously. There is no extension of thrombus into the deep veins of the left upper extremity. [**2156-10-22**]: Interventional Radiology Thrombosed right upper extremity AV grafts. Inability to pass the wire through to the venous outflow tract. No contrast flow noted from the AV graft into the venous outflow tract. IMPRESSION: 1. Unsuccessful attempts of thrombolysis at the right upper extremity AV graft. 2. Uncomplicated placement of a new 12 French 16 cm temporary hemodialysis catheter with VIP port through the right internal jugular vein. Catheter is ready for use. Brief Hospital Course: Ms. [**Known lastname 96136**] is a 56 year old woman with h/o ESRD on HD (MWF), DM2, who was admitted with acute respiratory failure and who had 2 PEA arrests in the ED. . ACTIVE ISSUES ============= #. s/p cardiac arrest/NSTEMI: There was concern for ACS, given EKG changes and elevated troponin, despite her end-stage renal disease. After each arrest, the patient's sedation was weaned and she was following commands, so no cooling was done. Her cardiac enzymes were positive, with her CK-MB peaking at 86 (MB-index 6.5) and troponin up to 8.43. Echo showed new anterior hypokinesis and global worsening of systolic function. She was given full-dose ASA, high-dose statin, heparin IV, and continued on home Plavix. She was taken to cardiac cath the morning of [**10-19**], showing stenoses in the proximal and mid-LAD, which were thought to be the culprit lesions. She got two drug-eluting stents without any complications. After the procedure she was started on metoprolol instead of her home labetalol for rate control. She was also started on a low-dose ACE-inhibitor. The patient was discharged on ASA325mg (increase from prior home dose of 81mg) and Plavix 75mg. The patient was treated with atorvastatin 80mg while in house. Prior to discharge she reported a history of myalgias with multiple different statins (not listed on medication allergies). Upon review of atrius records there was a mild elevation of CPK in [**2149**] the setting of myalgias however no evidence of rhabdomyolysis. The risks and benefits were discussed with the patient including the strong indication for statin therapy given recent MI. A conclusion was decided that patient will start atorvastatin at lower dose (40 instead of 80mg) and she will stop medication and call PCP if any recurrence of myalgias. In addition the patient's PCP should trend CPK regularly and d/c the medication if concerning elevation or symptoms. . #. Hypoxic respiratory failure: Patient with acute hypoxic respiratory failure morning of admission while on her way to dialysis. Exam, CXR, and history all consistent with fluid overload. This was almost definitely triggered by ACS with worsening systolic function. She was given Lasix and nitro gtt in the ED, and on arrival to the ICU she underwent emergent dialysis. Her dialysis fistula had no thrill and seemed clotted (similar to [**2-/2156**]), so a temporary HD line was placed on arrival to the MICU. After dialysis, patient did well on the ventilator. After cardiac cath, she was extubated without difficulty. . #. ESRD: on HD MWF. Temporary HD line was placed in the right IJ on arrival to the MICU. Her fistula had clotted (s/p thrombectomy and revisions x2 in [**2-13**], done by Dr. [**First Name (STitle) **], so transplant surgery was consulted. She eventually underwent attempted thrombectomy by IR which was unsuccessful therefore she had a tunneled line placed on the right. She will follow-up outpatient in approximately 6 weeks for consideration of surgical thrombectomy once she has stabilized from a cardiac standpoint. She was continued on cincalcet, nephrocaps, and increased sevelamer to 3200mg TID. . #. Abdominal pain: Patient had abdominal pain on the evening prior to admission with radiation to lower back. Lactate peaked at 4.2, but trended down quickly to 0.8. After treatment for ACS and extubation, she no longer had abdominal pain. This may have been her anginal equivalent. . #. LIJ clot: s/p several attempts at central access in the ED, LIJ clot seen on bedside U/S in the MICU. This was confirmed on formal ultrasound. Given that patient is asymptomatic, the decision was made not to anticoagulate for the time being, as the patient is already on Aspirin and Plavix and therefore high bleeding risk. . #. Acute Systolic Heart Failure (EF 30% on admission, later improved to 45%): likely caused by acute MI. She was started on metoprolol and lisinopril. She will have volume management by HD. She was saturating well on room air prior to discharge. . #. HTN: She was previously on Clonidine, Amlodipine, and Labetalol. These were discontinued and she was started on metoprolol succinate and lisinopril to optimize heart failure management . # LUE erythema in antecubital fossa: This developed after admission and is most likely cellulitis related to previous IV placement. U/S was negative for abscess. Given MRSA history she was started on vancomycin while inpatient and she will receive 3 additional doses of vancomycin IV at her next 3 dialysis sessions. This was communicated by phone to dialysis center ([**Location (un) **] [**Location (un) **]) and patient was given prescription to take with her. . CHRONIC ISSUES =============== #. PAD: She was continued on ASA, Plavix . #. DM2: on Lantus and ISS as outpatient. She was given [**12-7**]-dose lantus while NPO, then returned to home dose. The patient does not follow a diabetic diet at home but she was encouraged to do so. She may benefit from outpatient diabetic counseling. . TRANSITION OF CARE ================== - Patient will need ASA indefinitely and Plavix for at least one year, and more likely indefinitely given her severe PAD. - Patient with history of myalgias on statins in the past but with strong indication for statin therapy given recent MI. PCP should trend CPK regularly and d/c medication if concerning elevation or symptoms. - Patient should receive 3 additional doses of vancomycin IV at her next 3 dialysis sessions. This was communicated by phone to dialysis center ([**Location (un) **] [**Location (un) **]) and patient was given prescription to take with her. - Abdominal Pain may be patient's anginal equivalent as she never had chest pain with her MI. Medications on Admission: - albuterol 90mcg inhalter 1-2 puffs Q6hrs PRN - amlodipine 10mg daily - Renal Caps 1 cap daily - cinacalcet 30mg daily - clonidine 0.1mg [**Hospital1 **] - Plavix 75mg daily - insulin aspart sliding scale - insulin glargine 25 units QPM - labetalol 200mg [**Hospital1 **] - pregabalin 25mg [**Hospital1 **] - sevelamer 2400mg TID - tizanidine 2mg QHS - aspirin 81mg daily - docusate 100mg [**Hospital1 **] - senna PRN - Citalopram 10mg daily - Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six hours Discharge Medications: 1. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*120 Tablet(s)* Refills:*1* 3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. tizanidine 2 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for constipation. 7. docusate sodium 50 mg/5 mL Liquid Sig: [**12-7**] PO BID (2 times a day) as needed for constipation. 8. Toprol XL 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*1* 9. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. Lantus 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. 11. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous three times a day: Dose as directed by sliding scale. 12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. neomycin-bacitracnZn-polymyxin 3.5-400-5,000 mg-unit-unit/g Ointment Sig: One (1) Appl Topical once a day for 7 days: apply to affected area on left arm. Disp:*1 bottle* Refills:*0* 14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 15. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-7**] Inhalation every six (6) hours as needed for wheeze/cough. 16. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous with dialysis for 3 doses: HD sliding scale. Disp:*3 doses* Refills:*0* 17. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 18. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: Do not drive or operate heavy machinery while taking this medication. Disp:*10 Tablet(s)* Refills:*0* 19. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime: Stop this medication if you feel any muscle pain or weakness. Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary - Cardiac Arrest - Myocardial Infarction - Hypoxic Respiratory Failure - Acute Systolic Heart Failure (EF 30%) - AV Graft Thrombosis - Left Internal Jugular Venous Thrombosis - Cellulitis Secondary - End Stage Renal Disease - Insulin Dependent Diabetes - Hypertension 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 96136**], it was a pleasure taking care of you here at [**Hospital1 18**]. You were admitted to the hospital because you were feeling short of breath. While you were in the emergency room your heart stopped entirely on two separate occassions and you nearly died. Fortunately you were able to be resuscitated both times. It appears what happened was that you had a heart attack on Sunday night prior to your admission. This caused your heart to not pump well and then on monday your heart stopped entirely. During your admission you had a cardiac catheterization where 2 blockages were discovered in your coronary arteries. These blockages were likely what caused your heart attack. Therefore these blockages were opened up with stents. There are many things that you can do to reduce your risk of having another heart attack. One is controlling your blood pressure with medications. A second is lowering your cholesterol. It is also important that you keep taking Aspirin and Plavix every day. Your Aspirin dose will be increased to 325mg daily. Do NOT stop taking aspirin and plavix without talking to your cardiologist first. In addition it is very important that you quit smoking. This is the MOST important thing that you can do for your health. Another complication of your illness was that your dialysis access in your right arm formed a blood clot and is not useable. Therefore you had a tunneled line placed for you to have dialysis. You also developed a skin infection (cellulitis) in your left arm. You received antibiotics in the hospital and you will receive 3 more doses at dialysis. If you have fever or your arm does not improve you should call your primary care doctor. You should also apply antibiotic ointment to the area of skin breakdown once daily for 1 week. The following changes were made to your medications: STOP: Clonidine STOP: Amlodipine STOP: Labetalol INCREASE: Sevelamer Carbonate to 3200mg (Four 800mg tabs) Three times daily with meals INCREASE: Aspirin to 325mg daily START: Metoprolol Succinate (Toprol XL) 200mg daily START: Lisinopril 5mg daily START: Atorvastatin (Lipitor) 40mg daily before bed START: Vancomycin 1000mg IV for 3 doses with dialysis START: Triple Antibiotic Ointment apply daily to affected area on left arm for 1 week. Many of your medications were adjusted therefore it is important that you bring an updated medication list to all of your doctor's appointments. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 177**] E. Location: [**Hospital1 641**] Department: Internal Medicine Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 3530**] Appointment: Wednesday [**2156-10-27**] 11:00am Name: NP [**First Name5 (NamePattern1) 2563**] [**Last Name (NamePattern1) 96137**] Location: [**Hospital1 641**] Department: Cardiology Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2258**] Appointment: Wednesday [**2156-11-10**] 8:30am Department: VASCULAR SURGERY When: THURSDAY [**2156-11-11**] at 11:15 AM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Diaylsis [**Location (un) **] Phone: [**Telephone/Fax (1) 5972**] Nephrologist-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Schedule-M/W/F *Your nephrologist will follow up with you at your next diaylsis day.

[ "278.01", "357.2", "V49.73", "428.21", "V45.11", "250.60", "285.9", "305.1", "250.50", "453.86", "682.3", "427.5", "493.90", "362.01", "427.31", "272.4", "403.91", "428.0", "518.81", "585.6", "410.71", "414.01", "996.73", "V49.75" ]

icd9cm

[ [ [] ] ]

[ "00.66", "37.22", "38.93", "38.95", "88.56", "99.62", "96.04", "96.71", "36.07", "17.55", "00.40", "00.46" ]

icd9pcs

[ [ [] ] ]

17402, 17459

9022, 14716

293, 525

17779, 17779

3343, 3343

20437, 21596

2756, 2866

15268, 17379

17480, 17758

14742, 15245

17962, 20414

2906, 3324

4255, 8999

246, 255

553, 2345

3359, 4238

17794, 17938

2367, 2618

2634, 2740

67,067

176,565

7911

Discharge summary

report

Admission Date: [**2104-3-13**] Discharge Date: [**2104-3-25**] Date of Birth: [**2043-11-1**] Sex: F Service: MEDICINE Allergies: Codeine / Vicodin / Percocet / Compazine / Percodan / Tigan / Latex / Betadine Viscous Gauze / Protonix / Surgical Lubricant Attending:[**First Name3 (LF) 2474**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 28445**] is a 60 year old woman with a history of cirrhosis secondary to EtOH abuse and fatty liver who presented to the [**Hospital1 18**] ED with hypotension, hyponatremia and worsening LE edema. The patient is a vague historian who has great difficulty recalling recent events. She notes that she has been feeling steadily worse over the past few weeks, with decreased appetite and PO intake. In addition, she has beomce more fatigued, with increasing lower extremity edema and light-headedness. Over the past week in particular, she has developed abdominal pain which she has difficult describing. She also notes that recently, she has been unable to walk very far before needing to rest, though it is difficult for her to say if that is because of dyspnea or another symptom. She complains that she has been unable to engage in normal daily activities like cooking or going outside recently. She endorses EtOH intake, though she is vague about the exact amount per day. She denies fevers/chills, vomiting or diarrhea, cough, URI symptoms, chest pain, dyspnea, dysuria. She is normally aided in daily activities by her [**Last Name (LF) 8317**], [**First Name3 (LF) **], but according to PCP notes he has become overwhelmed with her medical issues. . On the day of admission, she presented to her PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**], who noted 20 lbs of weight gain, blood pressure of 76/50 and serum Na of 125. He send her to the [**Hospital1 18**] ED for evaluation. In the ED, her BP was 68/37 HR 102, T Afeb, RR 14, SaO2 96% RA. She was given 1L NS with only transient improvement in her BP. A RIJ line was placed and the patient was given Levophed with improvement of her BP to 103/57. Due to diffuse abdominal tenderness, the patient was given IV ceftriaxone and received an Abd/Pelvis CT which showed small ascites. She was admitted to the MICU for further evaluation. On the floor, her vitals were Afeb, 112/67, 104, 95%RA. She was receiving levophed and in no acute distress. Past Medical History: 1. Cirrhosis 2. H/o pancreatitis 3. ETOH abuse 4. Cholelithiasis 5. Obesity 6. Hypothyroidism 7. Venous Insuffuciency 8. Chronic Lower extremity edema 9. Spinal Stenosis 10. Reflex Sympathetic Dystrophy 11. Hypokalemia 12. Mitral regurgitation 13. Neuropathy 14. Bilateral Hand weakness 15. Osteoporosis 16. Macrocytic anemia 17. Thrombocytopenia 18. Uterine fibroids Social History: Lives with her roomate. Is a former constable and volunteer police officer. Drinks 3-4 beers/day x 12 yrs. No h/o withdrawl szs. No tobacco or illicit drug use. Estranged from family. No HCP, though patient believes that father or [**Name2 (NI) 8317**] [**Name (NI) **] could be HCP. Family History: Aunt with cirrhosis. Mother with alcoholism Physical Exam: Admission: VS: Afeb, 112/67, 104, 95%RA, Weight 248 lbs GEN: No acute distress, morbidly obese HEENT: MMM, no scleral icterus, RIJ line in place CV: nl S1/S2, no m/r/g LUNGS: CTAB, good air entry ABD: distended, obese, soft, diffuse tenderness, most prominent tenderness in RUQ. Difficult to palpate liver due to tenderness. Hypoactive bowel sounds. EXT: 2+ pulses in all extremities. Marked, tense swelling in bilateral lower extremities with erythema, warmth and tenderness to palpation. Flaky, scaling skin on legs bilaterally. NEURO: AOx2 (date = "19 something"), mild asterixis Discharge: PE: 98.1 98/D (98-114/D-80) 86 (85-99) 20 97% RA Gen: morbidly obese, AOx3 HEENT: MMM CV: RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: mild crackles at bilateral bases, no wheezes, otherwise [**Last Name (un) **] anteriorly Abd: obese, midline surgical scar, normal BS, soft, diffuse TTP, no palpable HSM, midline reducible ventral hernia Extremities: 2+ pulses in UE B, 1+ pulses in LE B, peripheral swelling, tender to palpation, with appearance consistent with venous stasis changes. Neuro/Psych: improved asterixis Pertinent Results: [**2104-3-19**] RUQ US with Dopplers: 1. Hepatic cirrhosis. Limited study, but findings are consistent with patent hepatic vasculature. 2. Ascites. 3. Splenomegaly. KUB: [**2104-3-17**]: IMPRESSION: New gaseous distention of small bowel,with some gas within the large bowel, ascites, and mucosal fold thickening. The findings may reflect early or partial small-bowel obstruction or ileus. There is moderate gastric distention for which placement of an NG tube should be considered. CT ABD [**2104-3-13**]: 1. Cirrhosis with ascites. 2. Growing ventral wall hernia containing fat and ascites but no bowel. 3. Scattered diverticulosis without diverticulitis. Culture data: URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. This isolate demonstrates carbapenemase production. Consider Infectious Disease Consultation.. MEROPENEM = RESISTANT ( <=1 MCG/ML ). MINOCYCLINE = SENSITIVE. FOSFOMYCIN = SENSITIVE. DOXYCYCLINE = SENSITIVE. Tigecycline = SENSITIVE ( 0.5 MCG/ML ). ISOLATE SENT TO [**Hospital1 4534**] LABORATORIES FOR COLISTIN SENSITIVITY TESTING [**2104-3-19**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- <=1 R MEROPENEM------------- R NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- I TETRACYCLINE---------- S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- =>16 R ------- [**2104-3-18**] 12:08 pm URINE Source: Catheter. **FINAL REPORT [**2104-3-21**]** URINE CULTURE (Final [**2104-3-21**]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. YEAST. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R Brief Hospital Course: Patient is a 60 F w/ cirrhosis, EtOH abuse and obesity admitted for hypotension and hyponatremia initially managed in the MICU then transferred to the floor when normotensive with a hospital course complicated by ESBL UTI and ileus which resolved after decreasing home pain regimen. #Hypotension: Her hyponatremia was thought to be secondary to worsening liver disease, very likely exacerbated by continued EtOH intake as seen through patient history, persistent macrocytic anemia, and isolated AST elevation. She only required levophed for a very short time in the ED. Patient is normally quite hypotensive at home with SBP's of 80-90's. A diagnostic paracentesis was performed and was negative for SBP. Blood cultures were negative. Patient developed UTI after foley placed and may have contributed to her hypotension. Initially lasix and spironolactone were held, however both were restarted at lower doses. She is currently on lasix 40 mg daily and spironolactone 50 mg daily. If blood pressure is stable, would incrase lasix to home dose of 60 mg daily on Friday, [**2104-3-28**]. If blood pressure continues to be stable after increasing lasix, would titrate up spironolactone to home dose of 200 mg daily. #Hyponatremia: Secondary to volume overload and chronic liver disease, SIADH. Given her hypotension, her furosemide and spironolactone were intially held. On discharge, her furosemide was restarted at 20 mg po daily and her spironolactone was restarted at 50 mg daily. These should be uptitrated to home doses, if tolerated, while at rehab. #Ileus: Patient developed an ileus on [**2104-3-17**] with nausea, vomiting, and dilated loops of bowel on KUB. Repeat CT was done and did not show any sign of obstruction. The ileus was thought to possibly be caused by her pain medications and morphine SR was decreased from 60 mg po q12 to 30 mg po q12. An NG tube was placed for decompression and she was keep NPO with IVF and albumin. Her ileus resolved 2 days later and she was advanced to clears and then a regular diet without issue. #UTI: Patient developed foley catheter associated UTI. Her UCx on [**3-14**] grew ESBL E. coli which was intially treated with nitrofurantoin but was then discovered it was resistant and she was switched to tobramycin iv as she was unable to take po abx while NPO for ileus. Repeat urine on [**3-18**] showed VRE, however per ID was thought to be colonized rather than infection. She will continue tobramycin IV until [**2104-3-26**] and then switch to tetracycline PO 500 mg QID starting [**2104-3-27**] until [**2104-3-31**]. #Cirrhosis: Patient continued to drink EtOH at home as she recounted in her history and also shown in her abnormal labs: elevated AST plus macrocytic anemia. LFTs improved over her length of stay. She had a paracentesis with a SAAG suggestive of portal hypertension but not SBP. Her diurectics were initially held given her hypotension. Her lasix was then restarted at a decreased dose of 20 mg po daily and spironolactone restarted at 50 mg PO daily. Her lactulose was initially given at 45 ml tid but was then decreased to 30 mg po tid as her encephalopathy improved. She was also started on rifaximin [**Hospital1 **] for encephalopathy. The liver team also recommended maintaining a [**2093**] calories per day diet. She will follow up in liver clinic. #Acute kidney injury: Creatinine increased to 1.2 on admission from baseline of 0.9-1.0, likely secondary to hypotension. Her creatinine improved throughout her lenghth of stay. #Lower extremity edema: Most consistenet with a stasis dermatitis. Medications on Admission: ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth once a week FUROSEMIDE - 20 mg Tablet - 3 Tablet(s) by mouth once a day MORPHINE 30mg q6h PRN Pain - MORPHINE [MS CONTIN] 60 mg TID OMEPRAZOLE - 20 mg daily POTASSIUM CHLORIDE - 10 mEq Tablet, ER Particles/Crystals - 2 Tab(s) by mouth twice a day PRAMIPEXOLE [MIRAPEX] - 1mg QHS SPIRONOLACTONE 200mg daily TOPIRAMATE [TOPAMAX] 200mg TID TRAZODONE 300mg QHS . Other PRN Meds: HYDROXYZINE HCL - 25 mg Tablet - 1 Tablet(s) by mouth four times a day as needed for prn for itching may cause drowsiness KRISTALOSE - 10G Packet - [**1-27**] PACKETS BY MOUTH EVERY DAY AS NEEDED FOR CONSTIPATION PHENAZOPYRIDINE - 100 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for dysuria . Uncertain/poor compliance meds: BETAMETHASONE VALERATE - 0.1 % Cream - apply to itchy areas twice a day CIPROFLOXACIN - 250 mg Tablet -[**Hospital1 **] x7 days CLONIDINE [CATAPRES-TTS-1] - (Prescribed by Other Provider) - 0.1 mg/24 hour Patch Weekly - one patch every week TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply to affected area twice a day LIDOCAINE [LIDODERM] - 5 %(700 mg/patch) Adhesive Patch ZOFRAN - 8MG Tablet - ONE BY MOUTH FOUR TIMES A DAY . OTC Meds: CALCIUM CITRATE-VITAMIN D3 - 315 mg-200 unit Tablet - 2 Tablet(s) by mouth twice a day replaces Caltrate (calcium carbonate) CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Tablet - 1 Tablet(s) by mouth once a day CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg Tablet - 1 Tablet(s) by mouth once a day DOCUSATE SODIUM - 100MG Capsule - ONE BY MOUTH TWICE A DAY MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 2. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO every twelve (12) hours. Disp:*60 Tablet Extended Release(s)* Refills:*2* 3. morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. potassium chloride 10 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO twice a day. 6. Mirapex 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. trazodone 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for itching. 9. lactulose 10 gram/15 mL Solution Sig: Two (2) PO three times a day. Disp:*2700 ML* Refills:*0* 10. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain: use as needed for pain on urination. 11. triamcinolone acetonide 0.1 % Cream Sig: One (1) Topical twice a day: apply as needed to affected areas. 12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical once a day: 12 hours on, 12 hours off. 13. Zofran 8 mg Tablet Sig: One (1) Tablet PO four times a day as needed for nausea. 14. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO twice a day. 15. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 16. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 18. Centrum Silver Tablet Sig: One (1) Tablet PO once a day. 19. tobramycin sulfate 40 mg/mL Solution Sig: One Hundred-Ten (110) mg Injection Q24H (every 24 hours): last dose on [**2104-3-26**]. Disp:*qs mg* Refills:*2* 20. furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 21. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 22. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 23. tetracycline 500 mg Capsule Sig: One (1) Capsule PO four times a day: Start on [**2104-3-27**], last day [**2104-3-31**]. 24. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 25. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 3 days: please recheck potassium in 3 days (Friday [**3-28**]) and cotninue if K <4.0. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - [**Location (un) 8545**] Discharge Diagnosis: Primary: -Decompensated cirrhosis -Hyponatremia -Urinary tract infection -Small Bowel Ileus 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 low blood pressure and low sodium. Since your blood pressure was so low, you were managed in the intensive care units. You were given in fluids and medications to raise your blood pressure. Your blood pressure stabilized and you were transferred to the medicine floor. You also had very low sodium. This was treated by restricting the amount of fluid you can drink to 1.2 L. This caused an increase in your sodium. We also found that you had a urinary tract infection and you were treated with antibiotics. You will need to continue to take antibiotics at home. You also developed a temporary blockage of your intestines. This condition is also called having an ileus. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube was placed to remove gastric fluid. The blockage resolved on its own and the tube was removed. The following changes were made to your medications: -START taking tobramycin daily, last day [**2104-3-26**]. -START taking tetracycline 500 mg four times a day starting [**2104-3-27**], last day [**2104-3-31**] -START taking rifaximin 550 mg twice a day -DECREASED Lasix to 40 mg once a day -DECREASED Spironolactone to 50 mg a day -STARTED potassium 20 meq a day for three days -STOPPED Clonidine -STARTED Lactulose to 30 ml three times a day -STOPPED Kristalose -DECREASED MS Contin from 60 mg every 8 hours to 30 mg every 12 hours -DECREASED morphine IR from 30 mg to 15 mg every 6 hours as needed for breakthrough pain Followup Instructions: Please keep the following appointments: Department: [**Hospital3 1935**] CENTER When: TUESDAY [**2104-4-8**] at 11:00 AM With: [**Location (un) 394**]/[**Name8 (MD) **] MD [**Telephone/Fax (1) 253**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: WEDNESDAY [**2104-4-9**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: LIVER CENTER When: WEDNESDAY [**2104-4-16**] at 10:20 AM With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**] MD, [**MD Number(3) 2478**] Completed by:[**2104-3-26**]

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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18171

Discharge summary

report

Admission Date: [**2139-9-8**] Discharge Date: [**2139-9-26**] Date of Birth: [**2082-11-16**] Sex: F Service: Newurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 57 year old female with no past medical history who had sudden onset of midback pain and severe headache. She said it felt like a bomb while giving a speech in [**Country 2784**]. She finished her speech and vomited once. This was on [**2139-9-4**]. The headache persisted. She returned to the United States the following day with increased fatigue, headache and backache. She went to [**Hospital3 **] Emergency Department on [**2139-9-7**], where a CTA revealed a large bilobed 1.2 to 2.0 centimeter ACA aneurysm, was transferred to [**Hospital 4415**] on [**2139-9-7**], for further workup. CTA was repeated confirming the previously mentioned aneurysm. She was transferred to [**Hospital1 69**] for embolization of the aneurysm. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: None. SOCIAL HISTORY: ETOH and was a thirty pack year smoker. PHYSICAL EXAMINATION: Neurologically she was completely intact. Speech was clear. The pupils were reactive to light and accommodation, 3.0 millimeters and brisk. No facial asymmetry. No drift. Speech was clear and fluent, awake, alert and oriented times three. Vital signs revealed blood pressure 92 to 106 over 60 to 70s, respiratory rate 14 to 18. HOSPITAL COURSE: The patient was admitted and went directly to the angiography suite where she had her bilobed ACA aneurysm coiled. The coiling was only partially done at that time. During the actual angiogram and coiling, the patient did complain of chest pain. She was seen by cardiology in the angiography suite and the chest pain resolved on its own. It was felt to be anxiety produced. Postoperatively, vital signs are temperature 96.0, blood pressure 103/60, pulse 69, respiratory rate 18, oxygen saturation 99%. The patient was awake, alert and oriented times three. She was unsure of which hospital but was recently transferred. She did know the month and not the day. Negative drift, symmetric smile. The pupils were equal and reactive times light and accommodation, 2.5 to 2.0. She did have some left conjunctival hematoma. Positive pedal pulse. Groin was intact with sheath. Her upper and lower extremities revealed motor strength was [**3-23**]. She followed commands. She had no headache. Her white blood cell count was 9.4, hematocrit 32.9. Her preoperative hematocrit was 37.7. Her prothrombin time was 15.4, partial thromboplastin time 150. INR was 1.6. On the first postoperative day, the patient's vital signs were in the 99 to 100 range. She was awake and alert and oriented times three. She complained of seven out of ten headache, no diplopia. Extraocular movements were full. Visual fields were intact. Negative drift. Grip was [**3-23**]. Positive femoral right pulse. She remained in the neurologic Intensive Care Unit where she received Nimodipine 30 mg q2hours, normal saline at 150 per hour. Central line was placed. Her blood pressure was kept less than 140. Heparin was continued at 600 per hour. On [**2139-9-9**], the patient was brought back to complete her coiling. Postoperatively, she was awake, alert and oriented times three. Her speech was fluent. Naming was intact. She followed commands. Her right groin sheath remained intact. Her blood pressure was kept in the 100 to 130 range. She needed to remain on Heparin as the apparent vessel was possibly thrombosed and we did not want to wean her off. Heparin was kept at 600 per hour. We did not want the area to thrombose quickly. Her coiling went well and was successful. She remained on Heparin postoperatively. The patient remained in the Intensive Care Unit on Heparin and her partial thromboplastin time was kept between 60 to 80. The sheaths remained in place. On [**2139-9-14**], the patient was awake, alert and oriented with no complaints and grips were [**3-23**], no drift. The patient's Heparin drip was reduced on [**2139-9-14**], and she was started on Aspirin 325 mg once daily. However, the patient did start to complain of blurry vision with peripheral type tunneling of the left eye lasting thirty to forty-five minutes. A retinal fellow was consulted where she was found not to have any evidence of vascular occlusion. She did have some decreased vision in the left eye, however, the patient claimed it was lasting greater than 1.5 years. It was felt to be an ocular migraine in her left eye. The patient did continue to stay on Heparin. On [**2139-9-15**], her partial thromboplastin time was at 50. She was seen by the retinal specialist who still felt that it was an ocular migraine and they did sign off and wanted to follow-up as an outpatient. Heparin was stopped on [**2139-9-16**]. Aspirin 81 mg was continued. Her sodium was 136, and had dropped to 134. Those were monitored twice a day. On [**2139-9-16**], the patient underwent a cerebral angiogram to check the progressive thrombus of the coiled left internal carotid artery. Stable appearance of the coils were noted on that day. She was to start on Plavix at 75 mg once daily and Aspirin 325 mg once daily. She no longer needed Heparin. Postoperative check, she was awake, alert. Extraocular movements were full, no drift. On [**2139-9-18**], she remained awake and alert with no headaches at this time. Extraocular movements were full. Her face was symmetric. Her sodium was 134. Again, her angiogram the previous day showed no spasm. Intravenous fluids were kept at 150 per hour. She did continue on the Nimodipine. On [**2139-9-18**], we did ask the retinal specialist to reexamine the patient as she complained of decreased vision in her left eye for the last one to two days. Her ophthalmic examination was within normal limits. Her decreased acuity to her left eye was unclear. Possibilities included mass effect, compression of the aneurysm. They recommended considering intravenous steroids, also recommended getting an ESR, CRP and then a neurologic ophthalmology consultation. Neurophthalmology did seen the patient and felt that there was some compression of optic neuropathy but they felt that it was related to her ACA aneurysm and mass effect. They did request some steroids. The patient was started on Decadron 4 mg p.o. q6hours. On [**2139-9-19**], her vision was improved. On [**2139-9-21**], the patient underwent status post neuroform stent mediated coiling of her right internal carotid artery aneurysm. Postoperatively, she did well with no intraoperative complications. Postoperatively, she was to stay on Plavix and Aspirin. Her sheaths remained in place overnight and she remained on Heparin overnight. Postoperatively, she was alert without complaints, denied headaches or double vision. Her left groin was oozing around the sheath. Dressing was replaced. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements were full. Visual fields were full to confrontation. They recommended one unit of packed red blood cells. Her blood pressure was kept in the 120 range and continued on Aspirin and Plavix. Postoperatively, her hematocrit was 28.5 and on [**2139-9-22**], she did receive one unit of packed red blood cells. Sheath was removed. On [**2139-9-23**], her vital signs were temperature 98.2, blood pressure 97/49. White blood cell count was 10.0, hematocrit was now 32.1, platelet count 364,000. The patient was neurologically intact. There was no sign of hematomas. On [**2139-9-24**], the patient was transferred out of the Neurologic Intensive Care Unit. She was given a physical therapy consultation. Her intravenous fluids were decreased to 100 per hour. Her diet was increased as tolerated. She was given intravenous boluses for her systolic blood pressure less than 100. She remained on the surgical floor. The patient was discharged on [**2139-9-26**]. DISCHARGE INSTRUCTIONS: 1. No strenuous exercise, no driving until cleared by Dr. [**Last Name (STitle) 1132**]. 2. She is to follow-up with Dr. [**Last Name (STitle) 1132**] in one week and neurophthalmology, she was given the telephone number to call. MEDICATIONS ON DISCHARGE: 1. Protonix 40 mg p.o. once daily. 2. Percocet 5/325 one to two tablets p.o. q3-4hours as needed. 3. Plavix 75 mg p.o. once daily. 4. Aspirin 325 mg p.o. once daily. 5. Decadron wean over a week. CONDITION ON DISCHARGE: The patient was discharged neurologically stable on [**2139-9-26**]. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern4) 26792**] MEDQUIST36 D: [**2139-10-28**] 13:00 T: [**2139-10-31**] 10:17 JOB#: [**Job Number 50244**]

[ "276.1", "430", "786.59", "346.80", "305.1" ]

icd9cm

[ [ [] ] ]

[ "88.41", "39.72" ]

icd9pcs

[ [ [] ] ]

8351, 8553

1054, 1061

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982, 1027

1142, 1477

170, 928

951, 958

1078, 1119

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32,286

164,257

51166

Discharge summary

report

Admission Date: [**2176-12-31**] Discharge Date: [**2177-1-13**] Date of Birth: [**2105-9-27**] Sex: M Service: MEDICINE Allergies: Sulfonamides / A.C.E Inhibitors / Angiotensin Receptor Antagonist / Keflex Attending:[**First Name3 (LF) 689**] Chief Complaint: fever and altered mental status Major Surgical or Invasive Procedure: Liver Biopsy Placement of tunneled dialysis line Dialysis Placement and removal of central line History of Present Illness: This is a 71 yo M with PMH of Afib (s/p AV nodal ablation & [**First Name3 (LF) 4448**] implant '[**61**] @ replacement in '[**63**]), EF 30-35%, myelofibrosis, and recurrent C. diff infections who presents with fever and altered mental status. He notes that yesterday he felt very "ill" but could not elaborate. His partner, [**Name (NI) **], notes that he was very fatigued yesterday and was having dry heaves last night as well as green emesis. Today she states that he awoke and did not know where he was was. He was very disoriented, so his partner called EMS, at which time the pt was taken to [**Hospital3 417**] hospital. . At the OSH, the pt was noted to have a temp of 104 F. He had a CT head which was negative there. He also received a liter of NS, Vanc 1 gm IV x1, Levofloxacin 750 mg IV x1. His SBP dropped to 85/31 so he was started on a dopamine gtt at 4mcg/hr. He also received toradol 15 mg IVx 1. He was transferred here for further care. . In the ED, his VS were: Tm 100.8, HR 74-90, BP 85-106/32-49, RR 16-20, Sat 97% 4L NC. He received 2 L NS. A triple lumen R groin line was placed and he was started on a levophed gtt. CXR here was negative for any new infiltrate. He was found to have purulent discharge from the tunneled dialysis line, so transplant surgery pulled the line in the ED after blood cultures were obtained. He also received toradol 30 mg IV x1 and gentamycin 80 mg IV x1. Per ED report here, the pt received 3% NS for a Na level of 118 at OSH, however OSH records do not appear to record this and his Na was 128 there. . Of note, the pt was recently hospitalized here from [**Date range (3) 106200**] for viral gastroenteritis, and then CT contrast-induced ATN. He had a tunnelled line placed in his L IJ on [**2176-12-24**]. He also had a L groin pseudoanuerysm s/p femoral temporary dialysis catheter removal. This was injected with thrombin. . At this time, the pt has no complaints. He denies n/v, fevers, chills, chest pain, shortness of breath, abdominal pain, diarrhea, constipation, headache, or any other symptoms. Past Medical History: Idiopathic Myelofibrosis, dx [**2175**] Recurrent C. Diff colitis Pancreatitis c/b pseudocyst Lap cholecystectomy [**2165**] Partial Colectomy for Diverticulitis [**2164**] BPH Osteoarthritis [**Year (4 digits) **] Dependent after AV Nodal Ablation for a-fib Sarcoid in 20's CHF chronic systolic/diastolic, EF 30-35% Social History: Home: lives with wife Occupation: retired trial lawyer [**Name (NI) 1139**]: smoked for 40yrs, quit in [**2151**] EtOH: previously heavy, quit in [**2151**] Drugs: denies Family History: Father died of MI at 56 Brother in late 60s with CAD, Parkinson's, and renal failure Mother died of aortic stenosis in her late 80s Extensive family h/o alcohol abuse Physical Exam: Physical Exam: VS: T 98.3 BP 100/46 HR 77 R 14 Sat 100% on 4L NC GEN: pleasant, comfortable, oriented to self, slow to respond to questions HEENT: PERRL, EOMI, anicteric, dry, op without lesions NECK: JVP difficult to assess given obese neck RESP: CTA BL with some decreased breath sounds at the bases CV: RR, S1 and S2 wnl, grade 2/6 SEM at LUSB ABD: distended but nontender, +b/s, soft EXT: [**12-4**]+ pitting in the BL LE up to the knees, 1+ distal pulses SKIN: blanching erythema and warmth around the prior tunnelled L IJ site; dressing c/d/i but site oozing dark blood without purulence: ?eccymosis on chin; well-healed abdominal excision scars NEURO: oriented to self but not time or place; moves all 4 extremities equally and symmetrically. Pertinent Results: EKG: V paced, rate of 79 bpm, seems to have underlying rhythm of afib . ADMISSION LABS [**2176-12-31**] 03:20PM BLOOD WBC-57.32* RBC-4.61 Hgb-12.4* Hct-37.8* MCV-82 MCH-27.0 MCHC-32.9 RDW-17.0* Plt Ct-493* [**2176-12-31**] 03:20PM BLOOD Neuts-69 Bands-5 Lymphs-7* Monos-9 Eos-1 Baso-0 Atyps-0 Metas-4* Myelos-2* Promyel-1* NRBC-2* Other-2* [**2176-12-31**] 03:20PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+ Tear Dr[**Last Name (STitle) **]1+ [**2176-12-31**] 03:20PM BLOOD PT-31.3* PTT-77.1* INR(PT)-3.2* [**2176-12-31**] 03:20PM BLOOD Glucose-92 UreaN-44* Creat-5.8* Na-132* K-4.9 Cl-96 HCO3-21* AnGap-20 [**2176-12-31**] 03:20PM BLOOD ALT-16 AST-67* LD(LDH)-1449* CK(CPK)-64 AlkPhos-364* TotBili-1.5 [**2176-12-31**] 03:20PM BLOOD Lipase-14 [**2176-12-31**] 03:20PM BLOOD cTropnT-0.04* [**2176-12-31**] 03:20PM BLOOD Calcium-9.0 Phos-5.2* Mg-1.8 [**2176-12-31**] 03:20PM BLOOD Cortsol-36.8* [**2176-12-31**] 07:20PM BLOOD Type-MIX Temp-37.1 Rates-/16 O2 Flow-4 pO2-43* pCO2-43 pH-7.31* calTCO2-23 Base XS--4 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2176-12-31**] 03:28PM BLOOD Lactate-2.1* [**2176-12-31**] 07:20PM BLOOD Lactate-1.7 [**2176-12-31**] 07:20PM BLOOD O2 Sat-74 IMAGING CXR 1. Interval placement of dual lumen left-sided IJ hemodialysis catheter with tip in the distal SVC. 2. Interval development of hazy opacity overlying the right mid and lower lung zone. This may be partially secondary to a posterior layering pleural effusion. However, a right lower lung zone early/developing pneumonia should also be considered. Followup radiographs may be of benefit. Brief Hospital Course: # Bacteremia/Sepsis: Patient intially admitted to ICU from OSH. The patient's HD line was pulled and it was expressing pus. Blood cultures from the OSH showed MSSA and cultures from the line tip also showed MSSA. Patient was initially on levophed in the ICU and he was supported with fluid boluses. Pressors were weaned off and his hypotension resolved. He was called out to the floor. Blood cultures have been negative here. A TTE did not show evidence of vegitations. A new HD line was placed after surveillance cultures were negative and the patient was afebrile. He will complete a two week course of Vanc per HD protocol. . # ESRD on dialysis: The patients renal failure is recent onset from hypotension-induced ATN and CT contrast induced ATN during his last hospitalization. A new tunneled HD line was placed during this admission and dialysis was continued. As of this date, there has not been any renal recovery. Of note, he has had difficulty taking his phosphate binders because of the size of the pills. His phosphate is not currently elevated but it should be closely monitored as an outpatient. . #Left IJ clot - Patient has a clot in his left IJ, a site of previous instumentation. He also intially had a left subclavian clot that is now resolved. He was maintained on a heparin gtt while in the hospital, except for the period directly after his liver biopsy. He will be transitioned back to coumadin. . #Groin hematoma / Hip Pain - After removal of the patient's femoral central line that was placed in the ED, he developed a hematoma. Intially there was a concern of another pseudoaneurysm developing. Repeat ultrasound was without evidence of pseudoaneurysm, and there was no indication for thrombin. He continued to have pain at that sight. It was discussed with vasc [**Doctor First Name **] and pain is not atypical for a large hematoma. Plain films of the hip were obtained and discussed with ortho, no acute process on film to account for pain. He had limited range of motion because of active pain. Peripheral pulses were intact in the leg and he intact sensation and [**4-7**] strength in his foot. His pain improved during the hospital stay and he had improved range of motion. He will continue physical therapy as rehab. . #Increased LFTs - The source is not entirely clear. Alkphos and GGT elevated so likely from liver. Bilirubin also elevated during the admission. Ultrasound x2 without evidence of ductal dilation. He was seen by the liver team. They were concerned about cirrhosis or a component of his myeloproliferative disease. A liver biopsy was obtained and he will follow up in the hepatology clinic for the results as the pathology was pending at the time of discharge. Serologies obtained also were negative. . # V paced rhythm, h/o afib: Pt is s/p AV nodal ablation, on coumadin. Coumadin was held because of his multiple procedures. He was maintained on a heparin gtt except directly after liver biopsy. He was restarted on coumadin at time of discharge. The rehab will monitor his INR and stop the heparin gtt when he is at goal. . # Systolic Dysfunction: EF 45%, he was fluid overloaded on presentation, and he continued dialysis. Fluid will continue to be removed at his dialysis sessions. His carvedilol and imdur were held while he was in the ICU and on the medical floor. They can be restarted as he tolerates at rehab. . #dysphagia - Patient complained of some difficulty swallowing. He was seen by speech and swallow and cleared for a regular diet. No evidence of oropharyngeal dysfunction. He was able to eat and drink without difficutly in house. He was set up with a GI follow up appointment as an outpatient to further evaluate his symptoms. . # Myelofibrosis: Patient has chronic elevation of his WBC count. Baseline is usually in 30s. It was intially elevated on presentation with his sepsis. It trended down with treatment, but again increased later in the hospitalization. There was no clear new source of infection and it stablized at discharge. His Diff was also not consistent with a blastic transformation. The case was dicussed with heme/onc while in house. He will plan to follow up with them soon after discharge to possibly begin therapy. . #Anemia - Patient was below baseline in house. Iron studies consistent with chronic kidney disease and he was guiac negative. His HCT should be monitored by both his PCP and heme/onc if they are planning on starting treatment for his Myelofibrosis. HCT was stable at the time of discharge after his liver biopsy. . #Pain at coccyx - Patient had evidence of a small pressure ulcer. Red skin noted without any breakdown. Nursing staff was informed and he was seen by the wound care nurse. A lidoderm patch was given for pain. This should be closely followed at his rehab facility. . # HTN: carvedilol held in house, can be restarted at rehab as he tolerates . # Hypothyroidism: continued synthroid . # Hyperlipidemia: continued simvastatin Medications on Admission: Fluticasone nasal inh twice daily Synthroid 50 mcg dialy Imdur 30 mg daily Simvastatin 20 mg daily Protonix 40 mg daily Coumadin 3 mg daily B complex vitamins Carvedilol 12.5 mg twice daily Ambien 15 mg as needed at night calcium acetate 667 mg three times a day Ultram 100 mg every 6 hrs as needed for pain Discharge Medications: 1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) spray Nasal twice a day. 2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 6. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 7. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO three times daily with meals. 8. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): to arms and legs. 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on for 12 hours and off for 12 hours. please apply to coccyx. 12. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gm Intravenous HD PROTOCOL (HD Protochol): continue until [**1-14**]. 13. Hydromorphone 2 mg Tablet Sig: 1-2 mg PO every six (6) hours as needed for pain. 14. Heparin IV Sliding Scale continue until INR>2.0 for 24 hours 15. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY16 (Once Daily at 16): titrate as needed based on INR. 16. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for cough. 17. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: Sepsis from line infection Chronic Systolic Congestive Heart Failure Atrial Fibrillation Myelofibrosis Discharge Condition: stable Discharge Instructions: You were seen in the hospital for an infection of your dialysis line. You will be treated with a two week course of antibiotics. You also had a liver biopsy while in the hospital to evaluate some liver dysfunction noted on lab tests. . You will need to follow up with the following services after discharge Liver Clinic - [**Telephone/Fax (1) 2422**]. Primary Care - [**Telephone/Fax (1) 1792**] Gastroenterology - [**Telephone/Fax (1) 463**] Hematology - [**Telephone/Fax (1) 9645**] . Either return to the emergency room or call your priamry care physician if you have any fevers, chest pain, shortness of breath, increasing pain in your abdomen or legs, or other symptoms of concern to you. Followup Instructions: LIVER CLINIC: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2177-1-15**] 2:10 . Hematology :Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2177-1-16**] 2:30, Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2177-1-16**] 2:30 . Primary Care - Saturday [**2177-1-25**] at 12:40pm with Dr. [**Last Name (STitle) 1789**] . Gastroenterology: You will need to follow up with the [**Hospital **] clinic in regards to your trouble swallowing. Provider: [**First Name4 (NamePattern1) 3520**] [**Last Name (NamePattern1) 3521**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2177-1-31**] 8:30 Completed by:[**2177-1-13**]

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icd9cm

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icd9pcs

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25,326

109,204

4928+4929

Discharge summary

report+report

Admission Date: [**2120-1-15**] Discharge Date: [**2120-1-25**] Date of Birth: [**2058-5-23**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 3290**] Chief Complaint: Fever, AMS Major Surgical or Invasive Procedure: [**1-15**] right femoral line placement [**1-15**] left tunneled catheter removal [**1-16**] left arterial line placed History of Present Illness: 61 male with history of seizure disorder, nonischemic cardiomyopathy EF 20-30%, ESRD on HD (T/Th/Sat, last session on saturday), hepatitis B, CAD, CVA, recent admission for line bacteremia given vanco for 2 week course, who was at his rehab center and found to be febrile with altered mental status and hypoglycemia. His sugars there were in the 30s and he was given oral glucose which improved his finger stick to 156. His baseline mental status is A+0x3 but today he was A+O x2. . Pt had recent admission in [**11/2119**] for staph epidermidis and CONS bacteremia, thought to be from tunnel line (tunnel tip grew CONS). At that time, tunnel line was changed ([**2119-12-4**], fluro guided tunnel line, exchanged over wire). Pt was given vancomycin for 2 week course, dosed per HD protocol. . In the ED inital vitals were, T 102.2 HR 105 BP 94/44 RR 18 pOx 98% 2L. Tm 104. Pt noted to have pus coming out of his tunnel line on left. His temp spiked at 104, SBP initialy 160s. Tunnel line culture was sent off. AAOx2 (not to location). Patient was given 4L NS, MAPs dropped to the low 60s, placed femoral line (goal was to preserve other sites sinec pt likely currently bactermic and will likely need new line), started levophed infusion 0.06 (BP 94/45). For fever of 104, given rectal tylenol 650mg, linezolid 600mg, zosyn 4.5 (not given vanco bc history of VRE). Cultures were obtained including blood, urine, HD catheter swab. Labs were significant for CBC WBC 11.9, Hgb 9.4, HCT 31, PLT 366. N 88%. INR 1.3, PTT 34. Phos low at 1.6, Mg 2, Ca 9.7. Lytes revealed UA: large euks, blood, 300+ protein, sh 1013, pH 6.5. Na 135, K 5.1, Cl 94, Bicarb 25, BUN 33, Cr 8.2, Gluc 107. AG was 16. Lactate 2.3. ABG: pH 7.43, CO2 41, O2 58, HCO3 28 CXR showed: no signs of pneumonia, mildly increased pulm vascular pressures. Access includes 18G right and left forearm and right neck. Femoral line and tunnel line. Most Recent Vitals: 101 80/44 18 82 96% 2LNC . On arrival to the ICU, pt is A+O x3, states he has a doctorate in history and music. He is at times sleepy, and at times very sharp and able to answer questions such as the details of his PhD. Denies any pain anywhere, no cough, no abd pain, last bm yesterday, no diarrhea, states he has been admitted several times for recurrent tunnel line infections. . Review of systems: (+) Per HPI (-) Denies 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: - Seizure disorder since mid [**2097**]'s after starting dialysis - MSSA HD line infection with septic lung emboli [**9-1**] with left pleural effusion - H/o Hepatitis B, treated - Non-ischemic cardiomyopathy, last EF 20-30% - MI [**2086**] per pt - CVA [**2086**] per pt (?residual LE weakness) - ESRD on hemodialysis [**1-25**] HTN. EDW 80 kg as of [**2118-1-3**]. - Multiple thrombectomies in LUE and R thigh AV fistula - Graft excision for infected thigh graft [**2117-5-26**] - Hungry bone syndrome status post parathyroidectomy - Pituitary mass - Anemia of chronic disease - s/p PEG tube placement [**2117-10-29**] - Admission to MICU in [**10-2**] for seizure and hypotension - Swab positive for MRSA and VRE at left groin site in [**10-2**] and MRSA positive from same site [**11-2**] - [**11/2119**] admission for staph epidermidis bacteremia and CONS bacteremia sp vanco x 2 weeks -[**9-/2119**]: MSSA and VRE bacteremia -MSSA [**12/2117**] and [**4-/2118**] Social History: Retired piano and organ teacher. Has 2 PhDs (history and music) and prefers to be called "Dr. [**Known lastname 2026**]." Walks with a walker at baseline. Never smoker, no other drug use. Drinks 1 drink/week. Has 2 sisters that live out of state, son died few years ago ("was shot to death"). Family History: Father with DM, mother died at age 41 of renal failure Physical Exam: ADMISSION PHYSICAL EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: anterior lungs are clear bilaterally CV: Regular rate and rhythm, normal S1 + S2, systolic murmur left sternal border, no rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley with scant dark urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Slightly decreased skin turgor. Right knee with warm patellar joint, ballotable. Neuro: CN 2-12 intact, sensation throughout, [**4-27**] stregnth throughout, small pinpoint pupils, EOM intact, A+O x3. Pertinent Results: LABS: On admission: [**2120-1-15**] 09:00AM BLOOD WBC-11.9*# RBC-3.63* Hgb-9.4* Hct-30.9* MCV-85 MCH-25.8* MCHC-30.4* RDW-16.0* Plt Ct-366 [**2120-1-15**] 09:00AM BLOOD Neuts-88.0* Lymphs-6.1* Monos-3.1 Eos-2.7 Baso-0.1 [**2120-1-15**] 09:00AM BLOOD PT-14.0* PTT-34.0 INR(PT)-1.3* [**2120-1-15**] 09:00AM BLOOD Glucose-107* UreaN-33* Creat-8.2*# Na-135 K-5.1 Cl-94* HCO3-25 AnGap-21* [**2120-1-15**] 09:00AM BLOOD Calcium-9.7 Phos-1.6*# Mg-2.0 [**2120-1-15**] 02:59PM BLOOD TSH-0.45 [**2120-1-15**] 02:59PM BLOOD Cortsol-40.3* [**2120-1-16**] 02:58AM BLOOD Cortsol-25.6* [**2120-1-15**] 09:00AM BLOOD Digoxin-1.5 [**2120-1-15**] 09:11AM BLOOD pO2-58* pCO2-41 pH-7.43 calTCO2-28 Base XS-2 [**2120-1-15**] 09:11AM BLOOD Glucose-102 Lactate-2.3* K-5.1 calHCO3-27 Micro: Blood Cx [**1-16**], 25, 26, 29: no growth to date Blood Cx [**1-15**]: MRSA Femoral CVL tip [**1-19**]: no growth to date HD catheter tip [**1-15**]: MRSA Joint fluid: [**2120-1-17**] 12:00; culture showed no growth. WBC RBC Polys Lymphs Monos [**Telephone/Fax (1) 20491**] 81 17 2 [**1-15**] Wound swab (from prior HD cath site): MRSA Urine cx: [**1-15**]: no growth Studies: [**2120-1-15**] Radiology CHEST (PORTABLE AP) Mild cephalization which could reflect mild pulmonary venous congestion. [**2120-1-16**] Cardiovascular ECHO The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 55%) with subtle basal inferior hypokinesis. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2119-11-30**], the LVEF has improved. [**2120-1-17**] Radiology KNEE 2 VIEW PORTABLE RI There are degenerative changes with narrowing of the lateral compartment which causes valgus angulation at the knee. There is spurring at the inferior pole of the patella. There is no joint effusion. There are no focal lytic or blastic lesions. There is some soft tissue swelling. [**2120-1-18**] Radiology CHEST (PORTABLE AP) HD catheter has been removed. There is no evident pneumothorax. If any there is a small right pleural effusion. Cardiac size is top normal. The aorta is tortuous. The chin of the patient obscures the right apex. There is mild vascular congestion. There are no new abnormalities from [**1-15**]. There are low lung volumes. Widened mediastinum and deviation of the trachea towards the right is due to enlarged thyroid gland. Multiple left rib fractures are noted. Brief Hospital Course: BRIEF HOSPITAL COURSE: This is 61 male with history of seizure disorder, nonischemic cardiomyopathy EF 20-30%, ESRD on HD (T/Th/Sat, last session saturday), hepatitis B, CAD, CVA, several admissions in the past for tunnel associated MSSA/CONS/VRE bacteremia, recent admission 1 month ago for Staph epidermidis and CONS line bacteremia given vanco for 2 week course, who presented with MRSA bacteremia likely due to an infected tunnel line. . ACTIVE ISSUES SEPTIC SHOCK: The patient persented with Fever (Tm 104), Leukocytosis (WBC 12), Tachycardia (HR 100s), lactate 2.3, mental status change, and BP 94/44 on low dose Levophed and after 4L, consistent with septic shock. Methicillin resistant staph aureus grew from the [**3-27**] blood culture bottles, swab of the catheter and culture of the tip of the catheter line. Pus was noted surrounding the catheter site which was evaluated by general surgery and no I/D indicated. His urine culture revealed no growth despite large amount of leukocytes. His presenting chest xray was clear and joint fluid analysis of his right knee was not consistent with septic arthritis. A TTE demonstrated no evidence of vegetations. A TEE was deferred given it would not change antibiotic duration. He briefly required pressor support with levophed via a femoral line placed in the ED. He was initially started on linezolid which was discontinued in favor of vancomycin and zosyn in the intensive care unit which were narrowed to vancomycin alone when culture data was available. His HD was line was removed and he HD was deferred for 1 week before a temporary femoral line was placed. Surveillance blood cultures were all negative following his admission cultures on [**2120-1-15**]. Duration of therapy 6 weeks ([**0-0-**]) with vancomycin to be given with HD. A tunneled right subclavian line was placed prior to discharge. . ESRD: T/Th/Sat. Last HD prior to admission was 2 days PTA, on Saturday. HD was deferred for as long as possible, to allow for a line holiday given segnificant bacteremia and sepsis. Patient was monitored on telemetry, electrolytes checked daily, small boluses of fluid given for hypotension. HD cath pulled [**1-15**]. line was replaced on [**1-19**], w/ HD on [**1-20**], now back on prior Tu/Th/Sat schedule. . ALTERED MENTAL STATUS: Patient is significantly altered from baseline. Initially, AMS felt to be due to hypoglycemia. Likely multifactorial-- septic shock, uremia. Per patient??????s family, his mental status has been declining for >1 year. Neuro exam non focal. Patient had one witnessed seizure on the day of HD (5 days into admission), and it was discovered that he had been under dosed on his keppra during the admission. It is possible that he has been having seizures during this time that have been affecting his MS, however, his postictal state is not similar to his mental status throughout the admission. Mental status continued to improved. RPR negative. B12 and folate wnl. TSH wnl. Head CT in [**2119-8-24**] demonstrated expected expected age-related changes. [**Month (only) 116**] consider neurocognitive testing in the outpatient setting. . HYPOGLYCEMIA: Likely [**1-25**] acute infectious state. Can also see in renal failure (because insulin cleared by kidneys), hypopit (pt has known pituitary mass), adrenal insuf (had normal cortisol Am level check on prior admission), insulinoma. Most likely etiology is sepsis. TSH WNL. Patient's blood glucose WNL after 1 day into admission. . SEIZURE DISORDER: Patient is on oxcarbazepine and keppra as an outpatient. Patient was underdosed Keppra during his HD vacation this admission. He experienced a brief localized seizure consisting of 1 minute of facial twitching 5 days into admission. Pt was apparently on the incorrect seizure medication, which was per his prior d/c summary and outside facility list (was ~ [**12-26**] of his appropriate dose [**First Name8 (NamePattern2) **] [**2119-5-24**] neuro note). Pt??????s prior seizures were more generalized, last documented in [**2117**], attributed to medication non-compliance. Neurology was consulted and Pt was restarted on Keppra 500 tid plus 500 mg dose after HD, and oxcarbazepine 300 mg tid plus 300 mg dose after HD. Pt apparently tends to have seizures after HD. Pt states that he typically has a small facial seizure every few months. Pt did not have any further seizures during his hospitalization. . ANION GAP METABOLIC ACID: Likely [**1-25**] lactic acidosis and renal failure. Gap closed as patient restarted on HD 5 days into admission. . CAD/CHF: Mild pulm edema on CXR, however on exam pt appears mildly volume down with some decreased skin turgor. Pt given several liters of IVF in setting of septic shock. He is at risk for pulmonary edema so will trend his O2 requirement and exam closely. HD was restarted 5 days into admission, which will manage volume status. Continued home simvastatin and ASA, and digoxin dosed according to HD. . ANEMIA: HCT baseline 27-30. HCT currently 31, at baseline. Likely multifactorial: anemia [**1-25**] ESRD and anemia of chronic disease. He was given epoeitin in dialysis. . INR 1.3: Likely [**1-25**] poor nutrition, recent antibiotics. No diarrhea. INR trended. He was given vitamin K prior to discharge . HYPOPHOSPHOTEMIA: Phos 1.9 on admission (repleted), lower then expected given renal failure. Pt is sp parathyroidectomy. Differential includes poor nutrition, osetomalacia, diuretics, hyper-parathyropidism, hyperthyroidism, recovery from starvation, steroids. Baseline phos is usualy [**1-27**]. Repeat Phos levels remained WNL. TSH WNL, PTH high. . RIGHT KNEE PAIN. Pt was complaining about knee effusion, which felt warm and was tapped by orthopedic service. Fluid showed 200 WBC, 1625 RBC, 81% Polys 17% Lymphs, no organisms on gram stain, no crystals. Pt was treated with analgesics with improvement in his pain. . TRANSITIONAL ISSUES - vancomycin for 6 weeks (last date [**2120-2-27**]) - consider neurocognitive testing Medications on Admission: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. calcium acetate 667 mg Capsule Sig: Four (4) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA): extra dose to be given on dialysis days after dialysis. 7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO three times a day. 10. oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO three times a week (Tues, Thurs, Sat): extra dose to be given on dialysis days after dialysis. 11. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: do not exceed 4 grams in 24 hours. 14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 15. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 16. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 17. senna 8.6 mg Capsule Sig: One (1) Capsule PO at bedtime: hold for loose stools; pt may refuse. 18. chlorhexidine gluconate 4 % Liquid Sig: One (1) Topical [**12-25**] times each week. 19. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) Topical once a day: APPLY LIBERALLY TO SKIN ON HANDS, FEET 20. vancomycin in D5W 1 gram/200 mL Piggyback Sig: as directed Intravenous HD PROTOCOL (HD Protochol): To be dosed based on trough and given on hemodialysis; continue until [**2119-12-13**]. 21. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours as needed for pain. Discharge Medications: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO once a day. 5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO HD DAYS (). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO ON HD DAY (). 10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 14. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. 15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily). 16. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous with HD for 1 doses: To be dosed based on trough and given on hemodialysis days. (Duration 6 weeks, last day [**2120-2-28**]). Disp:*qS * Refills:*0* 17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: 1. Methicillin Resistant Staphylococcus Aureus Bactermia 2. End Stage Renal Disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 2026**], . You were admitted for a fever and found to have another infection in your blood likely related to your hemodialysis line. Your tunneled catheter was removed and dialysis was stopped for 1 week. A temporary catheter was then placed in your groin before a new tunneled catheter could be placed in your right subclavian site. You will need to continue antibiotics for a total of 6 weeks. . The following changes were made to your medication list: 1. CONTINUE Vancomycin with hemodialysis for 6 weeks (last day [**2120-2-27**]) 2. STOP Ferrous Sulfate 3. HOLD Sevelamer until otherwise directed 4. HOLD Calcium acetate until otherwise directed . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please follow-up with the physicians at your facility and your outpatient nephrologists. Admission Date: [**2120-1-15**] Discharge Date: [**2120-1-25**] Date of Birth: [**2058-5-23**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 3290**] Chief Complaint: Fever, AMS Major Surgical or Invasive Procedure: [**1-15**] right femoral line placement [**1-15**] left tunneled catheter removal [**1-16**] left arterial line placed History of Present Illness: 61 male with history of seizure disorder, nonischemic cardiomyopathy EF 20-30%, ESRD on HD (T/Th/Sat, last session on saturday), hepatitis B, CAD, CVA, recent admission for line bacteremia given vanco for 2 week course, who was at his rehab center and found to be febrile with altered mental status and hypoglycemia. His sugars there were in the 30s and he was given oral glucose which improved his finger stick to 156. His baseline mental status is A+0x3 but today he was A+O x2. . Pt had recent admission in [**11/2119**] for staph epidermidis and CONS bacteremia, thought to be from tunnel line (tunnel tip grew CONS). At that time, tunnel line was changed ([**2119-12-4**], fluro guided tunnel line, exchanged over wire). Pt was given vancomycin for 2 week course, dosed per HD protocol. . In the ED inital vitals were, T 102.2 HR 105 BP 94/44 RR 18 pOx 98% 2L. Tm 104. Pt noted to have pus coming out of his tunnel line on left. His temp spiked at 104, SBP initialy 160s. Tunnel line culture was sent off. AAOx2 (not to location). Patient was given 4L NS, MAPs dropped to the low 60s, placed femoral line (goal was to preserve other sites sinec pt likely currently bactermic and will likely need new line), started levophed infusion 0.06 (BP 94/45). For fever of 104, given rectal tylenol 650mg, linezolid 600mg, zosyn 4.5 (not given vanco bc history of VRE). Cultures were obtained including blood, urine, HD catheter swab. Labs were significant for CBC WBC 11.9, Hgb 9.4, HCT 31, PLT 366. N 88%. INR 1.3, PTT 34. Phos low at 1.6, Mg 2, Ca 9.7. Lytes revealed UA: large euks, blood, 300+ protein, sh 1013, pH 6.5. Na 135, K 5.1, Cl 94, Bicarb 25, BUN 33, Cr 8.2, Gluc 107. AG was 16. Lactate 2.3. ABG: pH 7.43, CO2 41, O2 58, HCO3 28 CXR showed: no signs of pneumonia, mildly increased pulm vascular pressures. Access includes 18G right and left forearm and right neck. Femoral line and tunnel line. Most Recent Vitals: 101 80/44 18 82 96% 2LNC . On arrival to the ICU, pt is A+O x3, states he has a doctorate in history and music. He is at times sleepy, and at times very sharp and able to answer questions such as the details of his PhD. Denies any pain anywhere, no cough, no abd pain, last bm yesterday, no diarrhea, states he has been admitted several times for recurrent tunnel line infections. . Review of systems: (+) Per HPI (-) Denies 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: - Seizure disorder since mid [**2097**]'s after starting dialysis - MSSA HD line infection with septic lung emboli [**9-1**] with left pleural effusion - H/o Hepatitis B, treated - Non-ischemic cardiomyopathy, last EF 20-30% - MI [**2086**] per pt - CVA [**2086**] per pt (?residual LE weakness) - ESRD on hemodialysis [**1-25**] HTN. EDW 80 kg as of [**2118-1-3**]. - Multiple thrombectomies in LUE and R thigh AV fistula - Graft excision for infected thigh graft [**2117-5-26**] - Hungry bone syndrome status post parathyroidectomy - Pituitary mass - Anemia of chronic disease - s/p PEG tube placement [**2117-10-29**] - Admission to MICU in [**10-2**] for seizure and hypotension - Swab positive for MRSA and VRE at left groin site in [**10-2**] and MRSA positive from same site [**11-2**] - [**11/2119**] admission for staph epidermidis bacteremia and CONS bacteremia sp vanco x 2 weeks -[**9-/2119**]: MSSA and VRE bacteremia -MSSA [**12/2117**] and [**4-/2118**] Social History: Retired piano and organ teacher. Has 2 PhDs (history and music) and prefers to be called "Dr. [**Known lastname 2026**]." Walks with a walker at baseline. Never smoker, no other drug use. Drinks 1 drink/week. Has 2 sisters that live out of state, son died few years ago ("was shot to death"). Family History: Father with DM, mother died at age 41 of renal failure Physical Exam: ADMISSION PHYSICAL EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: anterior lungs are clear bilaterally CV: Regular rate and rhythm, normal S1 + S2, systolic murmur left sternal border, no rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley with scant dark urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Slightly decreased skin turgor. Right knee with warm patellar joint, ballotable. Neuro: CN 2-12 intact, sensation throughout, [**4-27**] stregnth throughout, small pinpoint pupils, EOM intact, A+O x3. Pertinent Results: LABS: On admission: [**2120-1-15**] 09:00AM BLOOD WBC-11.9*# RBC-3.63* Hgb-9.4* Hct-30.9* MCV-85 MCH-25.8* MCHC-30.4* RDW-16.0* Plt Ct-366 [**2120-1-15**] 09:00AM BLOOD Neuts-88.0* Lymphs-6.1* Monos-3.1 Eos-2.7 Baso-0.1 [**2120-1-15**] 09:00AM BLOOD PT-14.0* PTT-34.0 INR(PT)-1.3* [**2120-1-15**] 09:00AM BLOOD Glucose-107* UreaN-33* Creat-8.2*# Na-135 K-5.1 Cl-94* HCO3-25 AnGap-21* [**2120-1-15**] 09:00AM BLOOD Calcium-9.7 Phos-1.6*# Mg-2.0 [**2120-1-15**] 02:59PM BLOOD TSH-0.45 [**2120-1-15**] 02:59PM BLOOD Cortsol-40.3* [**2120-1-16**] 02:58AM BLOOD Cortsol-25.6* [**2120-1-15**] 09:00AM BLOOD Digoxin-1.5 [**2120-1-15**] 09:11AM BLOOD pO2-58* pCO2-41 pH-7.43 calTCO2-28 Base XS-2 [**2120-1-15**] 09:11AM BLOOD Glucose-102 Lactate-2.3* K-5.1 calHCO3-27 Micro: Blood Cx [**1-16**], 25, 26, 29: no growth to date Blood Cx [**1-15**]: MRSA Femoral CVL tip [**1-19**]: no growth to date HD catheter tip [**1-15**]: MRSA Joint fluid: [**2120-1-17**] 12:00; culture showed no growth. WBC RBC Polys Lymphs Monos [**Telephone/Fax (1) 20491**] 81 17 2 [**1-15**] Wound swab (from prior HD cath site): MRSA Urine cx: [**1-15**]: no growth Studies: [**2120-1-15**] Radiology CHEST (PORTABLE AP) Mild cephalization which could reflect mild pulmonary venous congestion. [**2120-1-16**] Cardiovascular ECHO The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 55%) with subtle basal inferior hypokinesis. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2119-11-30**], the LVEF has improved. [**2120-1-17**] Radiology KNEE 2 VIEW PORTABLE RI There are degenerative changes with narrowing of the lateral compartment which causes valgus angulation at the knee. There is spurring at the inferior pole of the patella. There is no joint effusion. There are no focal lytic or blastic lesions. There is some soft tissue swelling. [**2120-1-18**] Radiology CHEST (PORTABLE AP) HD catheter has been removed. There is no evident pneumothorax. If any there is a small right pleural effusion. Cardiac size is top normal. The aorta is tortuous. The chin of the patient obscures the right apex. There is mild vascular congestion. There are no new abnormalities from [**1-15**]. There are low lung volumes. Widened mediastinum and deviation of the trachea towards the right is due to enlarged thyroid gland. Multiple left rib fractures are noted. Brief Hospital Course: BRIEF HOSPITAL COURSE: This is 61 male with history of seizure disorder, nonischemic cardiomyopathy EF 20-30%, ESRD on HD (T/Th/Sat, last session saturday), hepatitis B, CAD, CVA, several admissions in the past for tunnel associated MSSA/CONS/VRE bacteremia, recent admission 1 month ago for Staph epidermidis and CONS line bacteremia given vanco for 2 week course, who presented with MRSA bacteremia likely due to an infected tunnel line. . ACTIVE ISSUES SEPTIC SHOCK: The patient persented with Fever (Tm 104), Leukocytosis (WBC 12), Tachycardia (HR 100s), lactate 2.3, mental status change, and BP 94/44 on low dose Levophed and after 4L, consistent with septic shock. Methicillin resistant staph aureus grew from the [**3-27**] blood culture bottles, swab of the catheter and culture of the tip of the catheter line. Pus was noted surrounding the catheter site which was evaluated by general surgery and no I/D indicated. His urine culture revealed no growth despite large amount of leukocytes. His presenting chest xray was clear and joint fluid analysis of his right knee was not consistent with septic arthritis. A TTE demonstrated no evidence of vegetations. A TEE was deferred given it would not change antibiotic duration. He briefly required pressor support with levophed via a femoral line placed in the ED. He was initially started on linezolid which was discontinued in favor of vancomycin and zosyn in the intensive care unit which were narrowed to vancomycin alone when culture data was available. His HD was line was removed and he HD was deferred for 1 week before a temporary femoral line was placed. Surveillance blood cultures were all negative following his admission cultures on [**2120-1-15**]. Duration of therapy 6 weeks ([**0-0-**]) with vancomycin to be given with HD. A tunneled right subclavian line was placed prior to discharge. . ESRD: T/Th/Sat. Last HD prior to admission was 2 days PTA, on Saturday. HD was deferred for as long as possible, to allow for a line holiday given segnificant bacteremia and sepsis. Patient was monitored on telemetry, electrolytes checked daily, small boluses of fluid given for hypotension. HD cath pulled [**1-15**]. line was replaced on [**1-19**], w/ HD on [**1-20**], now back on prior Tu/Th/Sat schedule. . ALTERED MENTAL STATUS: Patient is significantly altered from baseline. Initially, AMS felt to be due to hypoglycemia. Likely multifactorial-- septic shock, uremia. Per patient??????s family, his mental status has been declining for >1 year. Neuro exam non focal. Patient had one witnessed seizure on the day of HD (5 days into admission), and it was discovered that he had been under dosed on his keppra during the admission. It is possible that he has been having seizures during this time that have been affecting his MS, however, his postictal state is not similar to his mental status throughout the admission. Mental status continued to improved. RPR negative. B12 and folate wnl. TSH wnl. Head CT in [**2119-8-24**] demonstrated expected expected age-related changes. [**Month (only) 116**] consider neurocognitive testing in the outpatient setting. . HYPOGLYCEMIA: Likely [**1-25**] acute infectious state. Can also see in renal failure (because insulin cleared by kidneys), hypopit (pt has known pituitary mass), adrenal insuf (had normal cortisol Am level check on prior admission), insulinoma. Most likely etiology is sepsis. TSH WNL. Patient's blood glucose WNL after 1 day into admission. . SEIZURE DISORDER: Patient is on oxcarbazepine and keppra as an outpatient. Patient was underdosed Keppra during his HD vacation this admission. He experienced a brief localized seizure consisting of 1 minute of facial twitching 5 days into admission. Pt was apparently on the incorrect seizure medication, which was per his prior d/c summary and outside facility list (was ~ [**12-26**] of his appropriate dose [**First Name8 (NamePattern2) **] [**2119-5-24**] neuro note). Pt??????s prior seizures were more generalized, last documented in [**2117**], attributed to medication non-compliance. Neurology was consulted and Pt was restarted on Keppra 500 tid plus 500 mg dose after HD, and oxcarbazepine 300 mg tid plus 300 mg dose after HD. Pt apparently tends to have seizures after HD. Pt states that he typically has a small facial seizure every few months. Pt did not have any further seizures during his hospitalization. . ANION GAP METABOLIC ACID: Likely [**1-25**] lactic acidosis and renal failure. Gap closed as patient restarted on HD 5 days into admission. . CAD/CHF: Mild pulm edema on CXR, however on exam pt appears mildly volume down with some decreased skin turgor. Pt given several liters of IVF in setting of septic shock. He is at risk for pulmonary edema so will trend his O2 requirement and exam closely. HD was restarted 5 days into admission, which will manage volume status. Continued home simvastatin and ASA, and digoxin dosed according to HD. . ANEMIA: HCT baseline 27-30. HCT currently 31, at baseline. Likely multifactorial: anemia [**1-25**] ESRD and anemia of chronic disease. He was given epoeitin in dialysis. . INR 1.3: Likely [**1-25**] poor nutrition, recent antibiotics. No diarrhea. INR trended. He was given vitamin K prior to discharge . HYPOPHOSPHOTEMIA: Phos 1.9 on admission (repleted), lower then expected given renal failure. Pt is sp parathyroidectomy. Differential includes poor nutrition, osetomalacia, diuretics, hyper-parathyropidism, hyperthyroidism, recovery from starvation, steroids. Baseline phos is usualy [**1-27**]. Repeat Phos levels remained WNL. TSH WNL, PTH high. . RIGHT KNEE PAIN. Pt was complaining about knee effusion, which felt warm and was tapped by orthopedic service. Fluid showed 200 WBC, 1625 RBC, 81% Polys 17% Lymphs, no organisms on gram stain, no crystals. Pt was treated with analgesics with improvement in his pain. . TRANSITIONAL ISSUES - vancomycin for 6 weeks (last date [**2120-2-27**]) - consider neurocognitive testing Medications on Admission: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. calcium acetate 667 mg Capsule Sig: Four (4) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA): extra dose to be given on dialysis days after dialysis. 7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO three times a day. 10. oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO three times a week (Tues, Thurs, Sat): extra dose to be given on dialysis days after dialysis. 11. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: do not exceed 4 grams in 24 hours. 14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 15. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 16. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 17. senna 8.6 mg Capsule Sig: One (1) Capsule PO at bedtime: hold for loose stools; pt may refuse. 18. chlorhexidine gluconate 4 % Liquid Sig: One (1) Topical [**12-25**] times each week. 19. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) Topical once a day: APPLY LIBERALLY TO SKIN ON HANDS, FEET 20. vancomycin in D5W 1 gram/200 mL Piggyback Sig: as directed Intravenous HD PROTOCOL (HD Protochol): To be dosed based on trough and given on hemodialysis; continue until [**2119-12-13**]. 21. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours as needed for pain. Discharge Medications: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO once a day. 5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO HD DAYS (). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO ON HD DAY (). 10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 14. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. 15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily). 16. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous with HD for 1 doses: To be dosed based on trough and given on hemodialysis days. (Duration 6 weeks, last day [**2120-2-28**]). Disp:*qS * Refills:*0* 17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: 1. Methicillin Resistant Staphylococcus Aureus Bactermia 2. End Stage Renal Disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 2026**], . You were admitted for a fever and found to have another infection in your blood likely related to your hemodialysis line. Your tunneled catheter was removed and dialysis was stopped for 1 week. A temporary catheter was then placed in your groin before a new tunneled catheter could be placed in your right subclavian site. You will need to continue antibiotics for a total of 6 weeks. . The following changes were made to your medication list: 1. CONTINUE Vancomycin with hemodialysis for 6 weeks (last day [**2120-2-27**]) 2. STOP Ferrous Sulfate 3. HOLD Sevelamer until otherwise directed 4. HOLD Calcium acetate until otherwise directed . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please follow-up with the physicians at your facility and your outpatient nephrologists.

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38981, 39073

24072, 24128

36244, 37761

37895, 37981

34137, 36221

38187, 38958

24168, 24861

22331, 22750

19803, 19816

20002, 22312

24901, 28098

38017, 38163

22772, 23745

23761, 24056

75,333

140,692

54473

Discharge summary

report

Admission Date: [**2180-8-5**] Discharge Date: [**2180-8-9**] Service: NEUROSURGERY Allergies: Aspirin Attending:[**First Name3 (LF) 1271**] Chief Complaint: unresponsiveness Major Surgical or Invasive Procedure: none History of Present Illness: This is a [**Age over 90 **] year old right handed man with a history of colon and prostate cancer who was brought to ED by EMS after wife found him unresponsive and actively seizing. His wife called the EMS who came by and transported him to [**Hospital1 18**]. On the way to the hospital, the patient seized again and was given ativan which stopped the seizure. In the ED, he was intubated for airway protection and started on propofol. He also had a CT/brain that showed subdural hemorrhage. His wife reported that her husband had had two falls in the past week. None of these falls were associated with any loss of consciousness or headaches. Past Medical History: Atrial fibrillation hypertension gout anemia [**1-5**] MDS vs. side effect of lupron status post colon cancer resection in [**2165**] prostate cancer treated with Lupron, s/p radiation 10 years ago neuropathy and gait disturbance [**1-5**] Lupron OSA treated with CPAP osteoporosis w/ vit D deficiency and association w/ Lupron cervical and thoracic spinal stenosis glucose intolerance tinnitus urinary incontinence Social History: The patient is a retired architect. He states that he was a runner, up until approximately four years ago when he began to have trouble with his gait. He states that he quit smoking approximately 25 years ago after several years of smoking a pipe. He denies any alcohol use. He lives at home with his wife. [**Name (NI) **] has two sons and a daughter. [**Name (NI) **] lives in [**Location (un) 55**]. He states that he eats a varied diet including weekly red meat, poultry, and vegetables. Family History: Mother with CAD. Physical Exam: On Admission: T98.5 BP 102/72 P74 R18. Patient is is intubated and examined off propofol. He does not follow commands. His pupils are pin point and sluggish reactive. Corneal reflex a gag reflex are present. He is able to grimace when a noxious stimulus is applied.He doesnot purposefully move any extremities. His reflexes are +1 and he has an upgoing toe on the left leg and a downgoing toe on the right leg. General examination. His skin has full turgor. HEENT is unremarkable. Neck is supple and there is no bruit. Cardiac examination reveals regular rate and rhythms. His lungs are clear. His abdomen is soft. His extremities do not show clubbing, cyanosis,or edema. At time of discharge: He was awake and oriented x 3. He had no cranial nerve deficit. He had mild diffuse weakness of the LUE to 5- with some shoulder pain. Pertinent Results: [**8-5**] CT Head- IMPRESSION: Large right cerebral subdural hematoma measuring 1.3 cm at its greatest depth. Minimal associated focal and right lateral ventricle effacement with no significant shift of midline structures. No fracture identified. [**8-5**] CT C-spine- IMPRESSION: No fracture or acute malalignment. Multilevel degenerative changes. Endotracheal tube identified with tip traveling out of view. [**8-6**] Left Shoulder Xray- FINDINGS: Three views of the left shoulder demonstrate some minimal degenerative changes with small osteophytes. The alignment is normal and there is no fracture. [**2180-8-7**]: Shoulder X-rays Brief Hospital Course: Mr. [**Known lastname **] was admitted to the ICU for close neurological observation. His INR was noted to be sub therapeutic therefore did not require reversal. Later we discovered that he was not on Coumadin but he was on Plavix per his Cardiologist. He remained stable and CT was stable on [**8-6**] so he was cleared for extubation. It was noted that the patient has sleep apnea but he stated that he does not wear his CPAP at home, but we did provide that for him at [**Hospital1 **]. He complained of left shoulder pain with range of motion therefore xrays were obtained, but were negative for fracture. Pt was also noted to have dysphagia per nursing so he was kept NPO and a swallow evaluation was ordered. On [**8-7**] he was cleared for transfer to the floor. His dilantin level was sub therapeutic so a bolus dose was given. PT and OT were also consulted for assistance with discharge planning and they felt he required rehab. On [**8-8**] he was seen by Sp/Swallow team again and they cleared him for the following diet: PO diet: regular solids, nectar thick liquids, PO meds: whole with puree or nectar, TID oral care, assist with meal set up to maintain standard aspiration precautions. Dr. [**Last Name (STitle) **] saw him on [**8-8**] for some ST segment changes on EKG. Troponin was low on admission. His BP was stable and he has long standing Afib. He felt that he was cleared for rehab and recommended a helmet as he has had many falls. He discussed this with our team and his wife. The wife was in favor of the helmet for protection as well. He was measured for this prior to transfer to [**Hospital 100**] rehab on [**8-8**]. Medications on Admission: There have been varying med lists provided to the team: The wife provided [**Name2 (NI) 111481**] from his med list that he keeps in his wallet. He also varified some of his medications. Not all vitamins were given due to interactions with Dilantin. He specifically denied use of Vesicare and detrol. ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth weekly in the AM with 6-8oz of plain water, do not eat, drink or lie down for 30 mins ALLOPURINOL - (Prescribed by Other Provider) - 300 mg Tablet - 1 Tablet(s) by mouth daily EPINEPHRINE [EPIPEN] - 0.3 mg/0.3 mL (1:1,000) Pen Injector - As directed ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule - 1 Capsule(s) by mouth weekly LANSOPRAZOLE - 15 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day - No Substitution LEUPROLIDE [LUPRON] - (Prescribed by Other Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] - Dosage uncertain METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg Tablet Extended Release 24 hr - 1.5 Tablet(s) by mouth daily SOLIFENACIN [VESICARE] - 5 mg Tablet - 1 Tablet(s) by mouth once a day TOLTERODINE [DETROL] - 1 mg Tablet - [**12-5**] Tablet(s) by mouth once a day Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) 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. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever: max 4g/24 hrs. 4. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 6. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. alendronate 70 mg Tablet Sig: One (1) Tablet PO 1X/WEEK (MO). 10. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO once a day. 11. coenzyme Q10 200 mg Capsule Sig: One (1) Capsule PO once a day. 12. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Acute subdural hematoma / right side Seizure Dysphagia Atrial Fibrillation Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: General 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. ?????? You may not resume Plavix until seen by us in follow up. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. There were varying medications lists in our records. We spoke to you and your wife read us the med list you keep in your wallet. We have used this list to reconcile your medications at the time of discharge. We did not give you some of your vitamins due to interactions with Dilantin. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. You should see Dr. [**Last Name (STitle) **] within the month. Please call his office for this appointment:([**Telephone/Fax (1) 32215**] Office Location: One [**Location (un) **] Place, [**Apartment Address(1) 19746**] These appointments were in our system for you. Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2180-8-14**] 10:30 Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 133**] Date/Time:[**2180-12-11**] 10:00 [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2180-8-9**]

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icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

7400, 7466

3432, 5083

234, 241

7585, 7585

2770, 3409

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178, 196

269, 918

1933, 2751

7600, 7746

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1375, 1870

7,629

111,321

20356

Discharge summary

report

Admission Date: [**2119-4-19**] Discharge Date: [**2119-4-23**] Service: CARDIOTHORACIC Allergies: Amoxicillin / Tegretol / Dilantin / Heparin Agents Attending:[**First Name3 (LF) 281**] Chief Complaint: severe tracheal stenosis Major Surgical or Invasive Procedure: bronchoscopy, debridement of granulation tissue, placement of new tracheal stent History of Present Illness: This is an 83M who is well known to the IP service who comes in with severe TBM and tracheal stenosis for a bronch tomorrow. He was initially intubated on [**2115**] after a stroke. He had difficulty weaning from the vent and underwent a tracheostomy on [**3-28**]. He subsequently had a T-tube placed and then removed for granulation tissue. He then had a Y-stent placed and then removed and replaced. Most recently, he was admitted to an OSH [**2119-4-8**] for LLL PNA and transferred here today. He has been on Levaquin since [**4-8**], Flagyl since [**4-8**], and Aztreonam since [**4-11**] for Pseudomonas and Stenotrophomonas sensitive to Levo and Aztreonam. His antibiotics were discontinued prior to transfer. He has been on trach mask during the day and on the vent at night at 30%, 400x 12, PEEP 5, having copious secretions. Past Medical History: 1) Tracheomalacia, status post stent x 2 with failure secondary to stent migration. Status post trach revision [**3-28**]. Status post T-tube removal on [**2115-6-26**]. 2) Status post stroke in [**2109**] with TIA; right upper extremity weakness resulting. 3) Hypertension. 4) Seizure disorder. 5) History of MRSA. 6) Hemorrhoids. 7) Arthritis. 8) Depression. 9) History of CHF. 10) CRI Social History: Married and lives at home with wife with nursing care. Remote hx of smoking, duration unknown. Rare Etoh. Family History: NC Physical Exam: Admission: T 97.8, P 83, BP 130/67, RR 16, O2 96% on AC 40%, 400x 12, 5 Gen- NAD heart- RRR lungs- b/l coarse breath sounds abd- PEG without signs of infection, soft, NT/ND, BS normal ext- 1+ b/l edema Discharge: No change except improved breath sounds, less coarse and no upper airway stridor Pertinent Results: [**2119-4-19**] 10:31PM WBC-12.1*# RBC-4.30*# HGB-12.9* HCT-38.8*# MCV-90 MCH-30.0 MCHC-33.2 RDW-15.2 [**2119-4-19**] 10:31PM GLUCOSE-105 UREA N-25* CREAT-1.1 SODIUM-140 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-30 ANION GAP-13 [**2119-4-19**] 10:31PM CALCIUM-8.6 PHOSPHATE-2.7 MAGNESIUM-1.8 Brief Hospital Course: Mr. [**Known lastname 34384**] was admitted to the TICU under the care of the Interventional Pulmonary Team on [**2119-4-19**]. He had a CT trachea done which showed TBM, with the stent in place but with moderate to severe malacia distal to the stent in the main bronchi. Compared to his previous CT, the stent demonstrated decreased amount of stenosis. The next day he underwent bronchoscopy with IP, and had some granulation tissue removed and sent to pathology. The stent was then removed and replaced with a longer stent. He had some mild post procedure bleeding, which was evaluated with bronchoscopy that showed a clot behind the stent. This was managed conservatively with close observation (Hct remained stable, no transfusions were required), and he had no more episodes of bleeding. He was rebronched on PPD#1 [**4-21**]. He continued to do well without any issues. By PPD#2 and 3, he was weaned to trach mask for most of the day, with no respiratory issues. On PPD#3, he is afebrile, AVSS, tolerating tube feeds at goal, and he will be discharged to home with trach mask during the day, ventilator at night, with f/u with Dr. [**Last Name (STitle) **] in [**7-2**] weeks. Medications on Admission: insulin drip (2.5/h), KCl 20', simethicone 80''', HCTZ 12.5', lactinex QD, phenobarb 240 HS, nexium 40', duonebs QID, solu-medrol 80', nystatin s/s, versed PRN, fentanyl PRN Discharge Medications: 1. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Phenobarbital 20 mg/5 mL Elixir Sig: Two [**Age over 90 8821**]y (240) ml PO HS (at bedtime). 4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Albuterol 90 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed. 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation Q4H (every 4 hours). 10. Prednisone 20 mg Tablet Sig: 2 tablets x3 days, then 1 tablet x3 days, then stop Tablets PO DAILY (Daily) for 6 days: Take 2 tablets on [**4-9**], [**4-25**]. Take 1 tablet on [**5-11**], and [**4-28**], then stop prednisone. Disp:*9 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: tracheobronchial malacia Discharge Condition: good Discharge Instructions: Please call Dr.[**Name (NI) 14680**] office or go to the Emergency Room if you have any shortness of breath, bleeding, fevers > 101, nausea, vomiting, or any other questions or concerns. Continue your Prednisone taper as instructed. Followup Instructions: please call Dr.[**Name (NI) 14680**] office at [**Telephone/Fax (1) 3020**] to schedule a follow-up appointment for 6-8 weeks. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]

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icd9cm

[ [ [] ] ]

[ "96.71", "97.23", "33.21", "96.6", "96.56", "33.24", "31.93", "32.01" ]

icd9pcs

[ [ [] ] ]

4978, 4997

2446, 3638

288, 370

5066, 5073

2128, 2423

5355, 5576

1794, 1798

3863, 4955

5018, 5045

3664, 3840

5097, 5332

1813, 2109

224, 250

398, 1242

1264, 1654

1670, 1778

47,953

137,390

40416

Discharge summary

report

Admission Date: [**2177-7-11**] Discharge Date: [**2177-7-14**] Date of Birth: [**2102-12-22**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 88582**] Chief Complaint: Found unresponsive Major Surgical or Invasive Procedure: Intubated/Extubated History of Present Illness: 74 yo male h/o metastatic gastric ca, found down by family at home, unresponsive. He was was in his usual state of alertness last night, last seen by his daughter in the late evening. Typically, he interacts with his family members without significant difficulty, and is oriented, appropriate, and conversant. He has been generally bedbound, but can walk short distances, including to the bathroom and back. Early this morning, his daughter noticed the bathroom light was on for several minutes, and went to go check on her father. She found him down on the ground with his eyes open, but not making eye contact or tracking in any direction. He did not appear to be in pain. He was not moving, aside from a small movement of his left arm when his daughter called out his name. She called 911, and the patient was intubated in the field. EMS records indicate that BP only able to measured once, at 40/P; HR at that time was 40. FS was 126 . In the ED, initial vs were: 96.0 63 152/131 100% on vent. He had a large volume of old food suctioned. He had been bradycardic with normal pressures during his ED stay. FSBS on arrival was 7, with repeat confirmed at 4. Patient was given D50 x 2 amps with repeat FSBS at 165. EKG showed sinus bradycardia and lateral T wave flattening/inversion, but no STEMI. Bedside trauma u/s revealed no tamponade, no free fluid in the abdomen. A portable CXR was done to confirm ETT placement. He began to wake up after glucose administration so he was given 100 mg fentanyl and 2.5 mg versed for sedation at 0400 given his ETT. He was given 1+ liters of warmed normal saline. CT head was unremarkable. CT torso revealed a lung mass, left pleural effusion, no PE, no PTX; likely liver metastases. His left hepatic lobe was hypoenhancing compared with the right lobe, suggestive of occlusive left portal venous thrombosis. He also had intestinal/adrenal findings suggestive of hypotension, though there was no free air or fluid. The family arrived and confirmed full code status. Vitals prior to transfer were: 33.4 68 137/92 14 100% on vent settings of: peak 16 PEEP 5 TV 400 FiO2 100% rate 14. Most recent fingerstick was 143. . Per medical records, case management call to patient's daughter [**Name (NI) 88583**] and to hospice [**First Name9 (NamePattern2) 269**] [**Name (NI) **] reveals patient is newly bedbound and significantly declining, requiring 24 hour care. Similar note from two weeks prior indicates that patient is already declining, losing weight, and taking oxycodone for worsening upper chest wall pain. His pain is felt to be due to an expansile lytic soft tissue mass in the anterolateral third rib considered likely to be the cause of the patient's chest pain. He also has more recently found large left upper lobe mass invading the mediastinum with satellite nodules consistent with malignancy as well as an enlarging right upper lobe nodule. . On the floor, the patient is intubated and unresponsive, without active sedation. Past Medical History: -Gastric cancer since [**2169**] -s/p partial gastrectomy in [**2170**] for T3b N2 disease -s/p chemo and XRT (total 4500 cGy) in [**2170**] -lung mets and pancreatic tail mass discovered [**2174**] -lung nodule biopsied on [**2176-1-3**]. Pathology was consistent with non-small cell carcinoma with CK7 positive, compatible with several primary sites including pulmonary, pancreatic, and upper GI with morphologic features not typical for a lung primary [**Hospital **] hospice since [**2-/2176**] but has remained full code -Gout -Diverticulosis -PUD -H. pylori infection -Hypertension -Anemia -Cardiac arrhythmia -Erectile dysfunction -Knee surgery Social History: The patient began smoking at age 19 and averaged two packs per day subsequently. He has cut down at this point to a few cigarettes per day. He has a history of drinking heavily, and currently drinks "one nip" per day. Family History: No family history of malignancy. Physical Exam: Admission Exam: Vitals: 96.1, 79, 158/92, 16 Vent: A/C, Vt 450 cc, 14 bpm, 100% FiO2, PEEP 5 General: Cachectic, unresponsive to voice, sternal rub, or noxious stimuli HEENT: Face is symmetric. Sclera anicteric, ETT in place, dry MM, pupils 2-3 mm bilaterally, without response to light Neck: head rotated to the right, JVP not elevated, no LAD Lungs: course sounds at bases bilaterally (L>R), no wheeze CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Neuro: Pt unresponsive as above. No spontaneous movement of extremities, and no movement to verbal command or nail bed or sternal pressure. Pupils are fixed at 2-3 mm bilaterally, unresponsive to light. Ext: thin, warm, no edema, 2+ pulses Exam on transfer: VS: 35.8 ??????C (96.5 ??????F) 60 148/87 20 92%/2.5LxNC General: Severely cachectic, no distress, AOx3 HEENT: dry MM, pupils 2-3 mm bilaterally RRLA, EOMI, facial lipodystrophy Neck: thin, JVP flat, no LAD Lungs: CTAB, some rales no wheeze CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: scaphoid soft, non-tender, non-distended, bowel sounds present GU: foley in place Neuro: Spontaneously moves all extremities, answers questions appropriately & follows commands, CNII-XII intact, strength and reflexes not assessed Ext: thin, warm, no edema, 2+ pulses Pertinent Results: Labs on admission: [**2177-7-11**] 04:30PM GLUCOSE-107* UREA N-38* CREAT-1.0 SODIUM-142 POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-22 ANION GAP-18 [**2177-7-11**] 04:30PM ALT(SGPT)-163* AST(SGOT)-320* ALK PHOS-1427* TOT BILI-4.9* [**2177-7-11**] 04:30PM CALCIUM-7.8* PHOSPHATE-4.5 MAGNESIUM-1.8 [**2177-7-11**] 04:30PM WBC-12.2* RBC-3.80*# HGB-10.6*# HCT-33.0*# MCV-87 MCH-27.8 MCHC-32.1 RDW-20.7* [**2177-7-11**] 04:30PM PT-19.3* PTT-54.0* INR(PT)-1.7* Imaging: CT head [**7-11**] 1. No hemorrhage or other acute intracranial process. 2. Global parenchymal volume loss and white matter changes compatible with sequelae of chronic small vessel ischemia. 3. Rotation of C1 on C2, which may be positional, but clinical correlation is advised. CTA and ct a/p [**7-11**] 1. No evidence of pulmonary embolism or acute aortic syndrome. The aorta is atherosclerotic, and there is extensive mural thrombus in the descending thoracic aorta. 2. Multiple lung masses, the largest abutting left hila. Associated mediastinal and left hilar adenopathy and moderate left pleural effusion are also identified 3. Moderately severe emphysema. No evidence of superimposed pneumonia or aspiration. 4. Heterogeneous perfusion of the liver, likely reflecting presence of portal venous thrombus, which is partially occlusive in the main portal vein and occlusive within the left portal venous system. 5. Multiple hepatic hypodensities, concerning for metastases. 6. Findings compatible with CT hypoperfusion complex, including hyperenhancement of the bowel wall, adrenal glands, and kidneys. 7. Left lateral third rib lytic lesion, compatible with metastasis. 8. Marked cachexia. Brief Hospital Course: #Unresponsiveness: Patient was awake and intubated on arrival to the ICU, following dextrose infusion in the ED and bolus sedation with 100 mg fentanyl & 1 mg midazolam. Primary process thought to be severe hypoglycemia, as pt had two readings of BS <10 prior to ICU admission. Ruled out other diagnoses as follows: No acute intracerebral process on head CT. CT chest/abdomen revealed only disseminated metastasis involving the L perihilar region and liver. Pt may have had element of altered mental status from infection (aspiration pneumonia vs intrabdominal process), but WBC count was only minimally elevated and he was afebrile, asymptomatic, and responsive on IV fluids with dextrose. #Hypoglycemia. Pt eating at home per report, but given presentation and severe cachexia it appeas that he is unable to intake/absorb sufficient nutrition to maintain his body's metabolic needs. Undigested food was suctioned from his stomach in the ED. In addition, low muscle glyogen stores and a portal venous thrombus noted on CT likely further impair pt's ability to maintain BS via gluconeogenesis and glycogen mobilization. In the ICU he was eating, received q2H fingersticks, and D5 boluses as needed. Fingersticks from mid40s->100. Pt was asymptomatic & mentating appropriately even with fingersticks below 50, so severe hypoglycemia thought to be chronic. # Respiratory failure: He was initially intubated in the ED to protect his airway. Has known pulmonary involvement from malignancy, but does not require home oxygen. pH on admission labs was 7.39, so unlikely to be severely hypercarbic. Successfully extubated in the ICU on the morning after admission, and remained comfortable with O2sats >90 on supplemental oxygen. # PV thrombus: Noted on CT scan. No signs of symptoms of abdominal pain, though patient globally unresponsive. LFT abnormalities are as noted in HPI without prior labs available for comparison. Did not start anticoagulation given general instability, low hematocrit, possible low grade DIC on admission labs. # Renal insufficiency: Recent baseline renal function unknown. Elevated BUN and creatinine of 1.0 in cachectic patient likely indicates reduced GFR. Pt dry on exam, suspect perfusion-related kidney injury. # Metastatic gastric adenocarcinoma: CT torso now with likely involvement of liver, lung, pancreas, and chest wall. No therapeutic options, no intervention pursued. # Goals of care: Daughter [**Name (NI) 88583**] is health care proxy. Updated family on evening of admission, and held family meeting prior to floor transfer. Patient previously said he wanted "everything done." HCP changed his status to DNR/DNI at time of ICU admission. Code status was changed to CMO by HCP on evening of [**7-12**] and the patient was transferred to the floor where CMO level care was provided. On floor, discussed end of life options. Decision made to transition to skilled nursing with palliative care focus. Confirmed with daughter, patient is "Do not rehospitalize." For pain, is on nexium and PRN oxycodone. In hospital, patient requiring 1-2 doses of oxycodone 5mg in a day. On this dose, pain noted to be well controlled per patient and family. Medications on Admission: -Nexium 40mg daily -Oxycodone 5mg q4-6h prn pain -Naproxen Discharge Medications: 1. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain . 3. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: sherrillhouse Discharge Diagnosis: Primary Diagnosis : Hypoglycemia Secondary Diagnosis : Gastric cancer Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: It was a pleasure to care for you as your doctor. . You were brought to the hospital becuase of trouble breathing and a low blood sugar. After a brief stay in the ICU you were transferred to the regular medical floor. You will be discharged to home hospice where your comfort will be the main objective. . Take nexium twice a day and oxycodone as needed for pain. Followup Instructions: You will be followed by a doctor at your inpatient facility.

[ "197.8", "285.9", "V12.71", "V10.09", "V87.41", "274.9", "799.4", "251.1", "562.10", "452", "V49.86", "305.1", "197.0", "V15.3", "518.81", "607.84" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

11072, 11112

7469, 10654

293, 314

11227, 11227

5779, 5784

11750, 11814

4273, 4307

10764, 11049

11133, 11206

10680, 10741

11361, 11727

4322, 5760

235, 255

342, 3333

5799, 7446

11242, 11337

3355, 4019

4035, 4257

26,936

195,617

889

Discharge summary

report

Admission Date: [**2166-12-18**] Discharge Date: [**2166-12-21**] Date of Birth: [**2095-10-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4654**] Chief Complaint: DKA, weakness Major Surgical or Invasive Procedure: None History of Present Illness: 71yoM with a history of DMII (on home Metformin), dilated cardiomyopathy (unclear etiology), EF<20%, ICD, Obesity and OSA, per report since friday the patient has taken poor care of himself, eating poorly including juice, frappes and [**Last Name (un) 6058**]. The pt reports he drove to and from [**State 1727**] earlier today to buy a tv and close his summer home, and felt increasingly weak when he returned home. He also endorsed nausea without emesis. His friend called EMS who brought him to the ED. No fevers, chills but does endorse some recent weightloss (although he cannot quantify). No diarrea, melena or BRBPR. He has baseline orthopnea requiring 2 pillows. He states his weakness was overall fatigue and not focal in nature. The pt states he does not see a physician for his diabetes and does not check his sugars at home. . In the ED his vitals were, 98.4, 158/82 76, 16, 95% on RA, without signs of CHF. The BS 894, with an AG 16-17 and trace ketones. He received, 1L NS, and 10units IV insulin x2 and subsequently started on an insulin drip. He also received Zofran. . ROS: No edema, worsening cough, urinary frequency (goes 3-4x per night), dysuria, rash, ulcerations. Past Medical History: HTN DM II Multiple Arrhythmias ([**Last Name (LF) 6059**], [**First Name3 (LF) **], AF) S/P dual chamber pm/ICD Obesity OSA Social History: Rare ETOH. Quit tobacco 12 years ago. The patient lives with girlfriend, and cats. Was working in a steel mill in [**State 4260**] from [**Month (only) 958**] to [**2164-8-11**]. Close to son. Family History: Noncontributory Physical Exam: Vitals: T: 98.6 BP: 110/47 HR 88 RR 16 O2Sat 97% GEN: Obese, slightly lethargic but answering questions appropriately. NAD HEENT: PERRL, EOMI, sclera anicteric, no epistaxis or rhinorrhea, Dry MM NECK: No appreciable JVD, cervical lymphadenopathy, trachea midline COR: Distant HS, S1 S2 with occassional irregular beats no M/G/R appreciated radial pulses +2 PULM: Lungs CTAB anteriorly, no W/R/R ABD: Soft, Obese, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: + Asterxis, AOx3. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: On admission: [**2166-12-18**] 04:45PM BLOOD WBC-8.4 RBC-5.12 Hgb-15.1 Hct-44.4 MCV-87 MCH-29.6 MCHC-34.1 RDW-12.0 Plt Ct-230 [**2166-12-18**] 04:45PM BLOOD Neuts-82.3* Lymphs-11.4* Monos-5.5 Eos-0.4 Baso-0.3 [**2166-12-19**] 01:30AM BLOOD PT-13.0 PTT-24.7 INR(PT)-1.1 [**2166-12-18**] 04:45PM BLOOD Glucose-894* UreaN-45* Creat-2.1* Na-130* K-4.6 Cl-86* HCO3-28 AnGap-21* [**2166-12-18**] 10:51PM BLOOD ALT-37 AST-22 LD(LDH)-236 AlkPhos-75 TotBili-0.5 [**2166-12-18**] 04:45PM BLOOD CK(CPK)-49 [**2166-12-18**] 04:45PM BLOOD cTropnT-0.02* [**2166-12-19**] 09:20AM BLOOD CK-MB-4 cTropnT-<0.01 [**2166-12-18**] 10:51PM BLOOD Calcium-9.3 Phos-1.9*# Mg-2.1 [**2166-12-18**] CXR: IMPRESSION: No evidence of volume overload or pneumonia. Brief Hospital Course: 71yoM with a history of DMII (on home Metformin prior), dilated cardiomyopathy (unclear etiology), EF<20%, ICD, Obesity and OSA, presenting [**12-19**] after stating not taking good care of self with DKA. His BS 894, with an AG 16-17 and trace ketones. He received, 1L NS, and 10units IV insulin x2 and subsequently started on an insulin drip. Pt admitted to ICU - tx with insulin gtt - [**Last Name (un) 387**] consulted - gap closed/gtt d/c, and lantus started at 30units. Pt transferred to floor, BS up in upper 200s, lantus further increased to at the end to 40unit qpm (prior to dinner) by [**Last Name (un) **] at time of d/c. Metformin d/c. Pt with issues as below for f/u by PCP: # DM II, uncontrolled, with complications/resolving DKA- Likely secondary to extremely poor dietary compliance. Infection appears less likley given pt afebrile, without leukocytosis or focal symptoms. s/p insulin gtt with closed gap. Greatly appreciate [**Last Name (un) **] recs and will increase glargine 40 U and SSI. Will d/c on lantus, pt to keep BS log - to f/u with [**Hospital **] clinic this week for further titration, and d/c with humolog SSI as used here and reviewed by [**Last Name (un) **]. Arranged for glucometer and strips prior to d/[**Name Initial (MD) **] with RN on floor providing education on use and for insulin injections. Pt recieved pm dose of lantus prior to d/c [**12-21**] - to fill Rx (after working out Rx drug coverage with insurance company monday morning). - BCx NGTD - PCP and [**Name9 (PRE) **] to f/u - U/A negative - arranged for home VNA tomorrow for education and DM training -nutrition consulted for DM diet education - increase lantus to 40u qpm (prior to dinner) # Supraventricular tachycardia/and episodes of v-tach/Constipation - seen briefly on ekg - pt [**Name (NI) 6060**] but noted sig constipation. Occured [**12-20**]. Still with poorly controlled DM - needed to r/o ischemia (monitored on tele, CE were negx2). Note prior history and sig CM in past, has ICD. Pt [**Name (NI) 6060**] whole time, EKG as above, CE neg, on tele resolved to rate 60-70s soon after BM and stable overnight. -cont home stool softners -****given h/o repeat event, low EF, PCP to strongly consider placing pt on anti-coagulation. -increased metoprolol to 125mg [**Hospital1 **] (unit changed from XL, further titrated - will cont for now - PCP/cardiology to change back in near future given noted sCHF) Leukocytosis: - CXR negative, u/A negative, blood cultures ngtd - resolved this [**12-20**], stable at time of d/c # ARF: Cr 2.1 from 1.5 at baseline. Presumed pre-renal given hyperosmolar state and improvement with IVF. - Continue to encourage agressive po intake - ace-i not held prior - held from [**12-20**], will also give more room for BB - d/c off lasix/aldactone/ace-i - PCP to [**Name Initial (PRE) **]/u in next 2-3 days to reassess and re-start agents as indicated # Chronic Systolic CHF / DCM: Pt with EF <20%. On Lasix, Aldactone and ACEi as outpatient. Has ICD in place. - Holding Lasix, Aldactone and ACEi given ARF and total body fluid deplete. Euvolemic at time of d/c - PCP to [**Name Initial (PRE) **]/u closely - pt given CHF instructions. -BB # Hyperlipidemia - cont statin. # Full Code # Disp: can d/c today with DM teaching from our RN staff - has VNA set up - to see both PCP and [**Name9 (PRE) **] clinic this week as above - and cardiologist in near future to consider long-term anti-coagulation. Medications on Admission: Albuterol 2 puffs PO q4-6hrs PRN Lasix 80 [**Hospital1 **] Lipitor 80 mg daily Lisinopril 40 mg daily Glucophage 1000 mg twice a day Toprol-XL 200 mg daily Spironolactone 25 mg daily Aspirin 325 mg daily Coenzyme Q Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Metoprolol Tartrate 25 mg Tablet Sig: Five (5) Tablet PO BID (2 times a day). Disp:*300 Tablet(s)* Refills:*0* 7. Insulin Syringes (Disposable) 1 mL Syringe Sig: One (1) Miscellaneous qac, qhs. Disp:*120 120* Refills:*2* 8. Lantus 100 unit/mL Solution Sig: One (1) 40 Subcutaneous prior to dinner. Disp:*qs qs* Refills:*2* 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection qac, qhs: sliding scale as sheet provided to you in hospital by RN. Disp:*qs qs* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis: DKA/Diabetes type II (now insulin dependent) Secondary Diagnosis: Supreventricular tachycardia/A-fib Acute Renal Failure CHF Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please take 1 furesamide tab (40mg) if you gain more than 2 lbs. F/U with your PCP [**Last Name (NamePattern4) **] [**3-16**] days to re-assess to see if its safe to re-start your lasix. Please adhere to your insulin regime prescribed, home VNA services will come tomorrow to further help and assure you're comfortable. Please call your PCP or return to ED if you feel lightheaded/dizzy with diaphoresis and not improved with drinking juice as your blood sugars may be low from insulin. PLEASE NOTE FOLLOWING MEDICATION CHANGES: WILL GIVE YOU A NEW SCRIPT FOR YOUR CHANGED DOSE OF METOPROLOL STOP YOUR METFORMIN AND JUST USE THE INSULIN HOLD YOUR LISINOPRIL, LASIX, AND ALDACTONE TILL EVALUATED BY YOUR PCP THIS WEEK. Followup Instructions: 1. F/U with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 132**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 133**] in [**3-16**] days, call tomorrow morning first thing to make appointment. 2. Call [**Hospital **] clinic to make a f/u appointment this week some time. 3. Either contact your cardiologist or have your PCP facilitate making [**Name Initial (PRE) **] f/u appointment in the next 2-3 weeks to discuss your periodic fast irregular heart rate. [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**] Completed by:[**2166-12-21**]

[ "V15.81", "250.12", "278.00", "276.1", "428.0", "564.00", "427.31", "584.9", "V15.82", "403.90", "427.89", "428.22", "327.23", "585.9", "425.4", "V45.02", "V58.67" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8427, 8484

3466, 6965

332, 338

8678, 8687

2707, 2707

9567, 10193

1932, 1949

7231, 8404

8505, 8505

6991, 7208

8711, 9334

1964, 2688

9354, 9544

279, 294

366, 1555

8596, 8657

8524, 8575

2721, 3443

1577, 1703

1719, 1916

3,670

123,745

1916

Discharge summary

report

Admission Date: [**2109-3-14**] Discharge Date: [**2109-3-19**] Date of Birth: [**2063-8-3**] Sex: M Service: SURGERY Allergies: Penicillins / Sulfa (Sulfonamides) / Fentanyl / Morphine Attending:[**First Name3 (LF) 1481**] Chief Complaint: s/p Assault Major Surgical or Invasive Procedure: None History of Present Illness: 45 yo male s/p assault after reportedly initiating an attack on the other individiual. He was intubated for combativeness and transported to [**Hospital1 18**] for continued trauma care. Past Medical History: Hepatitis C Anxiety Family History: Noncontributory Pertinent Results: [**2109-3-14**] 10:49PM TYPE-ART PO2-87 PCO2-52* PH-7.31* TOTAL CO2-27 BASE XS-0 INTUBATED-NOT INTUBA [**2109-3-14**] 01:53PM GLUCOSE-102 UREA N-13 CREAT-0.8 SODIUM-142 POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-24 ANION GAP-11 [**2109-3-14**] 01:53PM ALT(SGPT)-75* AST(SGOT)-107* ALK PHOS-146* AMYLASE-93 TOT BILI-3.1* [**2109-3-14**] 01:53PM LIPASE-19 [**2109-3-14**] 01:53PM ALBUMIN-3.2* CALCIUM-7.7* PHOSPHATE-3.3 MAGNESIUM-1.9 [**2109-3-14**] 01:53PM WBC-4.5 RBC-3.67* HGB-12.3* HCT-36.1* MCV-98 MCH-33.4* MCHC-34.0 RDW-14.7 [**2109-3-14**] 01:53PM PLT COUNT-43* [**2109-3-14**] 01:35AM PT-16.3* PTT-29.1 INR(PT)-1.5* [**2109-3-14**] 01:35AM FIBRINOGE-110* CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2109-3-14**] 1:45 AM CT SINUS/MANDIBLE/MAXILLOFACIA Reason: r/o fx [**Hospital 93**] MEDICAL CONDITION: 45 year old man with assault REASON FOR THIS EXAMINATION: r/o fx CONTRAINDICATIONS for IV CONTRAST: None. The additional finding of a minimally displaced left zygomatic arch fracture, prompting report revision, was communicated to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10664**], [**First Name3 (LF) **] Quality Assurance Nurse, via her voice mail on [**2109-3-15**] at 11:30AM. INDICATION: Status post assault, rule out fracture. MDCT acquired axial images of the paranasal sinuses and facial bones were obtained with coronal reformatted images. FINDINGS: There is a fracture of the posterior wall of the left maxillary sinus, a left nasal bone fracture, and a minimally displaced fracture of the left lateral orbital wall. There also appears to be a slightly displaced fracture of the left inferior orbital wall posteriorly without entrapment of the extraocular muscles. There is layering hemorrhage in the left maxillary sinus. There is overlying soft tissue swelling. No other fractures are seen. IMPRESSION: Multiple facial fractures as above. ADDENDUM: There is a minimally displaced fracture of the left zygomatic arch. CT HEAD W/O CONTRAST [**2109-3-14**] 1:44 AM CT HEAD W/O CONTRAST Reason: r/o bleed [**Hospital 93**] MEDICAL CONDITION: 45 year old man with assault REASON FOR THIS EXAMINATION: r/o bleed CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Status post assault, rule out bleed. TECHNIQUE: MDCT acquired images of the head were obtained without contrast. FINDINGS: There is no evidence of acute intra- or extra-axial hemorrhage. [**Doctor Last Name **]-white matter differentiation appears preserved. There is no hydrocephalus or shift of normally midline structures. Basal cisterns appear patent. Bone windows reveal fractures of the left nasal bone, the posterior wall of the left maxillary sinus, and a minimally displaced fracture of the lateral left orbital wall. A large air fluid level is noted in the left maxillary sinus. IMPRESSION: 1. No evidence of acute intracranial hemorrhage. 2. Multiple facial fractures as above. Please also refer to the report from the CT sinus maxillofacial bones study that is dictated separately. CHEST (PA & LAT) [**2109-3-15**] 3:42 PM CHEST (PA & LAT) Reason: eval pna, effusion, edema, ptx [**Hospital 93**] MEDICAL CONDITION: 45 year old man with fever, cough, desats REASON FOR THIS EXAMINATION: eval pna, effusion, edema, ptx CHEST, TWO VIEWS. INDICATION: 45-year-old man with fever and cough, evaluate for pneumonia, effusion, edema. CHEST, TWO VIEWS: Comparison is made to prior study from earlier the same day. The heart is normal in size. The mediastinal and hilar contours are unremarkable. The pulmonary vasculature is normal. There is platelike atelectases in the right and left lower lobe. This has improved in comparison to the prior study from 5:07 a.m. IMPRESSION: Improved atelectasis in the lower lobes bilaterally. Brief Hospital Course: Patient admitted to the trauma service. Plastic Surgery and Ophthalmology were immediately consulted because of his injuries. Non operative intervention; Plastics recommended Levofloxacin, he initially received IV which was later changed to oral. This will continue for an additional 3 days after discharge to complete a 10 day course. He will follow up with Plastics in 1 month after discharge. Ophthalmology found no entrapment and recommended eye drops with follow up in their clinic as necessary. He continued to have midline bony tenderness posterior cervical region despite negative imaging for any fractures, dislocations of his cervical spine. He is being discharged with a soft collar for comfort. Pain control was an issue with patient during his hospitalization; he is being discharged with oral Dilaudid. Medications on Admission: Wellbutrin Ativan Lactulose Dilaudid Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: maximum: 12 pills in 24 hours. Disp:*30 Tablet(s)* Refills:*1* 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every Friday). Disp:*3 Patch Weekly(s)* Refills:*2* 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:*qs vials* Refills:*0* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 7 days. Disp:*14 Capsule(s)* Refills:*0* 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 7. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 8. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) drops Ophthalmic four times a day. Disp:*1 vial* Refills:*2* 9. Promethazine 12.5 mg Tablet Sig: 1-2 Tablets PO Q6H:PRN as needed for nausea. Disp:*15 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Discharge Diagnosis: s/p Assault Left facial fractures (maxillary) Discharge Condition: Stable Discharge Instructions: Discharge directly to prison per authorities. Continue the levofloxacin (antibiotic) until the medicine is gone. You may wear soft cervical for comfort. Use the eye drops as directed to avoid irritation. Followup Instructions: Call the plastic surgery clinic within a few days at [**Telephone/Fax (1) 5343**] for a follow up appoinment in 1 month for your facial fractures. You do not require follow up with the eye doctors unless [**Name5 (PTitle) **] have worsening vision, pain with eye movement, or anything else that concerns you. The [**Hospital 8095**] clinic number is [**Telephone/Fax (1) 253**]. Completed by:[**2109-3-20**]

[ "847.0", "802.0", "802.8", "507.0", "070.70", "372.72", "E968.2", "802.4", "801.00" ]

icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

6536, 6551

4450, 5270

327, 334

6641, 6650

645, 1440

6903, 7314

609, 626

5357, 6513

3817, 3859

6572, 6620

5296, 5334

6674, 6880

276, 289

3888, 4427

362, 550

572, 593

58,337

183,276

6932

Discharge summary

report

Admission Date: [**2156-5-31**] Discharge Date: [**2156-6-7**] Date of Birth: [**2087-1-30**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 896**] Chief Complaint: Chief Complaint: Vomiting, dehydration Reason for MICU transfer: DKA, hypotension Major Surgical or Invasive Procedure: Central Venous line Placement Arterial Line placement History of Present Illness: Pt is a 69yoF w/ h/o of IDDM with no prior episodes of DKA, HTN, PVD, and celiac disease who presented with 4 days of n/v. She also reports poor PO intake over the past several days (has not been able to tolerate even fluids), lightheadedness, dry mouth, visual changes x 2 days (objects look "bright" and slightly blurry). Pt reports that she has been using her insulin, but has not checked fingersticks x 4 d after her glucometer stopped working. In addition, she has not taken PO meds x 2-3 days. The pt has also has had some back pain after falling 1 1/2 weeks ago, but Xray at her PCP's showed no fractures. She denied any diarrhea or fevers. Her last BM wasa typical solid BM 2 days ago. She denied chest pain and SOB although her sister noted that her breathing was more labored than usual. In the ED, the patient was hypotensive with SBPs in the 60s and appeared confused. She received 4L IVF with poor response; therefore, a L IJ was placed and the patient was started on Levophed. Her physical exam was notable for diffuse abdominal tenderness and crackles bilaterally. Labs were notable for blood sugar 825 so patient was started on an insulin gtt. Na 123, K 6.2, bicarb 6, Cre 3.3, AG 36, and lactate 3.1. WBC was 19.8 and blood cultures and urine cultures were sent. The patient was also started on UA showed 1000 glucose, 10 ketones, 33 WBC and moderate bacteria with no nitrates and moderate leuk esterase. In the ED, the patient was started on vanc. Labs were also notable for a Trop-T of 0.78 and a proBNP 3933 even though the patient has no history of CHF. EKG showed sinus rhythm with TW changes in AVL and ST depression in leads II and V3-V5; these findings are different from her old EKG. En route to the MICU, the patient's vitals were HR 82 BP 100/39 100% on 2L. Upon arrival to the MICU, the patient's vitals were HR 99 BP 95/42 100% on 2L. The patient received a repeat EKG confirmed TWI and ST depressions seen in the ED. Past Medical History: Type 1 Diabetes c/b retinopathy and neuropathy Hypertension Breast CA Legally blind s/p cholecystectomy Hx of Stage II Breast Cancer Hyperlipidemia Celiac disease Chronic UTIs on suppressive methenamine Osteoporosis Social History: She lives alone, no tobacco or alcohol use. Family History: Notable for several members with breast cancer. Physical Exam: ADMISSION Vitals: T: 98.4 BP: 95/42 P: 99 R: O2: 100% on 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no CVAT bilaterally, no suprapubic tenderness GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: no focal deficits DISCHARGE: Pertinent Results: ADMISSION ================== [**2156-5-31**] 01:25PM BLOOD WBC-19.8*# RBC-3.91* Hgb-12.4 Hct-39.3 MCV-100*# MCH-31.7 MCHC-31.6# RDW-13.4 Plt Ct-453* [**2156-5-31**] 01:25PM BLOOD Neuts-92.4* Lymphs-4.0* Monos-3.3 Eos-0.2 Baso-0.2 [**2156-6-1**] 01:30AM BLOOD PT-9.4 PTT-20.8* INR(PT)-0.9 [**2156-5-31**] 01:25PM BLOOD Glucose-825* UreaN-57* Creat-3.3*# Na-123* K-6.2* Cl-81* HCO3-6* AnGap-42* [**2156-5-31**] 01:25PM BLOOD ALT-31 AST-47* CK(CPK)-309* AlkPhos-132* TotBili-0.3 [**2156-5-31**] 01:25PM BLOOD CK-MB-22* MB Indx-7.1* proBNP-3933* [**2156-5-31**] 01:25PM BLOOD Albumin-4.3 Calcium-8.8 Phos-9.5*# Mg-2.4 [**2156-5-31**] 02:49PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.012 [**2156-5-31**] 02:49PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2156-5-31**] 02:49PM URINE RBC-2 WBC-33* Bacteri-MOD Yeast-NONE Epi-<1 [**2156-5-31**] 02:49PM URINE CastHy-25* [**2156-6-1**] 08:07PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.012 [**2156-6-1**] 08:07PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [**2156-6-1**] 08:07PM URINE RBC-1 WBC-67* Bacteri-NONE Yeast-NONE Epi-1 [**2156-6-1**] 08:07PM URINE CastGr-8* CastHy-2* URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Prior to discharge: ======================= Imaging: ========================= TTE [**2156-6-1**]: 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 mildly depressed (LVEF= 45 %) secondary to hypokinesis of the apical half of the anterior septum, anterior free wall, and lateral wall, with focal apical dyskinesis. The rest of the left ventricular segments appear hyperdynamic without outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Renal U/S [**2156-5-31**]: Limited study. No evidence of hydronephrosis, stone, or mass in either kidney. CXR [**2156-5-31**]: Portable AP upright chest radiograph was obtained. Low lung volumes noted. Allowing for this, the lungs appear clear. No large effusion or pneumothorax is seen. The cardiomediastinal silhouette appears normal. A calcified granuloma projects over the right lateral mid lung. Bony structures are intact. Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: ======================================= Ms [**Known lastname 26077**] is a 69yoF with a history of Type 1 Diabetes and HTN who presented with nausea and vomiting found to have DKA, a UTI, and elevated Troponin ACTIVE ISSUES: ===================== 1.) Diabetic Ketoacidosis: The patient was admitted to the MICU and was placed on an insulin drip. She was hypotensive and required aggressive fluid repletion. After her anion gap was closed she was transitioned back to SC insulin and transferred to the medical floor. The precipitating factor for her DKA was most likely a urinary tract infection although alternatively it could have been that the cardiac event triggered the DKA and the UTI is incidental. -The patient's home insulin regimen was modified in consultation with [**Last Name (un) **]. NPH was changed to 26 U AM and 6 U PM. -She will follow-up closely with her endocrinologist at [**Last Name (un) **] 2.) NSTEMI / cardiomyopathy: In the MICU the patient was noted to have EKG changes and her troponin was as high as 3. Initially there was concern for an acute coronary syndrome; however she subsequently had an echocardiogram which showed apical hypokinesis consistent with TakoTsubo/Stress Induced Cardiomyopathy. This was likely due to physiologic stress from the DKA and profound volume depletion. The patient's cardiac biomarkers began to trend downwards without any coronary intervention. She never had chest pain at any point. Alternatively these EKG changes and biomarker elevations could be explained by a mid LAD infarction but this was deemed less likely based on patient's history. Cardiology was consulted who recommended that the patient continue aspirin and atorvastatin that she was already on. -Dr. [**Last Name (STitle) 171**] will see patient in cardiology clinic in ~3 weeks and will repeat an echocardiogram to assess for recovery of LV function and to determine whether further risk stratification (e.g. stress testing) is warranted. 3.) UTI: Cultures grew E. Coli sensitive to ceftriaxone. The patient has a history of recurrent UTIs and this developed despite patient being on suppressive therapy with methenamine. - Patient will go home on PO Cefpodoxime for a total course or 14 days antibiotic coverage - Outpatient workup on why patient has recurrent UTIs 4.) Acute Kidney Injury: Creatinine peaked at 3.3, but returned back to baseline of ~1.0 with volume resuscitation. Most likely it was Pre-renal azotemia from volume depletion from DKA. CHRONIC ISSUES: =================== #) Celiac Disease: - coninued gluten free-diet. TRANSITIONAL ISSUES: ======================== # Dr. [**Last Name (STitle) 171**] will see patient in cardiology clinic in ~3 weeks and will repeat an echocardiogram to assess for recovery of LV function # Communication: Patient, [**Name (NI) **] (sister) [**Telephone/Fax (1) 26078**] # Code: Confirmed Full Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. fosinopril *NF* 40 mg Oral daily 2. Atorvastatin 80 mg PO DAILY 3. NPH 30 Units Breakfast NPH 10 Units Bedtime Regular 10 Units Breakfast Regular 8 Units Dinner 4. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit Oral daily 3 tablets 5. omega-3 fatty acids-vitamin E *NF* 1,000 mg Oral daily 6. Aspirin 81 mg PO DAILY 7. methenamine hippurate *NF* 1 gram Oral [**Hospital1 **] 8. Ascorbic Acid [**2143**] mg PO BID 9. Actonel *NF* (risedronate) 35 mg Oral qweek 10. Multivitamins 1 TAB PO DAILY 11. codeine-guaifenesin *NF* 100 mg-10 mg/5 mL Liquid Oral 1 teaspoon(s) by Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Actonel *NF* (risedronate) 35 mg Oral qweek 4. Ascorbic Acid [**2143**] mg PO BID 5. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit Oral daily 3 tablets 6. fosinopril *NF* 40 mg Oral daily 7. Multivitamins 1 TAB PO DAILY 8. omega-3 fatty acids-vitamin E *NF* 1,000 mg Oral daily 9. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 6 Days RX *cefpodoxime 200 mg 2 Tablet(s) by mouth twice daily Disp #*24 Tablet Refills:*0 10. codeine-guaifenesin *NF* 100 mg-10 mg/5 mL Liquid Oral 1 teaspoon(s) by mouth q 4 hrs prn 11. NPH 26 Units Breakfast NPH 6 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary - Diabetic Ketoacidosis - Complicated UTI - Sepsis - NSTEMI and Stress Induced Cardiomyopathy - Constipation 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 26077**], it was a pleasure taking care of you here at [**Hospital1 18**]. You were admitted to the hospital because of nausea and vomiting. This was due to Diabetic Ketoacidosis. You were treated in the intensive care unit (ICU) and your blood sugars came back down. You had some modifications made to your insulin which are detailed on the next page. You also were treated for a urinary tract infection (UTI). You will need to keep taking antibiotics after you leave to complete a full course. We ask that you stop taking methenamine until you see Dr. [**Last Name (STitle) **] on [**6-11**]. In addition you developed a problem with your heart called "Stress Induced Cardiomyopathy". We think this was due to the stress on your body from your illness. You will need to see Dr. [**Last Name (STitle) 171**] in cardiology clinic as detailed below for further testing. Followup Instructions: Department: Endocrinology- [**Last Name (un) **] Diabetes Center Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10088**] When: Tuesday [**2156-6-8**] at 2:30 PM. Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3402**] Notes: Please arrive 30 minutes prior to your visit with Dr. [**Last Name (STitle) 10088**]. Department: Ophthalmology- [**Last Name (un) **] Diabetes Center Name: Dr. [**First Name8 (NamePattern2) 26079**] [**Last Name (NamePattern1) 26080**] When: Thursday [**2156-6-10**] at 9:00 AM Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3402**] Notes: You will be seen by a Senior Technician prior to your visit with Dr. [**First Name (STitle) 26080**]. Department: [**Location (un) 2788**] INTERNAL MED. When: FRIDAY [**2156-6-11**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], MD [**Telephone/Fax (1) 2789**] Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: CARDIAC SERVICES When: WEDNESDAY [**2156-6-23**] at 2:40 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10580, 10638

6158, 6405

387, 443

10799, 10799

3428, 4703

11900, 13478

2757, 2806

9847, 10557

10659, 10778

9103, 9824

10982, 11877

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280, 349

6420, 8682

4738, 6135

471, 2439

10814, 10958

8698, 8767

2461, 2679

2695, 2741

16,798

193,783

15977

Discharge summary

report

Admission Date: [**2173-5-17**] Discharge Date: [**2173-5-22**] Date of Birth: [**2119-5-15**] Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 53 year-old male with a history of coronary artery disease status post percutaneous transluminal coronary angioplasty is now admitted preoperatively for left stenting of his vertebral artery. The patient originally had symptoms of loss of peripheral vision. He has had symptoms for about six years. They have disappeared and returned last year. He denies nausea, vomiting, photosynthesis, sometimes saw a spot in the middle of his vision, which slowly grew. Visual symptoms has become worse and he was referred to Dr. [**Last Name (STitle) 1132**] and as mentioned he did have an angioplasty of the right vertebral artery in the past. He had felt great after that procedure, but two weeks later he developed worsening of blurred vision. PAST MEDICAL HISTORY: Coronary artery disease status post percutaneous transluminal coronary angioplasty in [**2157**] and [**2170**]. History of increased cholesterol, arthritis and ankylosing spondylosis. ADMISSION MEDICATIONS: 1. Celebrex. 2. Zantac. 3. Plavix. 4. Aggrenox. 5. Aspirin. 6. Atorvastatin. FAMILY HISTORY: No history of strokes. ALLERGIES: None. SOCIAL HISTORY: Quit smoking twenty years ago. Alcohol quit drinking in his 30s. PHYSICAL EXAMINATION: Blood pressure 133/70. Pulse 79. Temperature 98.2. Alert and oriented, fluent, attentive, no neglect. Peripheral pulses regular and symmetric. Normal S1 and S2. Lungs were clear. There is a positive right carotid bruit. Pupils reactive to light. Right pupil is 1 mm smaller then the left. No ptosis. Full extraocular movements intact. Face is symmetric. Tongue is midline. Motor 5 out of 5 in all limbs. Reflexes were 2 to 3 in the upper extremities and 3+ in the lower extremities. Sensory is intact. Coordination was normal. Gait was normal. Negative Romberg. The patient was brought to the angio suite on [**2173-5-19**] where he had an angioplasty of his left vertebral artery with improved flow and was doing well postop. He was monitored overnight in the Intensive Care Unit and transferred to the floor on [**2173-5-20**]. He did well postoperatively. No visual problems. [**Name (NI) **] had some trouble with nausea, which improved with Zofran. He was anticoagulated with heparin and that was stopped prior to leaving the unit. The patient did have a consult on [**2173-5-21**] from the stroke service who recommended the patient should continue to be on aspirin and Plavix. He should have his cholesterol monitored, have a homocystine level checked and started on a calcium channel blocker. The patient should have an outpatient TCD to follow degree of stenosis. The patient is being discharged on [**2173-5-21**] and the admitting date was [**2173-5-17**]. DISCHARGE INSTRUCTIONS: He is to watch his incisions sites for any redness, drainage or signs and symptoms of hematoma. He should follow up with Dr. [**Last Name (STitle) 1132**] in two to three weeks. It is recommended that he have an outpatient TCD to follow degree of stenosis. DISCHARGE MEDICATIONS: 1. Plavix 75 mg q.d. 2. Aspirin 325 mg q.d. 3. Zantac 150 b.i.d. 4. Atorvastatin calcium 20 mg three tablets q.d. 5. Celexabid 200 mg one b.o.d. 6. Oxycodone with acetaminophen 5/325 tablets one to two q 4 to 6 hours prn. 7. Zofran 4 mg tablets 0.5 tablets b.i.d. as needed for nausea. 8. Verapamil 240 mg one q.d. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern4) 32961**] MEDQUIST36 D: [**2173-5-22**] 09:50 T: [**2173-5-27**] 12:05 JOB#: [**Job Number 45766**]

[ "433.20", "414.01", "272.0", "413.9", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "39.50", "88.41" ]

icd9pcs

[ [ [] ] ]

1263, 1306

3216, 3799

2934, 3193

1162, 1246

1413, 2909

169, 929

952, 1139

1323, 1390

74,002

155,504

3267

Discharge summary

report

Admission Date: [**2190-12-12**] Discharge Date: [**2190-12-15**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 689**] Chief Complaint: LGIB Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] y.o. female, lives at home, d/c'd from rehab 5 days ago, with pmh of afib on coumadin, CHF (EF 35%), rectal cancer s/p resection in [**2178**], presents BRBPR x 10 days, along with R arm bruising and L buttock bruising. Per patient, it began at rehab. VNA stopped coumadin 2 days ago per the daughter. When her daughter found out she had been bleeding she was brought to ED. Of note, had recent admissions in [**10-16**] for appendicitis with abscess and in [**11-15**] for RLL pneumonia, and was at rehab until 5 days ago after the PNA admission. She denies abdominal pain, chest pain, and has baseline shortness of breath which is unchanged. She feels tired but otherwise has no complaints. . In the ED, vital signs were stable. Her INR was 6.4. Hct 23.5, slightly below basline of 26-28. Troponin 0.07 is at baseline and ECG unchanged from prior. She was given Vitamin K 10mg IV x1, 2 units FFP with 20mg IV lasix inbetween, IV protonix 40mg x1, and was ordered for 2 units PRBCs which were begun in the ICU. She was admitted to the ICU for close monitoring. Upon arrival to the ICU, her VS were stable (BP 130/80, HR 100), and she had a medium maroon stool. Past Medical History: Appendicitis c/b perforation and appendiceal abscess s/p percutaneous drainage Afib started on coumadin at 11/08 (although had pAfib for years) Sigmoid colon CA s/p resection in [**2178**] CAD s/p 3-vessel CABG in [**2176**] Chronic renal insufficiency (baseline Cr 1.1-1.3) CHF, systolic, EF 35-40% OA Gout DM2 HTN Hearing aid Cataracts s/p hernia surgery Social History: The pt immigrated from [**Location (un) 6079**] in [**2176**]. She currently is at [**Hospital3 2558**] for acute rehab. She drank cognac or vodka about twice a day but stopped about 3 years ago. No cigarette or substance use. Family History: Noncontributory Physical Exam: GEN: comfortable, no distress HEENT: NC. PERRL. EOMI LUNGS: CTA b/l HEART: Irregularly irregular ABD: +BS, soft, +TTP in RUQ and RLQ EXT: 2+ LE edema b/l SKIN: Violaceous bruising over the L buttock and arms. Pertinent Results: CBC: [**2190-12-12**] 01:45PM BLOOD WBC-8.1# RBC-3.00* Hgb-7.5* Hct-23.5* MCV-78* MCH-24.9* MCHC-31.8 RDW-15.7* Plt Ct-300# [**2190-12-13**] 01:13AM BLOOD WBC-10.4 RBC-3.57* Hgb-9.2* Hct-28.2* MCV-79* MCH-25.7* MCHC-32.5 RDW-15.0 Plt Ct-278 [**2190-12-13**] 08:59AM BLOOD Hct-31.3* . COAGS: [**2190-12-12**] 01:45PM BLOOD PT-54.6* PTT-45.0* INR(PT)-6.4* [**2190-12-13**] 01:13AM BLOOD PT-16.0* PTT-28.2 INR(PT)-1.4* . CHEM: [**2190-12-12**] 01:45PM BLOOD Glucose-100 UreaN-28* Creat-1.2* Na-143 K-3.4 Cl-107 HCO3-28 AnGap-11 [**2190-12-13**] 01:13AM BLOOD Glucose-106* UreaN-25* Creat-1.1 Na-143 K-3.9 Cl-107 HCO3-27 AnGap-13 . CE's: [**2190-12-12**] 01:45PM BLOOD CK-MB-NotDone cTropnT-0.07* [**2190-12-13**] 01:13AM BLOOD CK-MB-NotDone cTropnT-0.08* CXR [**2190-12-13**]: Severe cardiomegaly has worsened slightly, pulmonary vasculature is distinctly more dilated and early interstitial edema may be developing, all consistent with cardiac decompensation. Mediastinal veins are dilated to a stable degree. Pleural effusion if any is small. No pneumothorax. Dr. [**Last Name (STitle) 15259**] and I discussed these findings, at the time of dictation. . [**2190-11-8**] ECHO: The left atrium is markedly dilated. The right atrium is moderately dilated. A small secundum atrial septal defect is present. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is moderately depressed (LVEF= 35-40 %) with inferior and infero-lateral hypokinesis. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect with borderline normal free wall function. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**12-10**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2190-10-9**], the findings are similar (the LVEF was slightly underestimated on prior study). Brief Hospital Course: Hct was found to be 23.5 from BL of ~ 26-28. INR was 6.4. ECG was unchanged and CEs were negative. SHe received 2 units of FFP, 10 mg of IV vit K, and 20 mg of IV lasix and was admitted to the ICU for close monitoring. Upon arrival to the ICU, patient SBPs continued to be stable. Her beta blocker was initially held but then had a episode of AFib into the 120s and received 25 mg of oral metoprolol. She received 2 units PRBCs with 20 mg of IV lasix with each transfusion. Hct 23.5-> 28.2-> 31. INR this am 6.4-> 1.4. At 7 am this morning, patient had recurrent episode of AF with RVR and became acutely SOB. CXR c/w pulmonary edema. She received 5 mg of IV lopressor, 50 mg po lopressor, and 40 mg of IV lasix with good UOP and improved SOB. GI was consulted and came to evaluate patient. However, patient refused all endoscopy. She had 1 maroon stool last night but no further bleeding. This am, her diet was advanced to clears. . # BRBPR: Most likely LGIB. Brisk upper GI bleed also considered although less likely given hemodynamic stability. Etiologies of lower GIB include recurrence of colon cancer, diverticulosis, ulcer at anastomosis site, AVM, ischemic colitis. Complicated by supratherapeutic INR. No further bleeding now with INR reversed. Hct stable following transfusion. Patient refusing endoscopy. Favoring conservative management. PPI was discontinued as bleed was thought most likely lower in origin. Her coumadin was not restarted after long discussion with patient's daughter. [**Name (NI) **] aspirin was held until the day of discharge. . # supratherapeutic INR: in setting of coumadin administration. Corrected now after vit K and FFP. LFTs normal. Her INR remained subtherapeutic throughout hospitalization after reversal. . # Afib: long history of PAF although only recently initiated coumadin after hospital admission in 11/[**2189**]. Followed by Dr. [**Last Name (STitle) **] of Cardiology. Due to episodes of RVR at times of agitation while on the hospital floors beta blocker was uptitrated to 75 mg TID. HRs improved to 70s and BP tolerated. She was transitioned to Toprol XL 200 mg daily at the time of discharge. Long discussion held with family regarding risks and benefits or reinitiating coumadin. It was explained that this bleed was in the setting of a supratherapeutic INR and that she may not have any bleeding with INRs in the goal range of [**1-11**]. Risks of holding coumadin also discussed with daughter including risk of stroke as well as risk of embolization to organs and other tissues given known aortic thrombus at high risk of embolization. Patient's daughter remained convinced that she would not want her mother reinitiated on coumadin and so this medication was held. On the day of dischage a full dose aspirin was restarted. She was scheduled for Cardiology follow up as an outpatient. . # CAD: s/p CABG in [**2176**]. ECG unchanged and CEs negative despite GIB and RVR. She remained asymptomatic throughout admission. Aspirin was initially held in the setting of GI bleed but was restarted at the time of discharge. After stabilization of GI bleed, she was restarted on her beta blocker and ace inhibitor. She was continued on her statin throughout. . # thoracic aortic mural plaque: Found incidentally on recent CT abdomen. At high risk of embolism according to radiology read. As above, patient and family refusing systemic anticoagulation. . # Asymmetric LE swelling: L>R. Noted on admission and persisted despite diuresis. Per patient's daughter, this is a chronic condition. Given that the swelling was symptomatic, that had been present on systemic anticoagulation, as well as the fact that the patient was refusing further anticoagulation, LENI was not pursued. . # chronic systolic CHF: EF 35% on most recent ECHO. Worsened pulmonary edema in the setting of AF with RVR during admission which responded to diuresis. Her oral lasix was held and she received a total of 80 mg of IV lasix during her first 24 hours. On hospital day 3 she was saturating well on RA while supine without subjective SOB. She was continued on beta blocker as above which was transitioned to Toprol XL given better data for chronic systolic heart failure and to aid in compliance. She was continued on home dose beta blocker. Home dose lasix was restarted at the time of discharge. . # diarrhea: had non-watery diarrhea during hospitalization. However, given recent antibiotics for pneumonia, C difficile toxin was checked which was positive. She was started on flagyl. She had no fevers or abdominal pain. She was hemodynamically stable. . # DM2: Home glyburide was held until discharge. She was continued on insulin sliding scale throughout. . # HTN: Continued on lisinopril and beta blocker uptitrated. . # CRF: Cr at baseline. Slight increase in Cr from 1.1->1.3 with diuresis and reinitiation of ace inhibitor. Still within most recent baseline. 1.2 at discharge. . # CODE: extensive code status discussion held with patient's daughter. Throughout admission patient refused to comply with telemetry monitoring, foley catheterization and got agitated and upset with even minimal intervention including blood draws, vitals checks, and physical exams. She also refused sigmoidoscopy and colonoscopy. It seemed clear to her medical providers that she did not want to pursue invasive care. Her daughter did agree that her mother would probably not want aggressive and invasive care should it be necessary. However, despite ~ 45 minute discussion did not feel comfortable making that decision on her mother's behalf and preferred to discuss with her directly once her mother's mental status cleared. Medications on Admission: Warfarin 5.5mg PO Daily Senna 8.6 mg PO BID PRN Colace 100mg PO BID Albuterol MDI q6H PRN Aspirin 81mg PO Daily Multivitamin PO DAILY Bisacodyl 10 mg Tablet, PO DAILY as needed. Metoprolol Tartrate 50 mg PO TID Lisinopril 10 mg PO DAILY Atorvastatin 40 mg PO DAILY Furosemide 40 mg PO DAILY Acetaminophen 650mg PO Q6H PRN Trazodone 25 mg Tablet PO HS prn Insulin SS Glyburide 2.5 mg PO once a day. Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Insulin Lispro 100 unit/mL Solution Sig: One (1) injection Subcutaneous ASDIR (AS DIRECTED): per usual insulin sliding scale. 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 5. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: Please restart this medication on [**2190-12-17**] if diarrhea improving. 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 14 days. Disp:*42 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: Primary: 1. lower GI bleeding 2. supratherapeutic INR 3. acute pulmonary edema secondary to rapid atrial fibrillation 4. rapid atrial fibrillation Secondary: 1. paroxysmal atrial fibrillation 2. chronic systolic heart failure 3. coronary artery disease 4. rectal cancer 5. Diabetes 6. hypertension 7. chronic kidney disease Discharge Condition: Stable Hct. Rectal bleeding resolved. O2 saturations in mid 90s on RA. Breathing comfortably supine. HRs well controlled in 80s. Discharge Instructions: You were admitted to the hospital for bleeding from your rectum in the setting of a high coumadin level. Your bleeding resolved after reversing the coumadin. You received 2 pints of blood cells during the hospital to bring up your blood counts. You were also found to have C difficile diarrhea and were started on antibiotics which you will need to take for 14 days. Please take all medications as prescribed. Please note the following changes have been made to your medications: 1. Metoprolol has been changed to Toprol XL 2. Coumadin has been stopped 3. Aspirin has been increased to 325 mg daily 4. Your colace and senna have been stopped while you are having loose stools 5. Your lasix has been held. Please restart in 2 days on [**2190-12-17**] if diarrhea resolving. Otherwise discuss with your PCP. 6. You have been started on antibiotic flagyl for C difficile diarrhea. Please continue for 14 days. Please follow up with your regular doctors as listed below. Please weigh yourself daily and call your doctor if your weight increases by more than 2 lbs. Please adhere to a low salt diet. Please call your doctor or return to the hospital for recurrent bleeding from your rectum, palpitations, lightheadedness, shortness of breath, chest pain, abdominal pain, fevers, chills, decreased urine output, or any other concerns. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 10978**] on [**2189-12-22**] at 3:15 pm. Phone: [**Telephone/Fax (1) 4606**]. Please follow up with Dr. [**Last Name (STitle) **] on [**2189-12-27**] at 4:20 pm. Phone: ([**Telephone/Fax (1) 2037**].

[ "250.00", "428.22", "745.5", "V45.81", "585.9", "578.9", "403.90", "V10.06", "274.9", "427.31", "008.45", "428.0", "366.9", "414.00" ]

icd9cm

[ [ [] ] ]

[ "99.07", "99.04" ]

icd9pcs

[ [ [] ] ]

11950, 12025

4703, 10364

225, 231

12394, 12526

2351, 4680

13912, 14164

2089, 2106

10813, 11927

12046, 12373

10390, 10790

12550, 13889

2121, 2332

181, 187

259, 1443

1465, 1825

1841, 2073

27,944

143,163

31472

Discharge summary

report

Admission Date: [**2198-7-29**] Discharge Date: [**2198-7-31**] Date of Birth: [**2131-1-25**] Sex: M Service: MEDICINE Allergies: Vancomycin / Gentamicin Attending:[**First Name3 (LF) 106**] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Cardiac Catheterization Intubation Swan Ganz Balloon Pump central and arterial line History of Present Illness: 67M with ESRD on HD, paroxysmal a-fib, recent AVF abscess now p/w fever and SOB as a transfer from [**Hospital3 **]. He initially presented to [**Hospital1 **] on [**7-17**] with fever. Of note, he had an AV fistula angioplasty with a stent(by report) on [**2198-7-5**] in [**State 108**] apparently for stenosis. On [**7-9**], he started to develop fevers, and he began to notice a lump appearing over the AV fistula site as well. On [**7-17**], this lump was observed at his dialysis session and he was referred to [**Hospital3 **] and found to have an AV fistula abscess for which he was taken urgently to the OR by Dr. [**Last Name (STitle) 74087**] [**Name (STitle) 74088**]. Of note, he was found to be in a-fib at this time. He had a TTE on [**7-17**] followed by a TEE on [**7-18**] to r/o vegetation which revealed EF 55%, moderate MS, moderate AS ([**Location (un) 109**] 1.0) and an 8mm mobile density on the atrial side of the posterior leaflet thought to be old healed vegetation or disrupted leaflet. He was treated with antibiotics and was ultimately discharged on [**7-27**] although further details of the hospital course are at this point unclear. Mr. [**Known lastname **] returned to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on the [**7-28**], the day following discharge with fever and SOB. He was found to have an elevated WBC to 15.4 from 7.5 the day prior. Last dialysis was on [**7-27**]. VS: T 101.4 p 68 BP 135/79 rr 24 sats high 90s NRB. Sats improved to 97 on 4L after a couple of hours with improved BP on nitro gtt. He was treated for presumptive PNA with vanc/levaquin. He was admitted to ICU at [**Hospital1 **] and found to have an elevated TnI to 1.37 from 0.14 the day prior. There was no CK sent. ECG showed sinus with RBBB, no signs of ischemia. The physicians at [**Hospital1 **] were concerned for possibility of acute MI and arranged for transfer to [**Hospital1 18**]. He arrived at [**Hospital1 18**] in moderate respiratory distress, with vitals T 98.6, p 62 108/86 38 unable to find a sat though by ABG oxygenating well on 5L NC. . 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, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative Past Medical History: End Stage Renal Disease on hemodyalisis Atrial Fibrillation Social History: No etoh, tobacco, or drugs. Born in [**Country 2045**], moved to US 40 yrs ago. Has worked in management at the [**Company 49705**]. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 101.2 BP 125/65 HR 80 RR 14 92 O2 % on vent Gen: Intubated, sedated HEENT: NCAT. Sclera anicteric. perrl Neck: Supple with JVP difficult to assess with thick neck CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Early peaking systolic murmur loudest at apex. Chest: Respiratory distress, crackles [**12-12**] way up. No chest wall deformities, scoliosis or kyphosis. L sided tunneled HD line Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. R arm AV fistula with healing wound, no surrounding erythema or purulence. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: EKG demonstrated ECGs with alternating LBBB and RBBB regular in 50s-60s, no p-waves. Rhythm c/w CHB with a junctional escape. No clear signs of ischemia in setting of IVCD. . TELEMETRY demonstrated: paced rhythm s/p temp wire. [**2198-7-29**] 11:58PM TYPE-ART PO2-125* PCO2-36 PH-7.30* TOTAL CO2-18* BASE XS--7 [**2198-7-29**] 11:58PM LACTATE-6.9* [**2198-7-29**] 11:58PM freeCa-0.96* [**2198-7-29**] 11:47PM GLUCOSE-162* SODIUM-136 POTASSIUM-5.5* CHLORIDE-97 TOTAL CO2-16* ANION GAP-29* [**2198-7-29**] 11:47PM PTT-56.3* [**2198-7-29**] 11:33PM ALT(SGPT)-209* AST(SGOT)-5180* LD(LDH)-6904* ALK PHOS-209* AMYLASE-2908* TOT BILI-1.0 [**2198-7-29**] 11:33PM LIPASE-94* [**2198-7-29**] 11:33PM CORTISOL-17.2 [**2198-7-29**] 11:32PM CORTISOL-15.8 [**2198-7-29**] 09:45PM TYPE-ART TEMP-36.0 PO2-129* PCO2-34* PH-7.31* TOTAL CO2-18* BASE XS--8 [**2198-7-29**] 09:45PM GLUCOSE-74 LACTATE-7.7* K+-6.2* [**2198-7-29**] 09:45PM O2 SAT-98 [**2198-7-29**] 09:45PM freeCa-0.99* [**2198-7-29**] 06:26PM TYPE-ART PO2-153* PCO2-40 PH-7.28* TOTAL CO2-20* BASE XS--7 [**2198-7-29**] 06:26PM LACTATE-6.1* [**2198-7-29**] 06:26PM freeCa-1.08* [**2198-7-29**] 06:05PM GLUCOSE-111* UREA N-28* CREAT-6.1*# SODIUM-132* POTASSIUM-6.7* CHLORIDE-95* TOTAL CO2-17* ANION GAP-27* [**2198-7-29**] 06:05PM ALT(SGPT)-218* AST(SGOT)-5070* LD(LDH)-7715* ALK PHOS-251* TOT BILI-0.9 [**2198-7-29**] 06:05PM CALCIUM-8.2* PHOSPHATE-4.9* MAGNESIUM-2.2 [**2198-7-29**] 06:05PM WBC-20.5* RBC-3.67* HGB-9.8* HCT-31.2* MCV-85 MCH-26.6* MCHC-31.3 RDW-16.6* [**2198-7-29**] 06:05PM PLT COUNT-359 [**2198-7-29**] 06:05PM PT-23.3* PTT-59.6* INR(PT)-2.3* [**2198-7-29**] 02:28PM TYPE-ART PO2-280* PCO2-38 PH-7.39 TOTAL CO2-24 BASE XS--1 [**2198-7-29**] 02:28PM freeCa-1.04* [**2198-7-29**] 12:40PM PTT-66.4* [**2198-7-29**] 11:22AM TYPE-ART PO2-113* PCO2-47* PH-7.19* TOTAL CO2-19* BASE XS--10 [**2198-7-29**] 11:22AM GLUCOSE-119* LACTATE-8.6* K+-5.9* [**2198-7-29**] 11:22AM O2 SAT-97 [**2198-7-29**] 11:22AM freeCa-1.04* [**2198-7-29**] 10:14AM TYPE-ART PO2-121* PCO2-53* PH-7.13* TOTAL CO2-19* BASE XS--12 [**2198-7-29**] 09:40AM TYPE-ART PO2-116* PCO2-51* PH-7.03* TOTAL CO2-14* BASE XS--18 [**2198-7-29**] 09:40AM GLUCOSE-73 K+-6.5* [**2198-7-29**] 09:40AM O2 SAT-95 [**2198-7-29**] 09:40AM freeCa-1.06* [**2198-7-29**] 07:38AM GLUCOSE-128* UREA N-31* CREAT-7.6* SODIUM-131* POTASSIUM-6.8* CHLORIDE-95* TOTAL CO2-19* ANION GAP-24* [**2198-7-29**] 07:38AM estGFR-Using this [**2198-7-29**] 07:38AM ALT(SGPT)-31 AST(SGOT)-743* LD(LDH)-1673* CK(CPK)-109 ALK PHOS-247* AMYLASE-164* TOT BILI-0.8 [**2198-7-29**] 07:38AM LIPASE-113* [**2198-7-29**] 07:38AM CK-MB-5 cTropnT-0.62* [**2198-7-29**] 07:38AM NEUTS-84* BANDS-5 LYMPHS-6* MONOS-2 EOS-3 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2198-7-29**] 07:38AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-2+ [**2198-7-29**] 07:38AM PLT SMR-NORMAL PLT COUNT-375 [**2198-7-29**] 07:38AM PTT-150* [**7-31**] ABDOMEN PLAIN FILM IMPRESSION: 1. No obstruction or ileus is noted. [**2198-7-30**] BALLOON PUMP COMMENTS: 1. Successful placement of IABP without complications. 2. The Swan-Ganz catheter was adjusted and withdrawn by 10cm 3. Vasopressin was discontinued during the procedure. FINAL DIAGNOSIS: 1. Severe mitral regurgitation/flail mitral valve secondary to endocarditis, refractory hypotension and hemodynamic compromise, status post successful placement of IABP. [**2198-7-30**] ECHO Conclusions: The left atrium is moderately dilated. No thrombus is seen in the left atrial appendage. The right atrium is markedly dilated. Overall left ventricular systolic function is hyperdynamic. There are three aortic valve leaflets that are moderately thickened Mild to moderate ([**12-12**]+) aortic regurgitation is seen. There is no AS. There is partial mitral leaflet flail of both anterior and posterior leaflets. There is a large vegetation on the anterior mitral leaflet (.9 cm) and moderate vegetation on posterior leaflet. Severe mitral regurgitation is seen with flow reversal in pulmonary vein. There is a 8 mm gradient across the mitral valve due to mitral annular calcification and increased flow due to the MR. There is at least moderate pulmonary artery systolic hypertension with PASP 60-70. There is 3+ tricuspid regurgitation. The RV is dilated and hypokinetic. A pacemaker wire is seen entering into RV. IMPRESSION: endocarditis of mitral valve with partial flail leaflets Brief Hospital Course: 1. Respiratory failure: The patient had severe pulmonary edema. He patient was emergently intubated for severe respiratory failure with satting low 80s and strenuous work to breathe. He was covered with vancomycin and zosyn. Echocardiography revealed endocarditis with severe destruction mitral and tricuspid valves. The patient remained intubated and connected to hemodialysis until made CMO . . 2. Cardiac: Admitted in complete heart block, and transcutaneous temporal wire pacing was instituted at 80 bpm. Prior to this, he was in AF with a junctional escape rhythm with alternating RBBB and LBBB. He was anticoagulated. Soon after admission he required pressure support. Early on invasive monitoring was instituted, a central line and an arterial line were placed. He was unresponsive to fluid boluses and was eventually put on three pressors. A swan ganz was placed which revealed data consistent with cardiogenic shock, wedge>40. Cardio Surgery was consulted and agreed that the prognosis was extremely poor, with the only possible therapy being valve replacement in the unlikely event that the patient's liver and overall state would allow surgery. A balloon pump was placed in the cath lab as a temporizing measure, with minimal and transient improvement in the patient's hemodynamic status. Lactate was elevated at admission and remained elevated up until the time of the patient's death, in spite of optimum management of his hemodyalisis to alkalinize fluids. He developed adrenal insuficiency, liver shock (transaminases>6000), and kidney failure. His pancreatic enzymes were also elevated. Ultimately the patient's acidosis worsened and in view of the dismal prognosis life support was discontinued in full agreement with the [**Hospital 228**] health care proxy, with the patient passing away in 20 minutes. . . 3. ID There was a recent history of AV fistula abscess. The patient was put on broad spectrum antibiotics. Upon confirmation of endocarditis, flagyl and levaquin were added to vancomycin and zosyn. Data was not consistent with septic shock. . 4. Renal/electrolytes/Hyperkalemia: The renal team followed the patient closely. He was hyperkalemic on admission and his electrolytes were managed agressively. . Medications on Admission: Unknown Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "391.1", "276.7", "424.90", "427.31", "518.81", "414.01", "403.91", "585.6", "428.0", "785.51", "426.0" ]

icd9cm

[ [ [] ] ]

[ "89.64", "88.56", "96.04", "89.68", "88.53", "38.93", "37.22", "37.61" ]

icd9pcs

[ [ [] ] ]

10871, 10880

8542, 10781

303, 388

10931, 10940

3983, 7298

10996, 11006

3119, 3201

10839, 10848

10901, 10910

10807, 10816

7315, 8519

10964, 10973

3216, 3964

244, 265

416, 2869

2891, 2952

2968, 3103

7,908

169,006

14017

Discharge summary

report

Admission Date: [**2168-8-12**] Discharge Date: [**2168-8-15**] Date of Birth: [**2121-7-14**] Sex: M Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: The patient is a 47 year old gentleman status post orthotopic transplant for Hep. C. cirrhosis and alcoholic cirrhosis in [**2167-12-14**]. The patient had a history of hepatic artery stenosis with stent placed in [**2168-2-14**]. The patient had a routine follow up ultrasound on [**8-12**] which showed decreased flow and the patient underwent angiography on [**8-13**] which was found to have stenosis and two stents were placed and the patient was placed in the Intensive Care Unit for overnight observation. PAST MEDICAL HISTORY: Significant for Hep. C cirrhosis, cholangitis, chronic renal insufficiency, hypertension, encephalopathy, esophageal varices, and VRE and pneumonia, urinary tract infection. PAST SURGICAL HISTORY: Orthotopic liver transplant [**2167-12-14**] and wound dehiscence [**2168-1-14**] and [**2168-2-14**] - hepatic artery Stent placement. MEDICATIONS: Neoral Prednisone 7.5 mg po qd Protonix Epogen Atenolol 50 mg po qd Bactrim CellCept Plavix Aspirin HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit overnight for observation. The patient did well on hospital day No. 2. The patient's heparin drip at 500 units an hour was shut off and the patient was placed on Plavix and aspirin alone and the patient's liver function tests were perfectly normal and the patient underwent a follow up ultrasound which was normal and the patient was keen and ready for discharge on [**2168-8-15**]. Prior to discharge the patient was afebrile and vital signs were stable. Neurologically the patient was alert and oriented x 3. Chest was clear. Heart was regular rate and rhythm. Abdomen was soft, nontender and non-distended. Extremities - no edema. The patient is to be discharged home and the patient is instructed to have his full set of lab drawn on Thursday, [**8-18**], and the patient is to follow up in the [**Hospital 1326**] Clinic next week. Discharge medications including aspirin 325 mg po qd, Plavix 75 mg po qd, CellCept [**Pager number **] mg po bid, Bactrim single strength one tab po qd and atenolol 50 mg po qd, Epogen 10, 000 units subcutaneous q Saturday, Prednisone 7.5 mg po q d and Prevacid 30 mg po qd and cyclosporin or Neoral 125 mg po bid. The patient is to have his full set of lab including cyclosporin level drawn on Thursday. DISCHARGE DIAGNOSIS: Hepatic artery stenosis status post orthotopic liver transplant, hepatitis C cirrhosis, cholangitis, chronic renal insufficiency, hypertension, encephalopathy, esophageal varices, pneumonia and urinary tract infection. [**Last Name (LF) **], [**First Name3 (LF) 819**] J. M.D. [**MD Number(2) 3762**] Dictated By:[**Last Name (NamePattern4) 32455**] MEDQUIST36 D: [**2168-8-15**] 15:51:45 T: [**2168-8-15**] 18:09:39 Job#: [**Job Number 37690**]

[ "593.9", "998.2", "447.1", "996.74", "401.9", "996.82" ]

icd9cm

[ [ [] ] ]

[ "88.47", "39.50", "00.55", "39.90" ]

icd9pcs

[ [ [] ] ]

2512, 2990

1191, 2490

921, 1173

183, 699

722, 897

56,853

143,934

50402

Discharge summary

report

Admission Date: [**2155-2-13**] Discharge Date: [**2155-2-15**] Date of Birth: [**2090-5-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 800**] Chief Complaint: DVT and PE Major Surgical or Invasive Procedure: retrievable IVC filter placement History of Present Illness: Patient is a 64M with HTN, UC with polyarticular arthritis s/p L TKR and prior DVT who was sent to ED from PCPs office. On the day prior to admission he had episode of leg numbness/swelling and chest pain and dyspnea. He went to [**Hospital1 1774**] ER and had work up including chest xray and ekg and was sent home. They examined his leg, but it was not obviously swollen at that time. He serindipitiously had a PCP apt on day of admission. His PCP saw him and sent him to the [**Hospital1 18**] ED with concern of pe/dvt. . He is s/p knee surgery in [**2-23**] on left and [**2150**] on right. He had a right lower leg DVT in [**2150**] after a meniscectomy for which he was on lovenox and coumadin for ~1 month. He had a c-scope in . In the ED, initial vs were: T95, 124/81, HR 95, 22-24, 99%RA, trop 0.13, MB flat. EKG was tachy without evidence of ischemia. LENIs with right DVT, CTA with PE. Patient was given Heparin bolus and started on gtt. Given clot burden, d/w IR and Micu fellow and retrievable IVC filter to be placed. . In the MICU patient is comfortable but a little anxious. . Review of sytems: (+) Per HPI, recent URI with congestion and cough. +Nocturia. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No blood in stool. No dysuria. Denied myalgias. Past Medical History: Polyarticular arthritis - on prednisone s/p L TKA in [**2-23**] s/p R meniscectomy in [**2150**] and subsequent right lower leg DVT s/p left high tibial osteotomy ulcerative proctitis (since 20yo, active ~20% time) gastroesophageal reflux disease HTN Social History: Works as jeweler, married, 2 sons, no etoh, drugs, tobacco. Family History: Mom died of ovarian cancer at 73, Dad of ALS, Brother died at 4 of leukemia, Sister ~70 and without medical problems. Grandparents with DM. No other breast, prostate or colon cancer in family. No bleeding or clotting disorders. Physical Exam: Tmax: 37.4 ??????C (99.3 ??????F) Tcurrent: 37.4 ??????C (99.3 ??????F) HR: 93 (93 - 94) bpm BP: 99/64(72) {99/64(72) - 128/79(88)} mmHg RR: 17 (9 - 23) insp/min SpO2: 92% 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. Right leg with edema throughout. Pertinent Results: [**2155-2-13**] 09:00AM WBC-13.0*# RBC-5.38 HGB-15.5 HCT-44.3 MCV-82 MCH-28.8 MCHC-35.0 RDW-14.2 [**2155-2-13**] 09:00AM CK-MB-8 [**2155-2-13**] 09:00AM cTropnT-0.13* [**2155-2-13**] 09:00AM PT-13.8* PTT-30.1 INR(PT)-1.2* [**2155-2-14**] 02:08PM BLOOD PT-14.7* PTT-68.9* INR(PT)-1.3* [**2155-2-14**] 08:00AM BLOOD WBC-9.4 RBC-5.03 Hgb-14.3 Hct-41.3 MCV-82 MCH-28.4 MCHC-34.5 RDW-14.2 Plt Ct-204 . [**2-13**] LENIs: BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler son[**Name (NI) 1417**] of the bilateral common femoral, superficial femoral, and popliteal veins were performed. There is near-occlusive thrombus in the right common femoral vein and occlusive thrombus in the greater saphenous, superficial femoral, and deep femoral veins. The right iliac veins and IVC could not be assessed due to the patient's body habitus. The right popliteal vein demonstrates normal flow. There is normal flow in the left common femoral, superficial femoral, and popliteal veins. Compressibility and augmentation were not assessed on the left given limited assessment of the IVC. IMPRESSION: Occlusive clot of the right superficial femoral, deep femoral and greater saphenous veins extending into the common femoral vein. Iliac vessels and IVC not adequately assessed due to patients body habitus. . [**2-13**] CTA: There are bilateral central and segmental pulmonary emboli. There is no evidence of an aortic dissection. There is approximately 6 mm pulmonary nodule in the lingula. There is a 7 mm pleural-based pulmonary nodule in the right lower lobe. There are scattered subcentimeter mediastinal lymph nodes. There is no pericardial or pleural effusion. The right ventricle diameter appears greater than 1.5 times that of left ventricle, in keeping with right ventricular strain. The visualized liver and spleen appear unremarkable. Hiatus hernia. . MUSCULOSKELETAL: There is a well-circumscribed sclerotic focus in the body of T2 and a similar focus in the left sixth rib posteriorly. These most likely represent bone islands. . CONCLUSION: 1. Bilateral central and segmental pulmonary emboli. 2. 6 mm pulmonary nodule in the lingula and a pleural-based 8-mm nodule in the right lower lobe should be assessed/followed up with a chest CT in three months to ensure stability/change in size. 3. Right ventricular strain. . [**2-13**] IVC Filter OP Report: Successful deployment of IVC filter in infrarenal position. Brief Hospital Course: Mr [**Known lastname **] is a 64M with extensive right DVT burden and hemodynamically stable PE. . # PE/DVT: Patient with history in setting of provokation in [**2150**]. Now with significant burden without any risk factors except prior DVT. Patient needs age appropriate cancer screening. This could include repeat PSA (last in [**2152**]) and repeat c-scope (last in [**2153**], but pt has UC which has been active intermittently over his lifetime predisposing to CRC). Would consider outpt heme consult for discussion of testing for genetic, acquired thrombophilias and to discuss length of anticoagulation. Treated with IVC filter placement and heparin drip, discharged on lovenox to coumadin bridge. . # HTN: Normotensive, no change in home regimen. . # UC: Continued mesalamine. . # Arthritis: Continued prednisone . # GERD: Continued PPI Medications on Admission: Prednisone 3mg qd Omeprazole 20 mg qd Lialda 1.2 g qd Hydrochlorothiazide 25 mg qd Metoprolol 25 mg qd Mesalamine enema PR PRN Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Lialda 1.2 g Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO QAM. 5. Lialda 1.2 g Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QPM (once a day (in the evening)). 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Please check your INR regularly, goal [**1-21**]. Disp:*30 Tablet(s)* Refills:*0* 7. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a day for 7 days. Disp:*14 injections* Refills:*0* 8. Outpatient Lab Work Please have your INR checked within 2-3 days of your discharge and have the results faxed to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**], fax [**Telephone/Fax (1) 445**]. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO once a day. 10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 11. Mesalamine 4 gram/60 mL Enema Sig: One (1) Rectal AS DIRECTED: Please use as directed by primary care physician. Discharge Disposition: Home Discharge Diagnosis: deep vein thrombosis pulmonary embolism . ulcerative colitis hypertension rheumatoid arthritis Discharge Condition: improved Discharge Instructions: You were admitted to the hospital w dyspnea. You were found to have clots in your right leg vein, which likely got dislodged into your lungs. We treated you with anticoagulation and with a filter to prevent further clots going to your lungs. . We changed your medications as follows: 1. added lovenox, please continue injections twice daily until your INR becomes therapeutic (INR [**1-21**]) 2. added warfarin, you will likely need to take this medication long-term . If you have shortness of breath, chest pain, dizziness, or any other concerning symptoms, please seek medical care immediately. Followup Instructions: Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week of your discharge from the hospital: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**], [**Telephone/Fax (1) 133**]. . Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2155-3-7**] 4:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2155-3-7**] 4:20 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Completed by:[**2155-2-15**]

[ "V58.65", "530.81", "401.9", "V12.51", "714.0", "415.19", "V43.65", "453.41", "556.9" ]

icd9cm

[ [ [] ] ]

[ "38.7" ]

icd9pcs

[ [ [] ] ]

7891, 7897

5596, 6446

325, 359

8036, 8047

3147, 5573

8692, 9340

2230, 2461

6623, 7868

7918, 8015

6472, 6600

8071, 8669

2476, 3128

275, 287

1507, 1863

387, 1489

1885, 2137

2153, 2214

61,452

128,729

36961

Discharge summary

report

Admission Date: [**2120-5-27**] Discharge Date: [**2120-6-8**] Date of Birth: [**2043-9-17**] Sex: M Service: MEDICINE Allergies: Niacin Attending:[**First Name3 (LF) 398**] Chief Complaint: Acute on Chronic Respiratory Failure Major Surgical or Invasive Procedure: VATs Lung Biopsy Chest tube placement Endotracheal intubation Mechanical ventilation History of Present Illness: 76 y m with PMH of Rheumatoid Arthritis on Humira and Methotrexate, diastolic heart failure, peripheral neuropathy and atrial fibrillation with 2 months of progressive DOE with acute worsening 2 days prior to admission at [**Hospital 1562**] Hospital on [**2120-5-20**]. . Patient and wife report that over the last several months he has progressive shortness of breath with exertion. He denies PND or orthopnea. His wife also notes that his fingers and toes had become increasingly 'purple' over the last several weeks. He is normally very active, doing significant amounts of yard work, walking up a large [**Doctor Last Name **] on his property and does not normally have significant shortness of breath. He denies fever/chills, weight loss and night sweats. He does not wear oxygen at home and has never been diagnosed with lung disease. . On [**2120-5-18**] patient was drinking water and reports that it 'went down the wrong pipe' this was followed by an episode of severe coughing and shortness of breath that did not resolve. He then went to the ED at [**Hospital 1562**] Hospital where he was noted to be hypoxemic. CT showed diffuse interstitial changes thought to be secondary to rheumatoid-associated lung disease. Labs were significant for a normal WBC with 60% PMNs, XX% lymphocytes, 17% monocytes and 4% eosinophils. He was started on high dose iv steroids with improvement in his cyanosis and his comfort. He did not receive any antimicrobials as he was not felt to be infected. His echo revealed a normal EF of 55% with moderate to severe TR and moderately elevated pulmonary artery pressures. EKG showed an rate of 60 with old RBBB and right axis deviation. Though his symptoms did improve, repeat CT showed worsening of left lung process and patient was not able to be weaned off oxygen. He was transferred here to [**Hospital1 18**] for lung biopsy and further evaluation and management. . Yesterday when seen by pulm consult resident, patient reports that he is feeling fine and is without complaint. He is not SOB at rest and he is breathing comfortably on supplemental O2. He denies any tobacco use, chemical exposures, pets or recent travel. . Last night, he was taken to the OR for a VATs and pulmonary biopsy. He had biopsies performed of the lingula and LLL. He was extubated post-op but then re-intubated for hypoxia and increased work of breathing. Past Medical History: Rheumatoid Arthritis dx'ed in [**2116**] Diastolic Heart Failure Peripheral Neuropathy Atrial Fibrillation Social History: Married, retired from management. Never smoked, rare EtOH, no illicit drugs. Works outside frequently doing yard work. No recent travel. No pets. Denies chemical exposure. Family History: Father with DM. No family history of autoimmune diseases or lung cancer. Physical Exam: VITAL SIGNS: T 97 BP 137/70 HR 69 RR 19 O2 99% on 60%FiO2, 5 PEEP, 10 PS GENERAL: intubated and sedated HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. Pupils small and minimally reactive. ETT in place CARDIAC: irreg irreg, fixed split S2, no audible murmurs LUNGS: bibasilar dry crackles. ABDOMEN: Vertical midline scar, soft, nd, nabs EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. Moves all extremities. SKIN: stage 2 sacral decubitous ulcer Pertinent Results: [**2120-5-27**] 07:58PM GLUCOSE-191* UREA N-31* CREAT-0.9 SODIUM-138 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16 [**2120-5-27**] 07:58PM estGFR-Using this [**2120-5-27**] 07:58PM CALCIUM-8.3* PHOSPHATE-3.0 MAGNESIUM-2.2 [**2120-5-27**] 07:58PM DIGOXIN-0.5* [**2120-5-27**] 07:58PM WBC-9.5 RBC-3.28* HGB-11.2* HCT-31.6* MCV-97 MCH-34.1* MCHC-35.3* RDW-14.7 [**2120-5-27**] 07:58PM PLT COUNT-142* [**2120-5-27**] 07:58PM PT-14.4* PTT-25.3 INR(PT)-1.3* Brief Hospital Course: ASSESSMENT AND PLAN: 76 M w/ pmh Rheumatoid Arthritis on Humira and Methotrexate, diastolic heart failure, atrial fibrillation with p/w hypoxic respiratory failure s/p vats and Lingula/LLL biopsy. . #. Hypoxic respiratory failure: He appeared to be stable on 3L NC prior to the VATS procedure and per the OSH report, he dramatically improved clinically (and his pulmonary infiltrates improved) w/ steroids. Apparently he initally did well after extubation but then had increased work of breathing and hypoxia. It seems possible that he could have had flash pulmonary edema vs aspiration that caused acute decompensation requiring intubation. His CXR at the time of re-intubation looks dramatically worse than the prior CXR altough we have already been able to wean FiO2. . #. S/p VATS: Chest tube in place draining sero-sanguenous fluid. Small PTX on am CXR - would likely plan to d/c chest tube when drainage is < 100 cc/ 24 hrs. - appreciate thorasics input - daily CXR to eval for worsening PTX . #. Rheumatoid arthritis: . #. Macrocytic Anemia: Unclear etiology. - check b12, folate, iron studies - trend for now - guaiac all stools . #. CHF: Normal EF from OSH report but h/o diastolic dysfunction. As a result, likely does not tolerate a rapid rate or severe hypertension well. - maintain excellent BP control - rate control as below . #. Afib: on digoxin and metoprolol for rate control as an outpatient and coumadin for anticoagulation. - re-start coumadin per thorasics - as no systolic dysfunction, would opt to d/c digoxin and rate control w/ metoprolol for now . FEN: replete lytes prn . PPX: Sc heparin, bowel regimen prn, ranitidine -- [**5-31**] - path c/w UIP - discussed with rheum: hold humira x2wk post vats, hold mtx indefinitely - staph from sputum sensitivities pending . ACCESS: PIV's . CODE STATUS: Presumed full . EMERGENCY CONTACT: Wife [**Name (NI) 14880**] [**Name (NI) 732**] ([**Telephone/Fax (1) 83370**] . DISPOSITION: ICU pending resolution of above . [**5-30**] - Extubated, high O2 requirement, on 80% facemask - CT placed to waterseal, PTX stable - Weaned to 5L NC . [**5-31**] - weaned steroid down to 60mg methylpred - increased ptx on AM CXR but thoracics ok with keeping on water seal - attempted to reach outpt rheum - no answer from office. spoke with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] rheum attending here rec HOLD humira x2 weeks post VATS, then may restart if no infection identified. would HOLD mtx indefinitely and defer further tx choices to outpt rheum - path prelim c/w UIP, discussed with family - vanc trough 7, increased to 1g [**Hospital1 **] from 750mg [**Hospital1 **] - seen by speech and swallow failed swallow -> made npo . [**6-1**] - increased PTX, changed CT to suction from water seal - changed zosyn dosing - MIE Q2H, chest PT - NG tube placed, pulled out of position with question aspiration event, replaced . [**6-2**]: - desat to 70s up to 70% facemask PLUS nasal canula, but subsequently weaned weaned down to 35% without NC - afib with rvr got 5mg metoprolol with good response - CT placed back to suction given inc. size of PTX -> waterseal this AM - Family mtg held, ok to reintubate, if reach point with little hope of improvement, family will likely withdraw care . [**6-3**] - chest tube put on waterseal again in AM, but ptx worse on repeat chest film to returned to low wall suction - restarted digoxin - pulled out NGT -------- [**6-4**] -HR mainly in the 70-80s but occasional sympathetic driven spikes to 140-150. continued dig 0.125mg daily and changed PO lopressor to 5mg IV lopressor IV q4hrs -patient desats with any slight movement, for the most part on 6L NC -plan to call family regarding any need for intubation and they will likely say to not intubate at this point, still full code currently though -I/O goal even, by 7 p.m. even -changed CT to water seal, no real change in PTX, per thoracics attg patient will need pleuradesis as he will unlikely improve given stiff lungs related to ILD -MIE stopped -decreased solumedrol to 20mg IV x 1 today, with a plan to continue weaning rapidly -S+S to re-eval [**2120-6-5**] -haldol 0.5mg started tid prn anxiety ------- [**6-6**] - family meeting regarding goals of care - thoracics placed pneumo stat - repeat evening CXR with worsening PTX so placed on suction - 9 pm repeat evening CXR improved - started bactrim for PNA - d/c'ed all nonessential po meds -------------- -re-trial of pneumo-stat failed -chest tube replaced and placed to suction, plan to place to water seal in a.m. prior to discharge home with hospice. -scripts for zydis and morphine given to palliative care who picked up meds for patient Medications on Admission: On transfer: MethylPREDNISolone Sodium Succ 125 mg IV Q6H Order date: [**5-29**] @ 0401 Metoprolol Tartrate 10 mg IV Q4H hold for MAP < 65 Order date: [**5-29**] @ 0822 1000 mL LR Continuous at 75 ml/hr Change to peripheral lock when taking POs Order date: [**5-29**] @ 0402 Pantoprazole 40 mg IV Q12H Order date: [**5-29**] @ 0401 Digoxin 0.1 mg IV DAILY Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: [**5-27**] @ 1742 FoLIC Acid 1 mg IV Q24H Order date: [**5-29**] @ 0822 Propofol 5-40 mcg/kg/min IV DRIP TITRATE TO titrate to adequate sedation with MAP > 65 Order date: [**5-29**] @ 0822 Heparin 5000 UNIT SC TID Order date: [**5-29**] @ 0401 Insulin SC (per Insulin Flowsheet) Sliding Scale Order date: [**5-29**] @ 0401 . Home medications: Fosamax 70mg qweek Digoxin 0.125mg qd Toprol XL 50mg qd Coumadin 5mg qd Humira 40mg q2weeks Folic acid 1mg qd Methotrexate 2.5mg 5/7 days a week . Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for SOB or wheezing. 2. Morphine Concentrate 5 mg/0.25 mL Solution Sig: 5-20 mg PO q1 hour as needed for pain. Disp:*30 mL* Refills:*0* 3. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO twice a day. Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*2* 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation four times a day. 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 7. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. Disp:*45 Tablet(s)* Refills:*1* 8. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO twice a day as needed for anxiety. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*1* Discharge Disposition: Home With Service Facility: Hospice of [**Hospital3 **] Discharge Diagnosis: Primary Diagnosis: 1. Hypoxic Respiratory Failure 2. UIP 3. Rheumatoid arthritis Secondary Diagnosis: 1. Congestive Heart Failure 2. Macrocytic Anemia 3. Atrial fibrillation Discharge Condition: Stable. On 6L of nasal cannula oxygen while at rest. Discharge Instructions: You were admitted with increasing shortness of breath. You were transferred to [**Hospital1 18**] for a lung biopsy and further evaluation and management. You had a VATs and pulmonary biopsy procedure. Afterwards, you had trouble breathing so you were re-intubated for low oxygen levels. You were then transferred to the ICU. Your oxygenation got better, and you were taken off the ventilator. Thoracic surgeons also followed you in the hospital. You are being sent home with a chest tube to "water seal" meaning there is no significant suctioning applied to the space between your lung and chest wall but air cannot enter from the outside. Please continue to take your medications as prescribed. Speech and Swallow consult saw you, and recommended nectar thickened liquids. You should also increase your supplemental oxygen prior to movement. Please keep all your medical appointments. If you have any of the following symptoms, please call your doctor: fever>101, chest pain, increased shortness of breath, abdominal pain, or any other concerning symptoms. Followup Instructions: Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**1-5**] weeks.

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icd9cm

[ [ [] ] ]

[ "34.04", "96.72", "96.04", "33.20" ]

icd9pcs

[ [ [] ] ]

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4249, 8927

302, 389

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226, 264

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28,264

173,320

34344

Discharge summary

report

Admission Date: [**2122-8-6**] Discharge Date: [**2122-8-7**] Date of Birth: [**2063-11-5**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 492**] Chief Complaint: tracheobronchomalacia, scheduled for Y-stent placement Major Surgical or Invasive Procedure: OR [**8-6**]: bronchoscopy with Y-stent placement, therapeutic aspiration Bedside [**8-7**]: broncoscopy History of Present Illness: 58F witha history of severe COPD, OSA, CHF, Pulmonary HTN, initially presented to [**Hospital6 **] on [**2122-2-16**] in Respiratory failure. She was intubated, was difficult to wean, and got a tracheostomy and PEG. She was transferred to [**Hospital1 7932**] for rehabilitation and vent wean. Over following couple of weeks, she has had increased difficulty breathing and increased secretions. She was transferred to [**Hospital1 3278**] for Bronchoscopy to further evaluate her tracheostomy site. She was found to have severe tracheobronchomalacia, and was subsequently transferred to [**Hospital1 18**] for further workup on [**2122-7-22**]. She was admitted to surgical ICU and underwent a bronchoscopy which demonstrated mild tracheal stenosis w/ moderate amount of granulation tissue noted at the site of the stoma; the mid portion of the trachea had severe tracheomalacia; the distal trachea had mild tracheomalacia; the right main stem bronchus ahd mild bronchomalacia; the left main stem bronchus had moderate bronchomalacia. She went to the OR on [**2122-7-24**] for rigid bronchoscopy w/microdebrider to granulation tissue and APC to coaggulate bleeding. Tracheostomy stoma was then dilated with a Blue Rhino and a new tracheostomy, a Portex size #7, was inserted. She did well post operatively transferred back to rehab [**2122-7-25**]. She was readmitted to the surgical ICU on [**2122-8-6**] for scheduled stent placement. Past Medical History: Tracheobronchomalacia COPD OSA Pulmonary HTN systemic HTN Chronic renal insufficiency ischemic bowel s/p colectomy Depression Social History: 30 pack year former smoker married, lives with family Family History: non contributory Physical Exam: VS: Tm99.6 Tc99.6 HR79 BP146/60 RR16 CPAP: FiO2 50%, PEEP 5, Peak 15 Gen: pleasant, no acute distressed Chest/Neck: Trach site without erythema; no subcutaneous air appreciated CV: RRR, no m/g/r appreciated Pulm: tracheostomy; inspiratory and expiratory wheezing thoughout Abd: +BS, soft, nt/nd, obese with large panus, colostomy, PEG LE: +1 edema to ankles B/L Pertinent Results: [**2122-8-6**] 08:11PM BLOOD WBC-7.0 RBC-3.04* Hgb-8.8* Hct-29.1* MCV-96 MCH-28.9 MCHC-30.1* RDW-16.7* Plt Ct-266 [**2122-8-7**] 02:15AM BLOOD WBC-7.7 RBC-2.99* Hgb-8.5* Hct-28.5* MCV-95 MCH-28.4 MCHC-29.9* RDW-15.7* Plt Ct-266 [**2122-8-6**] 08:11PM BLOOD Plt Ct-266 [**2122-8-7**] 02:15AM BLOOD Plt Ct-266 [**2122-8-6**] 08:11PM BLOOD Glucose-100 UreaN-21* Creat-1.4* Na-140 K-4.3 Cl-101 HCO3-32 AnGap-11 [**2122-8-7**] 02:15AM BLOOD Glucose-92 UreaN-21* Creat-1.4* Na-142 K-4.5 Cl-102 HCO3-32 AnGap-13 [**2122-8-6**] 08:11PM BLOOD Calcium-9.6 Phos-4.0 Mg-1.8 [**2122-8-7**] 02:15AM BLOOD Calcium-9.6 Phos-3.5 Mg-1.6 Brief Hospital Course: The patient was admitted to the surgical ICU on [**2122-8-6**] for evaluation and treatment of chronic respiratory failure. She went to the OR on [**8-6**] for bronchoscopy: a Y-stent was placed for her tracheobronchomalacia; a Portex Perfit tracheostomy tube #8 was placed; she had therapeutic aspiration with flexible bronchoscopy; and, her stoma was revised. Her postoperative course was uneventful. She remained afebrile and hemodynamically stable. Her pain was well-controlled. She had a bedside bronchoscopy on [**8-7**] and R chest ultrasound: on bronchoscopy, the stent was correctly positioned with minimal to moderate secretions; The distal airways were patent and minimal secretions; the ultrasound revealed minimal pleural effusion on the right - a pleurocentesis was not necessary. A chest film and a chest CT had showed no signs of Left pleural effusion. On [**8-7**], the patient and staff felt that it was appropriate to discharge the patient to [**Hospital3 105**] Northeast - [**Hospital1 **], for further pulmonary care and rehab. She is being discharge stable, in good condition. Medications on Admission: Furosemide 20 mg PO/NG [**Hospital1 **] Albuterol-Ipratropium [**12-17**] PUFF IH Q6H Heparin 5000 UNIT SC TID Insulin SC Zantac Protonix, Metoprolol Tartrate 25 mg NG [**Hospital1 **] Fentanyl Citrate 25-100 mcg IV Effexor Albuterol Neb Trazadone Reglan Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] Discharge Diagnosis: tracheobronchomalacia, Y-stent placement Discharge Condition: tracheostomy on CPAP, good condition, stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. Followup Instructions: Please call the Chest Disease Clinic, [**Telephone/Fax (1) 72632**], to schedule a follow up appointment with Dr. [**Last Name (STitle) **] in 2 weeks. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**] Completed by:[**2122-8-7**]

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icd9cm

[ [ [] ] ]

[ "33.21", "96.05" ]

icd9pcs

[ [ [] ] ]

4651, 4726

3241, 4346

373, 479

4811, 4858

2598, 3218

5443, 5737

2183, 2201

4747, 4790

4372, 4628

4882, 5420

2216, 2579

279, 335

507, 1945

1967, 2095

2111, 2167

31,116

165,820

6778

Discharge summary

report

Admission Date: [**2163-1-12**] Discharge Date: [**2163-1-15**] Date of Birth: [**2085-10-2**] Sex: M Service: MEDICINE Allergies: Penicillins / Lisinopril / Sulfa (Sulfonamides) / Plavix Attending:[**First Name3 (LF) 2145**] Chief Complaint: Agitation/increased confusion Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 77yo man, NH resident w/ PMH dementia, DM, CKD, who p/w 2 day h/o increased agitation/confusion. No documented fevers, other sxs per notes. Of note, pt recently d/ced from [**Hospital1 2025**] on [**2162-12-29**] after presenting w/ MS changes, found to have likely pna on CXR. Per d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 17576**], has had problems w/ recurrent asp pna, gets honey thickened diet. He was treated w/ levofloxacin x ?length and d/ced back to NH. In [**Name (NI) **], pt's vitals were T 97.1, HR 109, BP 160/102, RR 22, O2 92% RA. Labs notable for Cr elevated at 3.2, K of 6.7, WBC 15.7. EKG w/ peaked t waves in V2-3. Pt given sodium bicarb, calcium carbonate, D50/insul, ?kayexalate in ED. CXR w/ evidence of multifocal pna, so pt given levoflox and aztreonam in ED. Head CT demonstrates 3 x 2cm acute R thalamic hemorrhage. Neurosurg and neurology seen in ED w/ recommendations given. Received haldol 1mg x 1 for agitation. Admitted to MICU. Currently pt able to talk slightly but unable to answer questions fully. Past Medical History: -Baseline dementia with history of delirium (vascular dementia) -CAD s/p CABG x 4 at [**Hospital1 2025**] in [**2144**] -CKD (?baseline Cr 2.4-2.8 in [**2160**]) -DM2 -Bipolar d/o -Anxiety -s/p AAA repair -Hypercholesterolemia -GERD -CHF (?no ECHO here) -AS (?no ECHO here) -H/o Aspiration PNA -recurrent c diff, currently on PO vanc -Urinary + bowel incontinence at baseline -Gait abnormality Social History: NH resident, can reportedly feed self and brush teeth if set up to do so at baseline. Ambulates unsteadily with walker per NH notes. Unclear history of tobacco, EtOH, and illicits. Family History: NC Physical Exam: Vitals: T 97.1 F BP 194/105 P 76 RR 20 SaO2 96% on 2L NC General: cachectic, elderly man, L arm flexed, tremulous, mouth rooting, able to say "hello" and answer some questions when urged. Not oriented. HEENT: NC/AT, sclerae anicteric, dry MM Neck: no bruits, no elevated JVP Lungs: course breath sounds at bases, no rhonci, no crackles CV: regular rate and rhythm, no MRG Abdomen: soft, NT/ND, bowel sounds present Ext: no C/C/E Skin: dry, no rashes Pertinent Results: Labs on admission: [**2163-1-11**] 06:40PM BLOOD WBC-15.7*# RBC-3.49* Hgb-10.5* Hct-33.0* MCV-94# MCH-30.0# MCHC-31.8 RDW-15.8* Plt Ct-339# [**2163-1-11**] 06:40PM BLOOD Neuts-82.4* Lymphs-13.4* Monos-1.9* Eos-2.2 Baso-0.1 [**2163-1-11**] 06:40PM BLOOD PT-14.4* PTT-27.7 INR(PT)-1.3* [**2163-1-11**] 06:40PM BLOOD Glucose-127* UreaN-64* Creat-3.2* Na-138 K-6.7* Cl-105 HCO3-22 AnGap-18 [**2163-1-12**] 02:13AM BLOOD ALT-40 AST-45* LD(LDH)-311* AlkPhos-166* TotBili-0.3 [**2163-1-12**] 02:13AM BLOOD Albumin-3.5 Calcium-9.7 Phos-5.2*# Mg-1.7 [**2163-1-12**] 02:13AM BLOOD Ammonia-20 [**2163-1-12**] 02:13AM BLOOD TSH-2.8 [**2163-1-12**] 02:13AM BLOOD Valproa-9* . Labs on discharge: [**2163-1-14**] 05:16AM BLOOD WBC-18.8* RBC-3.02* Hgb-9.2* Hct-29.0* MCV-96 MCH-30.5 MCHC-31.8 RDW-15.8* Plt Ct-307 [**2163-1-14**] 05:16AM BLOOD Glucose-122* UreaN-42* Creat-2.8* Na-147* K-4.3 Cl-112* HCO3-24 AnGap-15 [**2163-1-14**] 05:16AM BLOOD Calcium-8.6 Phos-5.0* Mg-1.5* . Microbiology: [**2163-1-11**] Blood cx - NGTD [**2163-1-11**] Urine cx - < [**2154**] colonies probable enterococcus [**2163-1-13**] C diff - negative . Imaging: [**2163-1-11**] CXR: IMPRESSION: Multiple vague areas of patchy opacification in both lungs concerning for multifocal pneumonia. . [**2163-1-11**] Head CT: IMPRESSION: 2.8 x 1.9 cm intraparenchymal hemorrhage involving the right thalamus, likely hypertensive. . [**2163-1-12**] Repeat Head CT: IMPRESSION: No significant change in the right thalamic hemorrhage with no new hemorrhages or intraventricular extension. Brief Hospital Course: Pt is a 77 year old man, Nursing home resident, w/ multiple medical problems including dementia, HTN, CAD, DM, CKD who presents from NH with increased agitation, found to have acute R thalamic stroke, as well as acute on chronic renal failure/hyperkalemia. . # Right thalamic stroke: Pt presented with mental status changes/agitation, in work up found to have Right thalamic stroke - per CT scan report, likely hypertensive. Patient with history of hypertension, and is on aspirin as an outpatient. Neurology was involved with his care and he was closely monitered, maintaining his blood pressure initially at 140-160 with IV labetalol PRN. Repeat head CT day after admission showed no change in stroke. He was discharged off of his antihypertensives except on lower metoprolol, with holding parameters and instructions to increase as needed for blood pressure control. He will have a repeat CT scan done in 4 weeks and follow up with neurology after the CT scan. . # Hypertension: On metoprolol, dilt SR 120 [**Hospital1 **], and hydralazine as outpt. Likely stroke above is hypertensive in nature. His antihypertensives were held on admission for more control over his blood pressure, and as above, he was discharged on only lower dose metoprolol 50 [**Hospital1 **], no other BP medications, with plans to adjust as needed to maintain SBP 120-140 over the coming weeks. Please consider restarting Dilt SR 120 [**Hospital1 **] after 4 weeks to recontrol his BP. . # Mental status changes/agitation: Patient presented from nursing home with increased agitation/confusion on top of baseline dementia. Likely caused by acute stroke above. Further work up included infectious work up given leukocytosis (see below), as well as sending off ammonia, TSH, LFTs, depakote level which were all normal. Mental status improved to baseline during hospital course. He was given seroquel as needed for agitation, as initially he was given haldol, but this caused alot of rigidity and parkonsonian features, so should be avoided. Only give Seroquel if truly needed as his MS had improved to baseline at time of discharge. . # Leukocytosis: Initial lab values demonstrated elevated WBC, no bandemia. Infectious work up was initiated including blood and urine cultures which were unremarkable, and a CXR that showed possible aspiration pneumonia. He was known to have had a recent admission to [**Hospital3 2576**] [**Hospital3 **] (d/ced [**2162-12-30**]) with an aspiration pneumonia, so it was unknown if the CXR was actually improved from this admission. He was initially maintained on Vancomycin, aztreonam, and flagyl for possible nosocomial/aspiration pneumonia coverage, but the patient's respiratory status remained stable, he had no fevers or hypothermia, so these were discontinued after 48 hours. The patient also reportedly had a history of c diff and was on PO vancomycin on admission. C diff was rechecked during hospital course and returned negative, but due to family insistence, he was continued on oral Vancomycin. His diarrhea was completely resolved and this should be discontinued in discussion with his Primary care doctors. . # Renal failure/Hyperkalemia: Patient has a history of CKD, baseline Cr 2.8-3.1 per records from [**Hospital3 **] [**Hospital3 **], as well as history of hyperkalemia in the past. On admission, his Cr was 3.2, K was 6.7. He was given IVF with resolution of his Cr to normal. His EKG initially did show peaked t waves, evidence of his hyperkalemia. He was given sodium bicarbonate, calcium gluconate, insulin/D50, kayexalate x multiple times with eventual resolution of his hyperkalemia. Given his difficult to control potassium, renal consult was obtained, and recommended starting the patient on lasix 40mg PO daily. He was started on this regimen, and his potassium stayed stable during remainder of hospital course. His Potassium was stable prior to discharge and Lasix was discontinued. . # Diabetes Mellitus: Patient is on glyburide and insulin sliding scale at his nursing home. His glyburide was held on admission and he was maintained on the ISS. He was discharged back on glyburide, and on ISS. . # Underlying dementia/bipolar: Continued outpatient remeron, wellbutrin, cymbalta, depakote and neurontin. As above seroquel PRN for agitation. . # Foley: His Foley Catheter was d/c'ed on [**1-15**] at 10am; please ensure that he urinates by the end of the day today. If he is not able to, please replace his Foley Catheter. . # Gout: Developed pain in R knee on day of discharge - similar to prior episodes of gout in the past. Given his renal dysfunction & recent diarrhea, cannot treat with either NSAIDs or Colchicine. Prescribed a course of Prednisone taper for treatment of his gout which he has been treated with in the past with good results. Will start Pred taper at rehab. . # FEN: Maintained on mechanical soft diet with nectar or honey thickened liquids. . # Code: DNR/DNI . # Communication: Daughter [**First Name8 (NamePattern2) **] [**Known lastname **]: (c) ([**Telephone/Fax (1) 25724**], (h) ([**Telephone/Fax (1) 25725**] Medications on Admission: Diltiazem SR 120 mg [**Hospital1 **] Glyburide 5 mg daily Depakote 250 mg qhs Vancomycin 250 mg PO QID Florastor 250 mg [**Hospital1 **] Cymbalta 60 mg Daily Metoprolol 50 mg QID Aspirin 81 mg Daily Gabapentin 100 mg Daily Hydralazine 25 mg TID Wellbutrin SR 150 mg Daily Remeron 7.5 mg daily Novolin N 100 unit/mL Susp, 157 Suspension Daily Discharge Medications: 1. Divalproex 250 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation. 6. Glyburide 5 mg Tablet Sig: 0.5 Tablet PO once a day. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Insulin Regular Human 100 unit/mL Solution Sig: 2-10 units Injection ASDIR (AS DIRECTED): As directed per sliding scale. 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day: Hold for SBP < 100, HR < 60 Can titrate up as needed to maintain BP of 120-140. Discharge Disposition: Extended Care Facility: [**Hospital 169**] Center-[**Location (un) **] Discharge Diagnosis: Primary: -Right sided thalamic stroke -HTN -Hyperkalemia now resolved -Chronic Renal Failure -Gout Flare . Secondary: -Baseline dementia with history of delirium (vascular dementia) -CAD s/p CABG x 4 at [**Hospital1 2025**] in [**2144**] -CKD (?baseline Cr 2.4-2.8 in [**2160**]) -DM2 -Bipolar d/o -Anxiety -s/p AAA repair -Hypercholesterolemia -GERD -CHF (?no ECHO here) -AS (?no ECHO here) -H/o Aspiration PNA -recurrent c diff, currently on PO vanc -Urinary + bowel incontinence at baseline -Gait abnormality Discharge Condition: Stable for discharge to rehab Discharge Instructions: You were admitted to the hospital with mental status changes/ agitation and found to have a new stroke. You were treated with close monitering of your blood pressure. You completed a course of Anbtiotics for a Pneumonia that was started at your previous admission at [**Hospital1 2025**]. You were continued on oral Vancomycin for treatment of your prior c.dif infection - please discuss this with Dr. [**Last Name (STitle) 2716**] to stop your oral Vancomycin when your course is complete. . Please take all medications as directed. . Please follow up with appointments as directed. . Please contact physician if develop worsening mental status changes, fevers/chills, diarrhea, abdominal pain, any other questions or concerns. Followup Instructions: Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2716**] in the coming weeks. . Please follow up to have repeat CT scan of head done on Monday [**2-14**] at 1:15PM. Please go to [**Hospital Unit Name **] on [**Location (un) 470**], located on [**Hospital Ward Name **] of [**Hospital1 18**]. . Please follow up with Dr. [**First Name (STitle) **] in the neurology department ([**Telephone/Fax (1) 7394**] on [**2-25**] at 10:30AM. Office is located in [**Hospital Ward Name 23**] building at [**Hospital1 18**] on [**Location (un) **]. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2163-1-15**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10872, 10945

4147, 9268

347, 354

11501, 11533

2577, 2582

12313, 13031

2086, 2090

9661, 10849

10966, 11480

9294, 9638

11557, 12290

2105, 2558

278, 309

3259, 3850

382, 1454

3998, 4124

2596, 3240

1476, 1872

1888, 2070